Chapter 36: Administering Intravenous Solutions and Medications My Nursing Test Banks

Chapter 36: Administering Intravenous Solutions and Medications

Test Bank

MULTIPLE CHOICE

1. The nurse anticipates that the malnourished post-operative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline. because it is:

a.

isotonic.

b.

hypotonic.

c.

hypertonic.

d.

total parenteral nutrition.

ANS: C

5% Dextrose in 0.45% saline is a hypertonic or high molecular solution and is a frequent choice for post-operative maintenance fluid.

DIF: Cognitive Level: Knowledge REF: p. 701, Table 36-1

OBJ: Theory #1 TOP: Types of Intravenous Solutions

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

2. The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a _____ set.

a.

piggyback

b.

primary infusion

c.

controlled-volume

d.

Y administration

ANS: D

A Y administration set is used to place the blood on one side and normal saline on the other. This is necessary so that the blood can be discontinued but the vein can remain open with the saline in the case of a transfusion reaction or other medically necessary situation.

DIF: Cognitive Level: Application REF: p. 728, Skill 36-6

OBJ: Clinical Practice #7 TOP: Administration Sets

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: reduction of risk potential

3. The nurse is aware that as a safety precaution against overhydration, the tubing drip factor set appropriate for a 6-month-old infant is _____ gtt/mL.

a.

60

b.

20

c.

15

d.

10

ANS: A

A microdrip infusion set, which delivers 60 gtt/mL, is used for infants and children.

DIF: Cognitive Level: Comprehension REF: p. 702 OBJ: Theory #3

TOP: Tubing Size KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

4. The nurse evaluating a piggyback IV setup finds an error in the construction of the fluids. Which situation would the nurse correct?

a.

Secondary bag is hung higher than the primary bag.

b.

Primary line clamp is closed.

c.

Slide clamp near the insertion site is open.

d.

Secondary line clamp is open.

ANS: B

When a medication is given via piggyback setup, the secondary bag is hung slightly higher than the primary line and, when the secondary infusion finishes, the primary one takes over again; therefore all clamps (roller and slide) must be open for the setup to work properly.

DIF: Cognitive Level: Application REF: p. 702 OBJ: Clinical Practice #1B

TOP: Secondary or Piggyback Intravenous Set

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: physical care and comfort

5. The nurse assisting in the initiation of a blood transfusion is aware that the only appropriate solution to infuse through a parallel infusion set before and after the transfusion is:

a.

5% dextrose in water.

b.

10% dextrose in water.

c.

lactated Ringers solution.

d.

normal saline.

ANS: D

Normal saline is the only solution used in conjunction with infusion of a blood product.

DIF: Cognitive Level: Comprehension REF: p. 702 OBJ: Clinical Practice #7

TOP: Blood Infusion KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: reduction of risk potential

6. To facilitate the administration of an IV antibiotic every 6 hours to a patient who is ambulatory, well hydrated, and on a regular diet, the nurse would insert a(n):

a.

primary IV line.

b.

secondary IV line.

c.

intermittent infusion device.

d.

central venous line.

ANS: C

Patients who do not require large amounts of fluid but receive intermittent IV medications benefit from an intermittent infusion device.

DIF: Cognitive Level: Application REF: p. 703 OBJ: Theory #1

TOP: Saline or PRN Lock KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: pharmacological therapies

7. A patient is receiving IV fluids through an infusion pump. How often should the nurse check the functioning of the pump?

a.

Every 15 to 30 minutes

b.

Every 1 to 2 hours

c.

Every 2 to 4 hours

d.

Once during the shift

ANS: B

An IV infusion pump should be checked every 1 to 2 hours to ensure that it is functioning properly.

DIF: Cognitive Level: Comprehension REF: p. 703, Box 36-1

OBJ: Clinical Practice #1A TOP: Infusion Pumps

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

8. When a patient receiving IV medication exhibits light-headedness, tightness in the chest, flushed face, and irregular pulse, the nurse suspects:

a.

speed shock.

b.

drug allergy.

c.

fluid overload.

d.

air embolus.

