Question 1

Which order should be clarified by a nurse when transcribing orders?

Accepted Answer

A)  Potassium chloride, 80 mEq in 1000 mL D5W in 24 hours 
B)  Potassium chloride, 40 mEq IV in 10 mL D5W IV push 
C)  Potassium chloride, 50 mEq in 500 mL D5W in 4 hours 
D)  Potassium chloride, 80 mEq in 1000 mL D5W in 12 hours 
A)  Potassium chloride, 80 mEq in 1000 mL D5W in 24 hours 
B)  Potassium chloride, 40 mEq IV in 10 mL D5W IV push 
C)  Potassium chloride, 50 mEq in 500 mL D5W in 4 hours 
D)  Potassium chloride, 80 mEq in 1000 mL D5W in 12 hours B

Question 2

Using an intravenous (IV)infusion system that delivers 60 drops/L, a nurse hangs a 1000-mL bag of 5% dextrose in water (D5W), which the physician has ordered to infuse at 80 mL/hr.It is now 1000.What time should the nurse anticipate the IV will need to be changed?

Accepted Answer

A)  1800 
B)  2000 
C)  2030 
D)  2230 
A)  1800 
B)  2000 
C)  2030 
D)  2230 D

Question 3

As part of a written standard protocol for the unit, a nurse adds that irrigation of an occluded cannula is not recommended.What is the rationale against performing this procedure?

Accepted Answer

A)  It may damage a venous valve. 
B)  It may introduce an air embolus into the line. 
C)  It may cause the patient pain. 
D)  It may force blood clots into the main bloodstream. 
A)  It may damage a venous valve. 
B)  It may introduce an air embolus into the line. 
C)  It may cause the patient pain. 
D)  It may force blood clots into the main bloodstream. D

Question 4

What steps should a nurse take when administering an intravenous (IV)push drug through a peripheral intermittent device? ______ (Place the events in the appropriate sequence.Do not separate answers with a space or punctuation.Example: ABCD.)

Accepted Answer

A) Clear the device with NS. 
B) Flush the device with NS only or a combination of NS and heparin. 
C) Check placement of the device. 
D) Slowly administer the drug through the device. 
E) Check the concentration of the drug. 
A) Clear the device with NS. 
B) Flush the device with NS only or a combination of NS and heparin. 
C) Check placement of the device. 
D) Slowly administer the drug through the device. 
E) Check the concentration of the drug.

Question 5

What instruction should a nurse provide to a patient when removing a central catheter?

Accepted Answer

A)  Lean forward and cough. 
B)  Take a deep breath and bear down. 
C)  Breathe deeply through the mouth. 
D)  Lie on the right side. 
A)  Lean forward and cough. 
B)  Take a deep breath and bear down. 
C)  Breathe deeply through the mouth. 
D)  Lie on the right side.

Question 6

What actions should a nurse implement when assessing a peripheral intravenous (IV)line for an infiltration? ______ (Place the events in the appropriate sequence.Do not separate answers with a space or punctuation.Example: ABCD.)

Accepted Answer

A) Elevate the arm. 
B) Apply warm compresses to the area. 
C) Restart the infusion at a different site. 
D) Stop the infusion. 
E) Notify the charge nurse. 
A) Elevate the arm. 
B) Apply warm compresses to the area. 
C) Restart the infusion at a different site. 
D) Stop the infusion. 
E) Notify the charge nurse.

Question 7

What is the source of calories in IV solutions?

Accepted Answer

A)  Electrolytes 
B)  Dextrose 
C)  Vitamins 
D)  Water 
A)  Electrolytes 
B)  Dextrose 
C)  Vitamins 
D)  Water

Question 8

A nurse explains to a patient that, in the event of an accidental needlestick, the nurse should adhere to hospital policy.What directives should the nurse follow? (Select all that apply.)

Accepted Answer

A)  Antibiotics are taken if infection is present. 
B)  Blood is drawn from both the nurse and the patient. 
C)  Repeat blood draws are performed 4 weeks after the stick. 
D)  Obtain the physician's permission to return to work. 
E)  An incident report is initiated. 
A)  Antibiotics are taken if infection is present. 
B)  Blood is drawn from both the nurse and the patient. 
C)  Repeat blood draws are performed 4 weeks after the stick. 
D)  Obtain the physician's permission to return to work. 
E)  An incident report is initiated.

Question 9

In an assessment of a patient who has been receiving intravenous (IV)fluids for the past 6 hours, a nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and pedal edema has developed.What should the nurse suspect?

Accepted Answer

A)  Infiltration of the IV site 
B)  Vascular fluid volume excess 
C)  Pulmonary air embolism 
D)  Phlebitis of the leg veins 
A)  Infiltration of the IV site 
B)  Vascular fluid volume excess 
C)  Pulmonary air embolism 
D)  Phlebitis of the leg veins

Question 10

Where is the best place to begin to select a vein for an initial intravenous (IV)site in a left-handed patient?

