Chapter 12: Parenteral Administration: Intravenous Route My Nursing Test Banks

Chapter 12: Parenteral Administration: Intravenous Route

Test Bank

MULTIPLE CHOICE

1. A patient is diagnosed with cancer and requires 6 months of chemotherapy infusions. Which type of intravenous (IV) access device will likely be used?

a.

Peripheral venous access device

b.

Midline catheter

c.

Winged needle venous access device

d.

Implantable venous infusion port

ANS: D

Implantable venous infusion ports are placed into central veins for long term therapy. Chemotherapy treatment is often irritating and best tolerated in the larger central veins. Peripheral lines are not used for administration of chemotherapy because of the risk of extravasation. A midline catheter is intended only for a 2 to 4 week interval, less than the projected length of time for chemotherapy infusion. Winged needles are for use in peripheral veins that are too small for ongoing infusion of chemotherapy.

DIF: Cognitive Level: Application REF: p. 172 | p. 174

OBJ: 5 TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The nurse notes that a patient with cardiac disease has IV heparin infusing and that it is behind by 2 hours. What is the best nursing action?

a.

Increase the IV rate and recheck in 1 hour.

b.

Change the infusion rate to TKO.

c.

Discontinue the solution using aseptic technique.

d.

Contact the health care provider for consultation.

ANS: D

The patient has a history of cardiac problems and is receiving a critical care medication, IV heparin. In this case, contacting the patients health care provider would be appropriate to avoid harm. Increasing the infusion rate might place the patient into fluid overload and might infuse too much heparin in a short time. Reducing the infusion rate to TKO or discontinuing the solution would put the schedule even further behind.

DIF: Cognitive Level: Application REF: p. 180 OBJ: 8

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

3. What is the composition of hypotonic intravenous solutions such as 0.45% NaCl?

a.

Fewer dissolved particles than blood

b.

Approximately the same number of dissolved particles as blood

c.

Higher concentrations of dissolved particles than blood

d.

Electrolytes and dextrose

ANS: A

Hypotonic solutions have fewer dissolved particles than blood. Half normal saline does not contain dextrose.

DIF: Cognitive Level: Knowledge REF: p. 176 OBJ: 4

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Which condition would the nurse expect to be treated with an isotonic solution?

a.

Fluid overload

b.

Hemorrhagic shock

c.

Cellular dehydration

d.

Cerebral edema

ANS: B

Isotonic solutions have approximately the same osmolality as blood. Isotonic fluids are ideal replacement fluids for patients experiencing an intravascular fluid deficit that occurs in conditions such as acute blood loss from hemorrhage and gastrointestinal bleeding. Isotonic fluids increase vascular volume, thus counteracting hypovolemia and hypotension. Administering isotonic solutions for fluid overload would exacerbate the problem. Hypotonic solutions are administered for cellular dehydration. Hypertonic solutions are administered for cerebral edema.

DIF: Cognitive Level: Application REF: p. 176 OBJ: 4

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

5. The nurse determines that an elderly patients IV of D50.2NS with 20 mEq KCl at 75 mL/hr is running 3 hours behind. After determining the IV site is patent, what action will the nurse take?

a.

Call the health care provider to obtain an order to decrease the IV rate.

b.

Administer a bolus to make up the deficit.

c.

Recalculate the flow rate and slowly make up the fluids.

d.

Maintain the ordered rate.

ANS: D

The safest action is to maintain the ordered rate. The health care provider should be consulted if the patient has not received critical IV replacement therapy. Increasing an IV rate without a health care providers order can be detrimental for patients who have cardiac, renal, or circulatory impairment. Normal aging process results in decreased cardiac, renal, circulatory function. The rate ordered is the one the provider intended for the administration of fluids; changing it to fit the prevailing situation is not appropriate. The bolus technique should only be used for the administration of medications or fluid challenges in patients who need a volume of IV fluid quickly. The flow rate must be consistent with the providers order.

DIF: Cognitive Level: Application REF: p. 169 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

6. Which technique by the nurse accurately maintains asepsis of a peripheral IV access device?

a.

Wear gloves when hanging all IV solutions.

b.

Apply a topical antibiotic ointment to the insertion site.

c.

Change fluid administration sets according to institutional policy.

d.

Flush with heparin before use.

ANS: C

Generally all IV solution bag and bottles should be changed every 24 hours to minimize the development of new infections. IV administration sets used to deliver blood and blood products are changed after each unit is administered. Administration sets to deliver lipids and TPN are often changed every 4 hours, whereas administration sets for maintenance fluids may be changed every 72 hours. It is important to follow institutional policies. All IV bags, bottles, and administration sets should be labeled with the date, time, and nurses initials of the set change. Wearing gloves is not required for maintenance of routine infusion. Topical antibiotics may promote fungal infections and antimicrobial resistance. A peripheral line that is infusing should not need an anticoagulant to maintain patency.