ANS: A

Light-headedness, tightness in the chest, flushed face, and irregular pulse are all signs of speed shock. Speed shock is when a foreign substance is infused into the body rapidly. The infusion should be stopped, the physician notified, and the patient monitored.

DIF: Cognitive Level: Analysis REF: p. 709, Table 36-2

OBJ: Theory #3 TOP: Intravenous Catheters

KEY: Nursing Process Step: Intervention

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

9. A patient is admitted with a peripherally inserted central catheter (PICC). As part of standard care for this patient, the nurse should:

a.

obtain the patients temperature every 2 hours.

b.

prepare to infuse fluids at high volumes.

c.

avoid taking blood pressures on the arm with the PICC line.

d.

have the catheter withdrawn while the patient is hospitalized.

ANS: C

PICC lines are inserted by physicians or specially trained nurses, and they are used for long-term therapy; blood pressures are not taken in the arm that has the PICC line to avoid interfering with the function or the life of the catheter. Many times this catheter is used in home care.

DIF: Cognitive Level: Application REF: p. 706, Clinical Cues

OBJ: Theory #3 TOP: PICC KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

10. A patient has just undergone placement of a central venous catheter through the subclavian vein. When the placement is complete, the nurse should:

a.

hang the prescribed fluid at a rate of 1 mL/min.

b.

assess the quality of the breath sounds.

c.

note the length of the tubing.

d.

wait for the results of the chest radiograph before beginning fluids.

ANS: D

Correct placement of subclavian catheters must be verified by radiographic studies before any fluid is infused through them.

DIF: Cognitive Level: Application REF: p. 707 OBJ: Theory #3

TOP: Central Venous Catheter Placement

KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity: reduction of risk potential

11. The nurse observes that the insertion site of an IV catheter looks pale and puffy and the area feels cool to the touch. The initial action for the nurse should be to:

a.

discontinue the infusion and start a new IV site.

b.

apply warm compresses to the site.

c.

monitor the patients temperature every 4 hours.

d.

call the physician and report these findings.

ANS: A

Infiltration is the most common complication of IV therapy, and it occurs when fluid or medication leaks out of the vein and into the tissue. The infusion should be discontinued immediately and a new insertion site initiated. Signs are pale, cool skin that is edematous (puffy).

DIF: Cognitive Level: Application REF: p. 709, Table 36-2

OBJ: Theory #3 TOP: Infiltration of Intravenous Fluids

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

12. A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing:

a.

bloodstream infection.

b.

catheter embolus.

c.

infiltration of the line.

d.

phlebitis.

ANS: D

Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness.

DIF: Cognitive Level: Comprehension REF: p. 709, Table 36-2

OBJ: Theory #3 TOP: Phlebitis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the _____ the head of the bed.

a.

right side and raise

b.

right side and lower

c.

left side and raise

d.

left side and lower

ANS: D

To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The physician is notified immediately.

DIF: Cognitive Level: Application REF: p. 709, Table 36-2

OBJ: Theory #3 TOP: Catheter Bolus

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

14. The nurse takes into consideration that according to The Joint Commission, the first IV antibiotics order for a community-acquired pneumonia must be administered within _____ hours.

a.

1 to 2

b.

2 to 4

c.

6 to 8

d.

24

ANS: C

The Joint Commission suggests that the first IV antibiotic administered for community-acquired pneumonia be administered in the first 6 to 8 hours after admission.

DIF: Cognitive Level: Comprehension REF: p. 726, Clinical Cues

OBJ: Theory #4 TOP: IV Antibiotics

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: pharmacological therapies

15. A nurse is monitoring the status of an elderly patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses:

a.

crackles in the lung fields.

b.

pulse rate of 64 beats/min, irregular.

c.

respirations of 16 breaths/min, regular.

d.

slight edema to the feet.

ANS: A

Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness of breath.

DIF: Cognitive Level: Analysis REF: p. 709, Table 36-2

OBJ: Theory #5 TOP: Elder Care: IV Therapy

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

16. A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of 100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute should the nurse regulate the infusion?

a.

