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Chapter 18: Intravenous Therapy

MULTIPLE CHOICE

1. In an assessment of a patient who has been receiving IV fluids for the last 6 hours, the nurse finds that the pulse is now bounding, the blood pressure is more than 15 mm Hg higher than the last reading, and there is pedal edema. The nurse evaluates these signs as associated with:
1. infiltration of the IV site.
2. vascular fluid volume excess.
3. pulmonary air embolism.
4. phlebitis of the leg veins.

ANS: 2
Excess fluid volume accounts for the changes in the vital signs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 287
OBJ: 5 TOP: Increased Vascular Fluid Volume
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. As part of a written standard protocol for the unit, the nurse adds that irrigation of an occluded cannula is not recommended. The rationale against performing this procedure is that it may:
1. damage a venous valve.
2. introduce an air embolus into the line.
3. cause the patient pain.
4. force blood clots into the main bloodstream.

ANS: 4
A cannula may be occluded because a clot has formed against the end of the shaft. By irrigating it, the clot is forced into the bloodstream.

PTS: 1 DIF: Cognitive Level: Comprehension
REF: 286, Nursing Care Plan OBJ: 2
TOP: Irrigating an Occluded Cannula KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

3. The nurse is assisting to prepare a nursing care plan for a patient with continuous IVs. The goal of IV therapy is to:
1. promote and maintain fluid and electrolyte balance.
2. promote drug blood levels when the patient is able to take liquid medication by mouth.
3. promote oxygen and carbon dioxide homeostasis.
4. balance plasma acidity levels.

ANS: 1
Patients who require IV fluids are those who cannot receive sufficient fluids to regain or maintain certain fluid and electrolyte balances.

PTS: 1 DIF: Cognitive Level: Application REF: 277
OBJ: 6 TOP: IV Care Plan
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

4. In making out the assignment for the evening shift, the LPN charge nurse is careful to assign IV rounds to be performed:
1. every 15 minutes.
2. every 30 minutes.
3. every 60 minutes.
4. twice per shift.

ANS: 3
IV checks every hour, made by a nurse, ensure maintenance of a proper rate, infusion condition, and complication detection.

PTS: 1 DIF: Cognitive Level: Application REF: 282
OBJ: 6 TOP: Time Checks for IV Infusions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

5. Using an IV infusion system that delivers 60 drops/mL, the nurse hangs a 1000-mL bag of D5W, which the physician has ordered to infuse at 80 mL/hr. It is now 10 AM. The nurse anticipates that the IV will need to be changed at:
1. 6 PM.
2. 8 PM.
3. 8:30 PM.
4. 10:30 PM.

ANS: 4
1000 mL (whole volume)/80 mL (volume infused per hour) = 12.5 hours. 10:00 AM + 12.5 hours = 10:30 PM.

PTS: 1 DIF: Cognitive Level: Application REF: 284
OBJ: 5 TOP: IV Rate and Times
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

6. Using an IV infusion system that delivers 60 drops/mL, the nurse hangs a 500-mL bag of NS at 8 AM. The physician has ordered a rate of 20 mL/hr. The nurse will set the roller clamp to deliver:
1. 10 gtts/minute.
2. 20 gtts/minute.
3. 25 gtts/minute.
4. 30 gtts/minute.

ANS: 2
20 mL (amount to be infused in 1 hour)  60 gtts = 1200 gtts per hour. 1200 gtts/60 minutes in 1 hour = 20 gtts per minute. This roller clamp is an old method to determine rates, but in the case of nonavailability of electronic delivery devices, it is a good thing to know.

PTS: 1 DIF: Cognitive Level: Application REF: 283
OBJ: 4 TOP: IV Calculations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

7. The physician orders a hypertonic IV for an extremely edematous patient. The nurse anticipates that the IV preparation will be:
1. D5W in normal saline.
2. lactated Ringer’s solution.
3. D5W in 0.25 normal saline.
4. 10% glucose in water.

