NURS 431- LAB KNOWLEDGE EXAM
QUESTIONS WITH CORRECT ANSWERS
A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin
hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The
nurse also observes pinkish blood return and fluid leaking from the insertion site. Based
on this information, which condition should the nurse suspect?
Select one:
a. Occlusion
b. Septicemia
c. Extravasation
d. Thrombophlebitis - Answer-c. Extravasation
Occlusion is a restriction of blood flow that causes the fluid to back up and cause
infiltration and dependent edema.
Septicemia is a systemic infection.
Thrombophlebitis is a venous inflammation with clot formation.
Upon inspection of a client's peripheral I.V. site, a nurse notes 3+ phlebitis of the client's
vein. Which action by the nurse is most appropriate?
Select all that apply:
a. Watch the site and document observations
b. Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes. - Answer-b.
Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes.
A nurse is ordered to administer an I.V. medication at scheduled intervals over a period
of time. The nurse understands that after administering the medication by I.V.:
Select one:
a. the drugs half-life is terminated
b. the rate of absorption is controlled over time
c. the medication is ineffective
d. the client must be monitored. - Answer-b. the rate of absorption is controlled over
time
, A nurse is about to administer an I.V. push medication. Which action should the nurse
take when pushing the medication?
Select one:
a. Hold a watch that has a second hand
b. Determine the amount of time needed to administer
c. Wipe the insertion site with an alcohol swab seconds
d. Apply pressure over the catheter insertion site. - Answer-b. Determine the amount of
time needed to administer
Having a watch with a second hand and wiping the insertion site are important, but not
the best action.
Pressure is applied over the site when REMOVING the IV.
What are the s/s of speed shock? - Answer-Headache
Syncope
Flushing
Tightness in chest
Irregular pulse
Can progress to shock and cardiac arrest
What are the nursing interventions for patients with speed shock? - Answer-Get them
back into bed and lying down
Inform/get help from primary/charge nurse, physician, or the rapid response team
A nurse suspects that a client with a peripheral access device is experiencing a venous
spasm. Which report by the client should prompt the nurse to suspect this condition?
Select one:
a. Redness along the vein
b. Cold feeling in the extremity
c. Sharp pain extending from the site of infusion
d. Increased temperature at the peripheral infusion site - Answer-c. Sharp pain
extending from the site of infusion
Redness=phlebitis
Cold feeling= cold infusate or infiltration
Increased temperature=phlebitis
A physician's assistant orders two medications for a client and instructs a nurse to
administer the medications together. The nurse questions the order because
incompatibilities can occur when two drugs are compounded. These incompatibilities
may include:
Select one:
a. intermittent, physical, and biotransformation incompatibilities
QUESTIONS WITH CORRECT ANSWERS
A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin
hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The
nurse also observes pinkish blood return and fluid leaking from the insertion site. Based
on this information, which condition should the nurse suspect?
Select one:
a. Occlusion
b. Septicemia
c. Extravasation
d. Thrombophlebitis - Answer-c. Extravasation
Occlusion is a restriction of blood flow that causes the fluid to back up and cause
infiltration and dependent edema.
Septicemia is a systemic infection.
Thrombophlebitis is a venous inflammation with clot formation.
Upon inspection of a client's peripheral I.V. site, a nurse notes 3+ phlebitis of the client's
vein. Which action by the nurse is most appropriate?
Select all that apply:
a. Watch the site and document observations
b. Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes. - Answer-b.
Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes.
A nurse is ordered to administer an I.V. medication at scheduled intervals over a period
of time. The nurse understands that after administering the medication by I.V.:
Select one:
a. the drugs half-life is terminated
b. the rate of absorption is controlled over time
c. the medication is ineffective
d. the client must be monitored. - Answer-b. the rate of absorption is controlled over
time
, A nurse is about to administer an I.V. push medication. Which action should the nurse
take when pushing the medication?
Select one:
a. Hold a watch that has a second hand
b. Determine the amount of time needed to administer
c. Wipe the insertion site with an alcohol swab seconds
d. Apply pressure over the catheter insertion site. - Answer-b. Determine the amount of
time needed to administer
Having a watch with a second hand and wiping the insertion site are important, but not
the best action.
Pressure is applied over the site when REMOVING the IV.
What are the s/s of speed shock? - Answer-Headache
Syncope
Flushing
Tightness in chest
Irregular pulse
Can progress to shock and cardiac arrest
What are the nursing interventions for patients with speed shock? - Answer-Get them
back into bed and lying down
Inform/get help from primary/charge nurse, physician, or the rapid response team
A nurse suspects that a client with a peripheral access device is experiencing a venous
spasm. Which report by the client should prompt the nurse to suspect this condition?
Select one:
a. Redness along the vein
b. Cold feeling in the extremity
c. Sharp pain extending from the site of infusion
d. Increased temperature at the peripheral infusion site - Answer-c. Sharp pain
extending from the site of infusion
Redness=phlebitis
Cold feeling= cold infusate or infiltration
Increased temperature=phlebitis
A physician's assistant orders two medications for a client and instructs a nurse to
administer the medications together. The nurse questions the order because
incompatibilities can occur when two drugs are compounded. These incompatibilities
may include:
Select one:
a. intermittent, physical, and biotransformation incompatibilities