15

b.

17

c.

25

d.

33

ANS: C

The formula for calculating IV flow rates is as follows: (Amount of solution in mL number of drops/min) / Time in minutes; (100 15) / 60 = 1500 / 60 = 150 / 6 = 25 drops/min.

DIF: Cognitive Level: Analysis REF: p. 710, Box 36-2

OBJ: Clinical Practice #3 TOP: IV Calculations

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

17. A nurse accessing the injection port of the IV tubing will scrub the hub for _____ seconds.

a.

5

b.

10

c.

15

d.

30

ANS: C

The hub of the injection port on a piggyback setup should be scrubbed for 15 seconds.

DIF: Cognitive Level: Application REF: p. 721, Skill 36-3

OBJ: Clinical Practice #1E TOP: IV Guidelines

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

18. A patient is to have an IV insertion site changed. The current line is in the lower right forearm. Which location is contraindicated for the new site?

a.

Right upper forearm

b.

Right hand

c.

Left upper forearm

d.

Left hand

ANS: B

A new IV site should not be placed distal to an old site; the right hand is distal to the right forearm, so it should not be used.

DIF: Cognitive Level: Analysis REF: p. 710 OBJ: Clinical Practice #4

TOP: Changing IV Site KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: reduction of risk potential

19. The nurse would plan to get another nurse to try to obtain a successful venipuncture if the first nurse was not successful in _____ attempt(s).

a.

five

b.

three

c.

two

d.

one

ANS: C

If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask another nurse to perform the task.

DIF: Cognitive Level: Application REF: p. 715, Skill 36-1

OBJ: Clinical Practice #4 TOP: Starting an IV

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. A nurse is aware that for a patient with a continuous IV infusion running, the IV bag should be changed when only ______ mL of solution remains in the bag.

a.

10

b.

25

c.

50

d.

100

ANS: C

When the container has only 50 mL of solution left, the next ordered solution is added to the setup and the flow begun to prevent air from entering the line.

DIF: Cognitive Level: Comprehension REF: p. 716 OBJ: Clinical Practice #5

TOP: Maintaining an IV KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: pharmacological therapies

21. A patient who requires an immediate transfusion of blood has previously signed a consent form to receive it. The nurse confirms that the consent was signed within the last _____ hours.

a.

8

b.

12

c.

24

d.

48 to 72

ANS: D

A consent to receive blood must be signed by the patient, usually no more than 48 to 72 hours before receiving the blood product.

DIF: Cognitive Level: Knowledge REF: p. 727 OBJ: Clinical Practice #7

TOP: Blood Transfusion Consent Form KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

22. A patient complains of chills, back pain, and shortness of breath a few minutes after the blood infusion is started. The first thing the nurse should do is:

a.

slow down the blood infusion.

b.

stop the blood infusion and start the saline.

c.

monitor vital signs and call the physician.

d.

start low-flow oxygen as per facility protocol.

ANS: B

If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or itching, the nurse should stop the infusion and start the saline to keep the line open.

DIF: Cognitive Level: Application REF: p. 729, Skill 36-6

OBJ: Theory #6 TOP: Blood Transfusion Reaction

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

23. The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing action is to:

a.

check the physicians order.

b.

stop the IV flow by clamping the tubing securely.

c.

wash hands and don gloves.

d.

quickly withdraw the cannula and apply pressure.

ANS: A

Checking the physicians order will prevent inadvertently discontinuing the IV and having to restart it.

DIF: Cognitive Level: Application REF: p. 727, Steps 36-4

OBJ: Clinical Practice #6 TOP: Discontinuing an IV

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. The nurse caring for a patient with an intermittent IV device should:

a.

attach continuous fluid infusion to the device.

b.

infuse saline or heparin solution to maintain patency.

c.

discontinue when the IV medication is finished.

d.

reduce patient activity to prevent dislodgement.

ANS: B

The intermittent IV device should be flushed periodically with saline or heparin, depending of facility policy, to maintain patency, which allows more freedom of movement for the patient.