Accepted Answer

A)  Antecubital vein of the right arm 
B)  Antecubital vein of the left arm 
C)  Right forearm 
D)  Left forearm 
A)  Antecubital vein of the right arm 
B)  Antecubital vein of the left arm 
C)  Right forearm 
D)  Left forearm

Question 11

A nurse assesses an area where an intravenous (IV)line had been recently removed.The area has redness, swelling, and warmth.What should the nurse suspect as the cause?

Accepted Answer

A)  Infiltration and air embolus 
B)  Inflammation and possible phlebitis 
C)  Blood loss and hemorrhage 
D)  Embolus from the former catheter 
A)  Infiltration and air embolus 
B)  Inflammation and possible phlebitis 
C)  Blood loss and hemorrhage 
D)  Embolus from the former catheter

Question 12

A patient has had an air embolus.What should be the immediate action of the quick-thinking nurse?

Accepted Answer

A)  Turns the patient to the left side and lowers the head of the bed 
B)  Calls the "code team" 
C)  Gives oxygen at 100% in a non-rebreathing mask 
D)  Notifies the charge nurse 
A)  Turns the patient to the left side and lowers the head of the bed 
B)  Calls the "code team" 
C)  Gives oxygen at 100% in a non-rebreathing mask 
D)  Notifies the charge nurse

Question 13

A nurse explains to a patient that the peripheral intravenous (IV)tubing administration set and dressing should be changed per ______.

Accepted Answer

The answer of A nurse explains to a patient that...

Question 14

Where should a nurse inject medication when administering an intravenous (IV)push medication to a patient who is receiving a continuous infusion?

Accepted Answer

A)  Into the hanging IV bag 
B)  Directly into the insertion cannula after temporarily disconnecting the IV bag 
C)  Into the port nearest to the insertion site to ensure quick delivery 
D)  Into the port nearest to the IV bag for less painful administration 
A)  Into the hanging IV bag 
B)  Directly into the insertion cannula after temporarily disconnecting the IV bag 
C)  Into the port nearest to the insertion site to ensure quick delivery 
D)  Into the port nearest to the IV bag for less painful administration

Question 15

An older adult patient is quite ill and confused and begins to cry pitifully when a nurse approaches the bed to start an intravenous (IV)line.What is the best action for the nurse at this time?

Accepted Answer

A)  Keep the infusion equipment out of sight as much as possible, talk slowly, and divert the attention of the patient. 
B)  Inform the patient that the physician has ordered the IV and calmly continue to prepare the site and start the IV. 
C)  Give an analgesic as ordered, wait a few minutes, and then proceed. 
D)  Restrain the patient's arm to a padded arm board and proceed as directed. 
A)  Keep the infusion equipment out of sight as much as possible, talk slowly, and divert the attention of the patient. 
B)  Inform the patient that the physician has ordered the IV and calmly continue to prepare the site and start the IV. 
C)  Give an analgesic as ordered, wait a few minutes, and then proceed. 
D)  Restrain the patient's arm to a padded arm board and proceed as directed.

Question 16

A nurse is choosing an intravenous cannula for an older adult patient and will choose the smallest size that will deliver the appropriate fluid.What size cannula is the most appropriate choice?

Accepted Answer

A)  12 gauge 
B)  14 gauge 
C)  18 gauge 
D)  22 gauge 
A)  12 gauge 
B)  14 gauge 
C)  18 gauge 
D)  22 gauge

Question 17

A physician prescribes a hypertonic intravenous line for an extremely edematous patient.What solution should the nurse anticipate to be prescribed?

Accepted Answer

A)  D5W in NS 
B)  Lactated Ringer solution 
C)  D5W in 0.25 NS 
D)  10% glucose in water 
A)  D5W in NS 
B)  Lactated Ringer solution 
C)  D5W in 0.25 NS 
D)  10% glucose in water

Question 18

A patient with a subclavian line complains of shortness of breath after an infusion.The patient is diaphoretic, and the blood pressure is 168/100 mm Hg, higher than a previous reading of 140/86 mm Hg.What should the nurse assess these symptoms as indicating?

Accepted Answer

A)  Fluid overload from too rapid an infusion 
B)  Incorrect dilution of the infused drug 
C)  Infection from faulty aseptic technique 
D)  Embolus from introduced air or blood clot 
A)  Fluid overload from too rapid an infusion 
B)  Incorrect dilution of the infused drug 
C)  Infection from faulty aseptic technique 
D)  Embolus from introduced air or blood clot

Question 19

A nurse has a patient with a central line.The insertion site is covered by an occlusive dressing with yesterday's date.The nurse is to give an intravenous drug through the central line.What should be the initial action of the nurse?

Accepted Answer

A)  Use any of the three ports for delivery. 
B)  Change the occlusive dressing. 
C)  Affirm catheter placement by withdrawing 10 mL of blood. 
D)  Check dilution of the drug. 
A)  Use any of the three ports for delivery. 
B)  Change the occlusive dressing. 
C)  Affirm catheter placement by withdrawing 10 mL of blood. 
D)  Check dilution of the drug.