ANS: 4
D5W in 0.25 normal saline is hypotonic. D5W in normal saline and lactated Ringer’s are isotonic; 10% glucose is hypertonic.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 278
OBJ: 2 TOP: IV Tonicity KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity

8. The nurse explains that caloric sources in IVs come from:
1. electrolytes.
2. dextrose.
3. vitamins.
4. water.

ANS: 1
Dextrose is sugar and the source of calories.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 278
OBJ: 2 TOP: Calories in IVs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

9. The nurse is checking IV sites carefully for signs of infiltration, which are:
1. burning sensation, pain, and puffy site.
2. pain, heat, and puffy site.
3. burning sensation and no feeling at the site.
4. red streak up the arm.

ANS: 1
IV fluid in the immediate tissues causes pain and swelling of the adjacent tissues.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 287
OBJ: 5 TOP: IV Infiltration
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10. The 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. The nurse should set the electronic infusion pump to deliver how many mL/hour?
1. 125
2. 100
3. 85
4. 42

ANS: 1
Whole volume (1000 mL) divided by number of hours (8) = 125 mL/hour. Volume per hour (125 mL)  8 hours = 1000 mL.

PTS: 1 DIF: Cognitive Level: Application REF: 283
OBJ: 4 TOP: IV Calculations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

11. The nurse assesses an area where an IV had been changed recently. The area has redness, swelling, and warmth, which are characteristics of:
1. infiltration and air embolus.
2. inflammation and possible phlebitis.
3. blood loss and hemorrhage.
4. embolus from the former catheter.

ANS: 2
IV sites may show signs of inflammation and/or infection after the IV has been removed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 287
OBJ: 5 TOP: Infection and Inflammation in Previous IV Site
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment

12. The 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 on it. The nurse is to give an IV drug through the central line. The nurse would initially:
1. use any of the three ports for delivery.
2. change the occlusive dressing.
3. affirm catheter placement by withdrawing 3 mL of blood.
4. check dilution of the drug.

ANS: 4
Checking the drug for proper dilution is essential. The dressing is not due to be changed. Drawing 3 mL of blood for site placement is excessive. Only two of the ports, which are color-coded, are to be used for drug, fluid, or blood administration.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279
OBJ: 3 TOP: IV Medication Through Central Line
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

13. The nurse is choosing an IV cannula for an older adult patient and will choose the smallest size that will deliver the appropriate fluid, which is a cannula of:
1. 12 gauge.
2. 14 gauge.
3. 18 gauge.
4. 22 gauge.

ANS: 4
The inside diameter, called the gauge, is expressed in reverse numerical order.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 278
OBJ: 6 TOP: IV Needle Sizes
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance

14. The nurse charts signs of infected phlebitis as:
1. rupture of the cannula with a lump under the skin.
2. pale, cool skin with swelling at the puncture site.
3. firm, cool, raised, painful area at the puncture site; oozing; and purulent drainage
4. puncture site red, warm, with an oozing drainage.

ANS: 4
Infection causes redness, warmth, and drainage from the IV site. Red streaks following the path of the vein may be visible.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 287
OBJ: 5 TOP: Phlebitis Signs
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

15. When removing a central catheter, the nurse would instruct the patient to:
1. lean forward and cough.
2. take a deep breath and bear down.
3. breathe deeply through the mouth.
4. lie on the right side.

ANS: 2
The patient is instructed to take a breath and bear down to prevent air from entering the bloodstream as the catheter is removed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 288
OBJ: 3 TOP: Removal of Central Line
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

16. An older adult patient is assessed by the nurse as showing signs of fluid volume excess, which are:
1. redness, warmth, and drainage of fluid at the IV site.
2. redness, warmth, and tenderness at the IV site.
3. complaints of shortness of breath and pounding pulse.
4. puffiness of face, dyspnea, and pain at the IV site.

ANS: 3
Fluid volume excess in the circulating volume can overload the heart’s ability to handle the excess blood. The excess fluid can leak into the pulmonary tree, causing shortness of breath and rales.