DIF: Cognitive Level: Application REF: p. 179 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

7. Which needle is used to access implanted infusion devices?

a.

Jamshidi

b.

Huber

c.

Gigli

d.

Crutchfield

ANS: B

The Huber needle is a special noncoring 90-degree needle used to penetrate the skin and septum of the implanted device. The Jamshidi needle is used for biopsy purposes such as bone marrow. The Gigli saw is a wire with serrations used to cut through cranial bone. Crutchfield tongs are used to stabilize the cervical spine by traction in cases of fracture.

DIF: Cognitive Level: Comprehension REF: p. 174 OBJ: 6

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. The nurse assesses erythema, warmth, and burning pain along the patients IV site. Which complication is this patient most likely experiencing?

a.

Air embolism

b.

Extravasation

c.

Phlebitis

d.

Pulmonary edema

ANS: C

Erythema, warmth, and tenderness along the course of the vein and swelling are signs of phlebitis. Air embolism occurs as a result of an air bubble entering the vascular system, and shortness of breath, chest pain, and hypotension are indicative of this complication. Extravasation is the leakage of an irritant and is accompanied by redness, warmth or coolness, swelling, and a dull ache to severe pain at the venipuncture site. Pulmonary edema is caused by fluid infusing too rapidly; dyspnea, cough, anxiety, rales, and possible cardiac dysrhythmias are indicative of pulmonary edema.

DIF: Cognitive Level: Comprehension REF: p. 196 OBJ: 9

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

9. An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea. The nurse notes shallow rapid respirations and a cough that produces frothy sputum. Which is the priority nursing action?

a.

Assess the urine output.

b.

Elevate the head of the bed.

c.

Encourage the patient to cough.

d.

Maintain the IV rate.

ANS: B

Elevating the head of the bed is an appropriate action for signs and symptoms of pulmonary edema. Urine output is important to assess, but it is not the priority nursing action. Encouraging the patient to cough and take deep breaths is not the priority nursing action. The IV rate should be slowed immediately based on the signs and symptoms the patient is displaying.

DIF: Cognitive Level: Application REF: p. 198 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

10. A diabetic patient requires the administration of insulin continuously at home. Which system would most likely be used in this instance?

a.

Central line catheter

b.

Microdrip set

c.

Piggyback system

d.

Syringe pump

ANS: D

Syringe pumps are used in patients with diabetes. A central line is not appropriate for the diabetic patient requiring insulin. A microdrip set is a type of IV tubing that is used when small volumes of fluid are given to patients with fluid volume concerns. A piggyback system is a type of administration set that connects to a primary setup and administers a small volume over 20 to 60 minutes.

DIF: Cognitive Level: Application REF: pp. 171-172 OBJ: 3

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

11. A patient is admitted with hypovolemia resulting from lack of fluid intake and requires an infusion of isotonic fluids. Which IV solution will the nurse administer?

a.

D50.2 NS

b.

D5W

c.

0.45 NS

d.

0.9 NS

ANS: D

0.9 NS is an isotonic solution appropriate for hypovolemia. D50.2 NS, D5W, and 0.45 NS are hypotonic solutions.

DIF: Cognitive Level: Comprehension REF: p. 176 OBJ: 4

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

12. Which potential complication will the nurse expect in patients with a venous access device?

a.

Circulatory overload

b.

Extravasation

c.

Infection

d.

Pain

ANS: C

Because venipuncture alters skin integrity, the patient is vulnerable to infection at all times. Circulatory overload is a concern but does not occur with any type of venous access device because the device may just be used for administration of small volumes of drugs (e.g., chemotherapy in cancer patients). Extravasation is a potential complication when there is infusion of an irritating chemical. IV drug administration is usually more comfortable for patients than other routes, and pain would not be considered a complication.

DIF: Cognitive Level: Application REF: p. 197 OBJ: 9

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

13. A patient has a peripherally inserted central catheter (PICC) line inserted to continue IV antibiotic therapy at home. With proper care, how long can this type of venous access device remain in place?

a.

2 months

b.

4 months

c.

6 months

d.

12 months

ANS: D

PICC lines routinely remain in place for 1 to 3 months, but can last for a year or more if cared for properly.

DIF: Cognitive Level: Knowledge REF: p. 173 OBJ: 3

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

14. In assessing a patient with a central venous access device, which sign or symptom indicates that the patient is experiencing an air embolism?

a.

