Chapter 18: Intravenous Therapy
Linton: Introduction to Medical–Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. 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?
a.
Infiltration of the IV site
b.
Vascular fluid volume excess
c.
Pulmonary air embolism
d.
Phlebitis of the leg veins
2. 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?
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.
3. What is a major advantage when medication is administered intravenously?
a.
Better maintained at a therapeutic blood level
b.
Less expensive than oral route
c.
Safer than administering by oral or intramuscular route
d.
Lower incidence of allergy than other routes
4. How often should intravenous (IV) rounds be performed during a nursing shift?
a.
Every 15 minutes
b.
Every 30 minutes
c.
Every 60 minutes
d.
Twice per shift
5. 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?
a.
1800
b.
2000
c.
2030
d.
2230
6. Using an IV infusion system that delivers 60 drops/mL, a nurse hangs a 500-mL bag of
normal saline (NS) at 0800. The physician has ordered a rate of 20 mL/hr. What should the
nurse set the roller clamp to deliver?
a.
10 gtt/min
b.
20 gtt/min
c.
25 gtt/min
d.
30 gtt/min
7. A physician prescribes a hypertonic intravenous line for an extremely edematous patient.
What solution should the nurse anticipate to be prescribed?
a.
D5W in NS
b.
Lactated Ringer solution
c.
D5W in 0.25 NS
d.
10% glucose in water
8. What is the source of calories in IV solutions?
a.
Electrolytes
b.
Dextrose
c.
Vitamins
d.
Water
9. What signs of infiltration should be assessed by a nurse?
a.
Burning sensation, pain, and puffy
b.
Pain, heat, and puffy
c.
Burning sensation and no feeling at the site
d.
Red streak up the arm
10. A physician orders an infusion of 1000 mL of 5% dextrose in 0.45% NS to be completed in 8
hours. The IV delivery system’s drop factor is 20 gtt. How many mL/hr should the nurse set
the electronic infusion pump to deliver the infusion?
a.
125 mL/hr
b.
100 mL/hr
c.
85 mL/hr
d.
42 mL/hr
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?
a.
Infiltration and air embolus
b.
Inflammation and possible phlebitis
c.
Blood loss and hemorrhage
d.
Embolus from the former catheter
12. A nurse has a patient with a tunneled central line with a triple-lumen catheter. 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?
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.
13. 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.
12 gauge
b.
14 gauge
c.
18 gauge
d.
22 gauge
14. A nurse assesses for signs of infected phlebitis. How should the nurse most accurately
describe this complication when documenting?
a.
Rupture of the cannula with a lump under the skin
b.
Pale, cool skin with swelling at the puncture site
c.
Firm, cool, raised, painful area at the puncture site; oozing and purulent drainage
d.
Puncture site red, warm, with an oozing drainage
15. What instruction should a nurse provide to a patient when removing a central catheter?
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.
16. An older adult patient is assessed by a nurse as showing signs of fluid volume excess. What
signs should the nurse assess?
a.
Redness, warmth, and drainage of fluid at the IV site
b.
Redness, warmth, and tenderness at the IV site
c.
Complaints of shortness of breath and pounding pulse
d.
Puffiness of face, dyspnea, and pain at the IV site
17. Where is the best place to begin to select a vein for an initial intravenous (IV) site in a
left-handed patient?
a.
Antecubital vein of the right arm
b.
Antecubital vein of the left arm
c.
Right forearm
d.
Left forearm
18. Where should a nurse inject medication when administering an intravenous (IV) push
medication to a patient who is receiving a continuous infusion?
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
19. An intravenous (IV) administration of doxycycline (Vibramycin) has extravasated. What
nursing action should be implemented after stopping the IV line?
a.
Notify the physician, and restart the IV line in another site.
b.
Restart the IV line at another site and document the extravasation.
c.
Flush NS through cannula at the insertion site.
d.
Discard the IV tubing and the IV bag.
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?
a.
300 mL
b.
800 mL
c.
1920 mL
d.
2220 mL
21. 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.
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
22. A patient has had an air embolus. What should be the immediate action of the quick-thinking
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 nonrebreathing mask
d.
Notifies the charge nurse
23. 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.
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 armboard and proceed as directed.
24. What action should the nurse implement when discontinuing an intravenous (IV) line?
a.
Remove the dressing, remove the catheter, dispose of the used equipment in the
sharps container, and chart observations and actions.
b.
Observe the site for redness, swelling, and pain, and put on sterile gloves. Remove
the dressing catheter and chart the findings and action.
c.
Observe the site for redness, swelling, and pain, and put on clean gloves. Remove
the dressing and catheter, place a 2 2 dressing over the site, and chart the
findings and action.
d.
Observe the site for redness, swelling, and pain and put on clean gloves. Remove
the dressing and catheter; chart the findings and action.
25. Which order should be clarified by a nurse when transcribing orders?
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
MULTIPLE RESPONSE
26. A nurse explains to a patient that, in the event of an accidental needle stick, the nurse should
adhere to hospital policy. What directives should the nurse follow? (Select all that apply.)
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.
COMPLETION
27. A nurse explains to a patient that the peripheral intravenous (IV) tubing administration set and
dressing should be changed every _____ hours.
OTHER
28. What steps should a nurse take when administering an intravenous (IV) push drug through a
peripheral intermittent device? (Separate the letters with a comma and space: A, B, C, D.)
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.
29. What actions should a nurse implement when assessing a peripheral intravenous (IV) line for
an infiltration? (Separate the letters with a comma and space: A, B, C, D.)
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.