PTS: 1 DIF: Cognitive Level: Application REF: 287
OBJ: 5 TOP: Fluid Volume Excess
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

17. To select a vein for an initial IV site, the best place to begin in a left-handed patient would be the:
1. antecubital vein of the right arm.
2. antecubital vein of the left arm.
3. forearm of the right arm.
4. forearm of the left arm.

ANS: 3
Unless there are other identified reasons, IVs should be started in the most distal portion of the nondominant arm or hand.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 281
OBJ: 6 TOP: Beginning an IV
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

18. As the LPN is replacing a container of fluids for a patient who is receiving total parenteral nutrition, he calculates that at the present rate of infusion, the IV solution will be hanging for 24 hours. The nurse should:
1. hang the fluids and chart the time.
2. increase the flow rate of the parenteral solution.
3. report to the RN so that the order can be clarified.
4. hang an isotonic fluid in its place until the MD can be notified.

ANS: 1
Hanging IV containers may be left in place for up to 24 hours safely. There is no need to notify the RN or MD, or to hang a nonprescribed fluid.

PTS: 1 DIF: Cognitive Level: Analysis REF: 283
OBJ: 6 TOP: IV Infusion: Total Parenteral Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

19. An IV that is labeled 0.9% sodium chloride is considered:
1. concentrated.
2. hypotonic.
3. hypertonic.
4. isotonic.

ANS: 4
Isotonic means of the same electrolyte concentration as the blood.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 278
OBJ: 6 TOP: Tonicity of IV Fluids
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

20. The patient is to receive ampicillin (an antibiotic) IV “piggy back” in 100 mL of fluid every 8 hours. The main IV of D5W is running at 80 mL/hour and is on time. It is the nurse’s responsibility to calculate the total 24-hour intake. At the end of the 24-hour shift, how much IV intake will the nurse chart that the patient has received?
1. 300 mL
2. 800 mL
3. 1920 mL
4. 2220 mL

ANS: 4
80 mL/hour  24 hours = 1920 mL. 100 mL  3 = 300 mL. Therefore, 1920 mL + 300 mL = 2220 mL in 24 hours.

PTS: 1 DIF: Cognitive Level: Application REF: 283
OBJ: 5, 6 TOP: IV Calculation for 24 Hours
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

21. The patient with a subclavian line complains of shortness of breath after an infusion. The patient is diaphoretic and the blood pressure is 168/100, higher than a previous reading of 140/86. The nurse assesses these symptoms as an indication of:
1. fluid overload from too rapid an infusion.
2. incorrect dilution of the infused drug.
3. infection from faulty aseptic technique.
4. embolus from introduced air or blood clot.

ANS: 4
Air can be introduced into the subclavian line from any of the ports that are left unclamped. The symptoms have occurred too quickly for an overload or infection.

PTS: 1 DIF: Cognitive Level: Analysis REF: 288
OBJ: 6 TOP: Embolus KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity

22. The patient has suffered an air embolus. The quick-thinking nurse immediately:
1. turns the patient to the left side and lowers the head of the bed.
2. calls the Code Team.
3. gives O2 at 100% in a nonrebreathing mask.
4. notifies the charge nurse.

ANS: 1
Lowering the head of the bed and turning the patient to the left side traps the air in the left atrium where it can be more readily circulated into the circulating volume and reabsorbed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 288
OBJ: 6 TOP: Air Embolus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

23. The older adult patient is quite ill and confused and begins to cry pitifully when the nurse approaches the bed to start an IV. The best action for the nurse at this point would be to:
1. keep the infusion equipment out of sight as much as possible, talk slowly, and divert the patient.
2. inform the patient that the doctor has ordered the IV and calmly continue to prepare the site and start the IV.
3. give an analgesic as ordered, wait a few minutes, and then proceed.
4. restrain the patient’s arm to a padded arm board and proceed as directed.