Question 20

A patient is to receive ampicillin (Unasyn)IV piggyback in 100 mL of fluid every 8 hours.The main intravenous (IV)line of D5W is running at 80 mL/hr and is on time.A nurse's responsibility is to calculate the total 24-hour intake.At the end of the 24-hour shift, how much IV intake should the nurse document that the patient has received?

Accepted Answer

A)  300 mL 
B)  800 mL 
C)  1920 mL 
D)  2220 mL 
A)  300 mL 
B)  800 mL 
C)  1920 mL 
D)  2220 mL

Exam 16: Intravenous Therapy

Which order should be clarified by a nurse when transcribing orders?

Using an intravenous (IV)infusion system that delivers 60 drops/L, a nurse hangs a 1000-mL bag of 5% dextrose in water (D5W), which the physician has ordered to infuse at 80 mL/hr.It is now 1000.What time should the nurse anticipate the IV will need to be changed?

As part of a written standard protocol for the unit, a nurse adds that irrigation of an occluded cannula is not recommended.What is the rationale against performing this procedure?

What steps should a nurse take when administering an intravenous (IV)push drug through a peripheral intermittent device? ______ (Place the events in the appropriate sequence.Do not separate answers with a space or punctuation.Example: ABCD.)

What instruction should a nurse provide to a patient when removing a central catheter?

What actions should a nurse implement when assessing a peripheral intravenous (IV)line for an infiltration? ______ (Place the events in the appropriate sequence.Do not separate answers with a space or punctuation.Example: ABCD.)

What is the source of calories in IV solutions?

A nurse explains to a patient that, in the event of an accidental needlestick, the nurse should adhere to hospital policy.What directives should the nurse follow? (Select all that apply.)

In an assessment of a patient who has been receiving intravenous (IV)fluids for the past 6 hours, a nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and pedal edema has developed.What should the nurse suspect?

Where is the best place to begin to select a vein for an initial intravenous (IV)site in a left-handed patient?

A nurse assesses an area where an intravenous (IV)line had been recently removed.The area has redness, swelling, and warmth.What should the nurse suspect as the cause?

A patient has had an air embolus.What should be the immediate action of the quick-thinking nurse?

A nurse explains to a patient that the peripheral intravenous (IV)tubing administration set and dressing should be changed per ______.

Where should a nurse inject medication when administering an intravenous (IV)push medication to a patient who is receiving a continuous infusion?

An older adult patient is quite ill and confused and begins to cry pitifully when a nurse approaches the bed to start an intravenous (IV)line.What is the best action for the nurse at this time?

A nurse is choosing an intravenous cannula for an older adult patient and will choose the smallest size that will deliver the appropriate fluid.What size cannula is the most appropriate choice?

A physician prescribes a hypertonic intravenous line for an extremely edematous patient.What solution should the nurse anticipate to be prescribed?

A patient with a subclavian line complains of shortness of breath after an infusion.The patient is diaphoretic, and the blood pressure is 168/100 mm Hg, higher than a previous reading of 140/86 mm Hg.What should the nurse assess these symptoms as indicating?

A nurse has a patient with a central line.The insertion site is covered by an occlusive dressing with yesterday's date.The nurse is to give an intravenous drug through the central line.What should be the initial action of the nurse?

Aspects of Medical-Surgical Nursing

Medical-Surgical Practice Settings

Medical-Surgical Patients: Individuals, Families, and Communities

Health, Illness, Stress, and Coping

Immunity, Inflammation, and Infection

Fluid, Electrolyte, and Acidbase Imbalance

The Patient With Cancer

Pain

Shock

The Older Adult Patient

Falls

Immobility

Delirium and Dementia

Incontinence

Nutrition

Surgery

The Patient With an Ostomy

Palliative and Hospice Care

Complementary and Alternative Therapies

Neurologic System Introduction

Neurologic Disorders

Cerebrovascular Accident

Spinal Cord Injury

Respiratory System Introduction

Upper Respiratory Disorders

Acute Lower Respiratory Tract Disorders

Chronic Lower Respiratory Tract Disorders

Hematologic System Introduction

Hematologic Disorders

Immunologic System Introduction

Immunologic Disorders

Cardiovascular System Introduction

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive System Introduction

Upper Digestive Tract Disorders

Lower Digestive Tract Disorders

Liver, Gallbladder, and Pancreatic Disorders

Urologic System Introduction

Urologic Disorders

Musculoskeletal System Introduction

Connective Tissue Disorders

Fractures

Amputations

Endocrine System Introduction

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes and Hypoglycemia

Female Reproductive System Introduction

Female Reproductive Disorders

Male Reproductive System Introduction

Male Reproductive Disorders

Sexually Transmitted Infections

Integumentary System Introduction

Skin Disorders

Special Senses Introduction

Eye and Vision Disorders

Ear and Hearing Disorders

Psychobiological Disorders

Using an intravenous (IV)infusion system that delivers 60 drops/L, a nurse hangs a 1000-mL bag of 5% dextrose in water (D₅W), which the physician has ordered to infuse at 80 mL/hr.It is now 1000.What time should the nurse anticipate the IV will need to be changed?