DIF: Cognitive Level: Application REF: p. 723 OBJ: Clinical Practice #1D

TOP: Medication to Intermittent Intravenous Device

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: pharmacological therapies

COMPLETION

25. A patient has an IV of 1000 mL 5% dextrose in -normal saline (0.45% sodium chloride) infusing via microdrip for 12 hours. The IV is infusing _____ gtt/min.

ANS:

83

1000 / 12 = 83.

DIF: Cognitive Level: Analysis REF: p. 710, Box 36-2

OBJ: Clinical Practice #2 TOP: Intravenous Medication Administration

KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity: pharmacological therapies

26. The nurse instills diluted medication in the portion of the controlled volume IV setup, which is called the ___________.

ANS:

burette

The burette is the tube-like chamber that holds only about 150 mL of fluid with diluted medication.

DIF: Cognitive Level: Knowledge REF: p. 724 OBJ: Theory #1

TOP: Burette KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

27. After the blood infusion has started, the nurse should let the blood flow at 2 mL/min for the first ___________ minutes.

ANS:

15

fifteen

The initial rate of blood infusion is 2 mL/min for the first 15 minutes. If the patient tolerates this rate, it can be gradually increased.

DIF: Cognitive Level: Comprehension REF: p. 729, Skill 36-6

OBJ: Clinical Practice #7 TOP: Monitoring Blood

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

MULTIPLE RESPONSE

28. The physician orders an IV of 5% dextrose in normal saline (0.45% sodium chloride) to infuse over a 10-hour period. Which of the following actions should the nurse take? (Select all that apply.)

a.

Monitor intake and output (I&O) every shift.

b.

Monitor weight daily.

c.

Flush with heparin solution intermittently.

d.

Monitor lung sounds every 4 hours.

e.

Monitor IV site for infiltration.

f.

Monitor blood sugar levels.

ANS: A, D, E

To monitor fluid overload, it is important to assess lung sounds and I&O. Monitoring the IV site for infiltration or phlebitis is also critical.

DIF: Cognitive Level: Application REF: p. 711, Box 36-3

OBJ: Theory #3 TOP: IV Nursing Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

29. The nurse is aware that the disadvantages of infusion pumps include: (Select all that apply.)

a.

a saline lock is required.

b.

infusion pump change-out every shift.

c.

the initial expense of machines.

d.

an alarm that can be deactivated by family.

e.

the need for special administration sets.

ANS: C, D, E

Infusion pumps have some disadvantages such as their initial expense, the need for special administration sets, and the fact that the alarm button sounds when the IV container is empty, when there is air in the line, and when there is an occlusion.

DIF: Cognitive Level: Comprehension REF: p. 704 OBJ: Theory #3

TOP: Topic: Infusion Pumps KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: reduction of risk

30. Signs that would cause the nurse to discontinue a blood transfusion would include: (Select all that apply.)

a.

hives.

b.

facial flushing.

c.

nosebleed.

d.

back pain.

e.

bloody colored urine.

ANS: A, B, D

Symptoms such as hives, facial flushing, back pain, itching, chills, apprehension, and fever are the most common reactions. Many times the physician will order Benadryl for the itching or hives and allow the blood to run.

DIF: Cognitive Level: Comprehension REF: p. 727 OBJ: Theory #6

TOP: Blood Reaction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: reduction of risk

OTHER

31. Place the steps in order for the preparation to initiate a blood line: (Separate letters by a comma and space as follows: A, B, C, D, E.)

A. Compare patient name, ID number on wrist bank with transfusion record.

B. Obtain Y-connector setup and saline and prime the filter with saline.

C. Clamp off saline and start blood.

D. Confirm the presence of a permission slip.

E. Obtain baseline vital signs.

ANS:

D, A, B, E, C

All permission slips and then identification must be accomplished prior to starting blood. The blood information is checked with two licensed persons. The filter is primed and the saline is started; vital signs are taken and then the blood is started.

DIF: Cognitive Level: Application REF: p. 728, Steps 36-6

OBJ: Theory #1 TOP: Preparation of Transfusion

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

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