Chest pain

b.

Erythema

c.

Frothy sputum

d.

Sweating

ANS: A

Chest pain is a symptom associated with air embolism. Erythema occurs with infiltration or extravasation. Frothy sputum occurs with circulatory overload or pulmonary edema. Sweating is indicative of a pulmonary embolism.

DIF: Cognitive Level: Application REF: p. 198 OBJ: 9

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. Following the insertion of a central venous access device, the nurse notes a weak, thready pulse and decreased blood pressure. The patient complains of shortness of breath and palpitations. Which action will the nurse take first?

a.

Place the patient on the left side.

b.

Reassess vital signs.

c.

Stop the infusion.

d.

Verify placement of the device.

ANS: A

Signs and symptoms indicate an air embolism. The nurses immediate action will be to place the patient onto his or her left side. The nurse has determined change in pulse and blood pressure already, and although it is appropriate to reassess, it is not the first action the nurse will take. There is no indication that anything is infusing into this venous access device. Verifying the placement of the device is not the first action the nurse would take.

DIF: Cognitive Level: Application REF: p. 198 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

16. The nurse is about to administer a prescribed medication IV push into a patients Hickman catheter. When providing this medication, the nurse will first:

a.

administer the prescribed drug.

b.

flush with saline.

c.

flush with heparin.

d.

prepare a pump.

ANS: B

Drugs given by IV push or bolus through a Hickman catheter generally follow the SASH guideline: saline flush first; administer the prescribed drug; saline flush following the drug; heparin flush line. A pump is not used when a drug is administered by push technique.

DIF: Cognitive Level: Application REF: p. 179 OBJ: 6 | 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment; Physiological Integrity

17. A 90 year old woman is admitted to an acute care facility with the diagnosis of pneumonia. She has a past medical history of diabetes mellitus, hypertension, and right sided mastectomy. When starting an IV for infusion of antibiotic therapy, the nurse will:

a.

insert the IV catheter into the left hand.

b.

use a lower extremity vein for insertion.

c.

choose the left radial artery for insertion.

d.

attempt insertion into the left antecubital space vein.

ANS: D

IV insertion should not be initiated in an arm with compromised lymphatic or venous flow such as a mastectomy. The left antecubital space vein would be a good choice for this patient given her age and medical history. In the older adult, using the veins in the hand area may be a poor choice because of the fragility of the skin and veins in this area. When possible, the veins of the lower extremities should be avoided for IV insertion because of the danger of developing thrombi and emboli. IV therapy should never be started in an artery.

DIF: Cognitive Level: Application REF: p. 180 OBJ: 6

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe, Effective Care Environment

MULTIPLE RESPONSE

18. What will the nurse explain when teaching a patient about a PICC line? (Select all that apply.)

a.

The catheter may have a single or double lumen.

b.

There is greater risk of clotting and infiltration with this type of catheter.

c.

The patient will be receiving infusions continuously to ensure patency.

d.

The tip of the catheter may be open or valved.

e.

The catheter may be used for drawing blood.

ANS: A, D

PICC lines may have more than one lumen. The catheter may have an open tip or a valved (Groshong) tip. The risk of infiltration and clotting is less than with other types of central lines. The line should be flushed with a saline heparin solution after every use, or daily, in order to maintain patency if it is not in continuous use. PICC lines are not appropriate for blood drawing because of their small size.

DIF: Cognitive Level: Comprehension REF: p. 173 OBJ: 3

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

19. Which patient assessment finding(s) suggest(s) extravasation of an IV solution? (Select all that apply.)

a.

Coolness

b.

Edema

c.

Fever

d.

Pain at venipuncture site

e.

Redness at the site

f.

Shortness of breath

ANS: A, B, D, E

Coolness, edema, pain, and redness are indicative of extravasation. Fever does not indicate extravasation. Shortness of breath does not indicate extravasation.

DIF: Cognitive Level: Comprehension REF: p. 197 OBJ: 9

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

20. The nurse assesses a patients right hand IV site to be infiltrated. Appropriate nursing actions include: (Select all that apply.)

a.

stopping the infusion.

b.

attempting to aspirate the medication.

c.

elevating the affected limb.

d.

checking capillary refill.

e.

removing the catheter as directed by policy.

ANS: A, C, D, E

For an infiltration, stop the infusion. Elevate the affected limb. Assess for circulatory compromise; check capillary refill and pulses proximal and distal to the area of infiltration. If the infiltration is caused by an IV solution, remove the catheter as directed by policy. For extravasation, attempts may be made to aspirate the medication.

DIF: Cognitive Level: Analysis REF: p. 198 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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