ANS: 1
Confusion during a bout of illness in older adults is common. Distraction usually gains compliance. Medication and/or restraints are not indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 285
OBJ: 6 TOP: IVs and Older Adult Patients
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity

24. When discontinuing an IV, the nurse will:
1. remove the dressing, remove the catheter, dispose of the used equipment in the “sharps” container, and chart observations and actions.
2. observe the site for redness, swelling, and pain and put on sterile gloves. Remove the dressing catheter and chart findings and action.
3. 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 findings and action.
4. observe the site for redness, swelling, and pain and put on clean gloves. Remove the dressing and catheter; chart findings and action.

ANS: 3
This is not a sterile procedure. Clean gloves protect the nurse from the body fluids. Placement of a small 2  2 dressing keeps the area clean until the insertion site closes.

PTS: 1 DIF: Cognitive Level: Application REF: 284
OBJ: 6 TOP: Discontinuing an IV
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

25. The nurse transcribing orders should clarify the order of:
1. potassium chloride, 80 mEq in 1000 mL D5W in 24 hours.
2. potassium chloride, 40 mEq IV in 10 mL D5W IV push.
3. potassium chloride, 50 mEq in 500 mL D5W in 4 hours.
4. potassium chloride, 80 mEq in 1000 mL D5W in 12 hours.

ANS: 2
Potassium chloride is never given by IV push in such a small amount of diluent. KCl is always dissolved in D5W and should be infused at no more than 10 mEq/hour.

PTS: 1 DIF: Cognitive Level: Analysis REF: 283
OBJ: 6 TOP: IV Potassium
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse explains to the patient that in the event of an accidental needle stick, the nurse should adhere to hospital policy, the usual directives of which are (select all that apply):
1. Antibiotics are taken if infection present.
2. Blood is drawn from both nurse and patient.
3. Repeat blood draws are performed 4 weeks after the stick.
4. Obtain doctor’s permission to return to work.
5. An incident report is initiated.

ANS: 1, 2, 5
Most policies follow the general guidelines of making an incident report in case of time lost from the injury, blood drawn from both nurse and patient to determine if and what infections may be present, and antibiotic protocol is given to the nurse in the event of infection in the patient. As a rule, there is no need for a doctor’s permission to return to duty or a blood draw in 4 weeks.

PTS: 1 DIF: Cognitive Level: Application REF: 284
OBJ: 3 TOP: Needle Stick KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

COMPLETION

1. The nurse explains to the patient that the peripheral IV tubing administration set and dressing should be changed every ____________________ hours.

ANS: 72

PTS: 1 DIF: Cognitive Level: Knowledge REF: 282, 284
OBJ: 6 TOP: IV Administration Sets Change
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

OTHER

1. The nurse is to give an IV push drug through a peripheral intermittent device. The nurse would (place these options in correct sequence):
1. Clear the device with normal saline.
2. Flush the device with saline only or a combination of saline and heparin.
3. Check placement of the device.
4. Slowly administer the drug through the device.
5. Check the concentration of the drug.

ANS:
5, 3, 1, 4, 2
IV push medication requires careful checking of the appropriate dilution, checking the placement of the device, flushing the device with saline to clear it, slowly injecting the drug, and flushing the device with saline or a combination of saline and heparin.

PTS: 1 DIF: Cognitive Level: Analysis REF: 281
OBJ: 3 TOP: Peripheral Intermittent Device
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

2. When the nurse assesses an infiltration at a peripheral IV site, the nurse should (place these options in correct sequence):
1. Elevate the arm.
2. Apply warm compresses to the area.
3. Restart the infusion.
4. Stop the infusion.
5. Notify the charge nurse.

ANS:
4, 3, 1, 2, 5
The infusion must be stopped to reduce the risk of further infiltration and then restarted to ensure that the adequate dose is received. The affected arm is elevated, warm compresses applied, and the charge nurse notified.

PTS: 1 DIF: Cognitive Level: Analysis REF: 285
OBJ: 5 TOP: Infiltration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity