Chapter 38: Intravenous Therapy
Multiple Choice
Identify the choice that best completes the statement or answers the question.
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____
1. The nurse is providing IV push meperidine (Demerol) through a free-flowing IV line and notes a hazy
appearance in the tubing. It is necessary to:
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1. Stop the infusion.
2. Discontinue the IV site.
3. Put all doses of meperidine on hold.
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4. Notify the supervisor.
____
2. The nurse is providing care for a client who is receiving a blood transfusion. Pre-transfusion vital signs were
blood pressure (BP), 144/78 mm Hg; temperature (T), 98.4°F; pulse (P), 86; respirations (R), 14. Now,
approximately an hour after the transfusion was initiated, the client’s
vital signs are BP, 168/92 mm Hg; P,
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98; R, 20. Next, the nurse should:
1. Record the vital signs.
2. Listen to the client’s breath sounds.
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3. Notify the physician.
4. Slow the transfusion rate.
____
3. A nurse could correctly provide which of the following via IV therapy as part of a maintenance fluid?
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1. Medication
2. Water
3. Plasma
4. Blood transfusion
____
4. The nurse is caring for a client with an IV. The client begins to have redness and swelling at the IV site. The
client also complains of burning and tenderness at the IV site. Which does the nurse suspect?
1. Hypovolemia
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2. Phlebitis
3. Extravasation
4. Infiltration
____
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5. The health-care provider orders that a client who is dehydrated receive
lactated ringer’s solution (LR). Which
statement made by the nurse indicates an understanding of safety items to consider?
1. “This is the most similar to electrolyte content.”
2. “I should check to see if the client is allergic to corn.”
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3. “This can irritate the client’s vein, so it should be infused in small
amounts.”
4. “I should confirm what other medications the client is on.”
____
6. The nurse who is caring for a client with an infusion of D5 1/2NS 1,000 mL with 20 mEq KCL at 100 mL/hr
notes that there is slight swelling at the insertion site and no blood abirb.com/test
return when aspirating at the injection port
closest to the IV site. Which of the following problems does the nurse suspect?
1. Air embolism
2. Fluid overload
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3. Infiltration
4. Thrombophlebitis
____
7. The nurse is providing care for a client who has a central line and a suspected air embolism. The best action
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by the nurse is to:
1. Elevate the head of the bed.
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Copyright © 2019 F. A. Davis Company
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2. Place telemetry leads on the client’s chest.
3. Instruct the client to bear down.
4. Place the client on her left side in Trendelenburg position.
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____
8. The nurse assumes responsibility for a blood transfusion that was initiated 2.5 hours ago. The client is
tolerating the procedure well, and there is roughly 50% of the blood remaining. The best action by the nurse is
to:
1. Increase the transfusion rate.
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2. Stop the infusion and return the unused blood to the blood bank.
3. Chart the current vital signs.
4. Notify the charge nurse.
____
9. A nurse knows that a client who needs an IV to provide simple water replacement because of lack of fluid
intake should be given which of the following?
1. An isotonic solution
2. A hypertonic solution
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3. A hypotonic solution
4. Plain water
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Multiple Response
Identify one or more choices that best complete the statement or answer the question.
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____ 10. The nurse who is working on a medical-surgical floor recognizes that
vesicant precautions should be taken
with which of the following? Select all that apply.
1. Ampicillin sodium (ampicillin)
2. Potassium chloride
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3. Promethazine (Phenergan)
4. Vancomycin (Vancocin)
5. Gentamicin sulfate (gentamicin)
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____ 11. The nurse is providing care to a client who is receiving a blood transfusion
and who becomes acutely short of
breath and anxious within a few minutes of the nurse’s initiating the transfusion. Which of the following
actions will be included in the nurse’s care? Select all that apply.
1. Frequent checks of the vital signs
2. Stopping the blood transfusion and notifying the physician abirb.com/test
3. Sending tubing and unused blood to the blood bank
4. Obtaining a urine sample for analysis
5. Discontinuing the IV site
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____ 12. When continuous IV infusion of a drug is desired, a nurse understands that which of the following is true?
Select all that apply.
1. The health-care provider must order the dosage of medication to be administered.
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2. The physician must perform the calculations to determine the amount of drug to add to a
specific volume of IV solution.
3. The volume of solution may vary from 250 to 1,000 mL.
4. The nurse must determine whether the medication is compatible
with the IV solution.
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5. The nurse must monitor the IV solution carefully to maintain the desired rate of IV
infusion.
____ 13. Which of the following clients would likely receive packed red blood
cells? Select all that apply.
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1. A client with acute blood loss
Copyright © 2019 F. A. Davis Company
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2.
3.
4.
5.
A client who took too much warfarin
A client with acute leukemia
A client who needs increase plasma volume
A client with symptomatic anemia
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____ 14. A nurse caring for several clients in the emergency department. The nurse will plan to monitor the rate of
infusion and assess the condition of an IV site every hour for which of the following clients? Select all that
apply.
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1. A 4-year-old child
2. A 38-year-old woman
3. A 72-year-old man
4. A 42-year-old man who is prone to circulatory fluid overload abirb.com/test
5. A 40-year-old woman who is prone to hypoglycemia
____ 15. The nurse is caring for the client who has allergies to corn and shellfish. Which of the following should the
nurse NOT use with the client? Select all that apply.
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1. 10% povidone-iodine
2. 2% tincture of iodine
3. 10% to 50% Dextrose
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4. 70% isopropyl alcohol
5. 3% to 5% sodium chloride
____ 16. Under the supervision of the RN, the LPN/LVN discusses the IV push route of administration to the client.
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Which statements by the LPN/LVN are accurate? Select all that apply.
1. “This method allows for quick administration of medication.”
2. “This method means the drug will take effect instantaneously.”
3. “We can administer this through the injection port you already have.”
4. “All LPNs and LVNs can administer medications this way.” abirb.com/test
5. “We’ll flush your device with saline before administering using this method.”
____ 17. The nurse asks a nursing student to help initiate a transfusion. Which of the following are parts of this
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process? Select all that apply.
1. The student has two RNs double check the order for a transfusion.
2. The tubing is hanging and primed with D5 LR.
3. The student is using Y-tubing for the transfusion.
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4. The student verifies the client’s name, birth date, and blood identification
tags.
5. The student assesses the client’s vital sign right before the infusion begins.
____ 18. The nurse is caring for a client who reports that the IV site is sore. The nurse notes swelling and tenderness at
the site, as well as a red streak up the arm. The nurse’s care shouldabirb.com/test
include which of the following? Select all
that apply.
1. Applying an ice pack to the area.
2. Discontinuing the IV.
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3. Requesting a new order for IV antibiotics to be infused at the site.
4. Elevating the arm on pillows.
5. Applying warm packs to the area.
____ 19. The nurse may administer which of the following IV solutions via abirb.com/test
a peripheral vein? Select all that apply.
1. 15% dextrose
2. 10% dextrose
3. 5% dextrose in 0.45% sodium chloride
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4. 3% sodium chloride
Copyright © 2019 F. A. Davis Company
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5. 50% dextrose
Other
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20. Place the following steps for hanging a new IV bag in the proper order (1–6). (Enter the number of each step
in the proper sequence without spaces; do not use commas).
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1. Remove the piercing pin.
2. Assess the IV site.
3. Remove the IV bag from the pole.
4. Hang the bag on the IV pole.
5. Stop the infusion.
6. Insert the piercing pin into the tubing port.
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Completion
Complete each statement.
21. The nurse needs to infuse a dose of 250 mL gentamicin over 120 minutes.
What drip rate should the nurse
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use, in mL/hr? Record your answer as a whole number. ____________________
22. A nurse knows that there is a risk for cerebral edema, increased intracranial pressure, rupture of brain cells,
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and death if there is an infusion of an excessive volume of a(n) ____________________solution.
23. Before preparing the equipment to administer peripheral venipuncture, the nurse should wash his or her hands
for ____________________seconds.
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24. A nurse knows that if a client needs IV fluid replacement because of low blood volume, he or she should be
given a ____________________solution.
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25. When there is a risk for hemorrhage, fluctuation of vital signs, or shock, such as when a client is scheduled for
surgery, the nurse should use a ____________________-bore needle when administering an IV.
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Copyright © 2019 F. A. Davis Company
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Chapter 38: Intravenous Therapy
Answer Section
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MULTIPLE CHOICE
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1. ANS: 1
Chapter: Chapter 38, Intravenous Therapy
Objective: 7. Relate possible complications of IV therapy, as well as their causes, prevention, and treatment. |
14. Apply knowledge of IV therapy in specific scenarios.
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Page: 859
Heading: Purposes of IV Therapy > Infusion of IV Medications
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
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Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
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1
This is correct. The nurse should never allow an infusion to continue if he or she sees
precipitates forming in the fluid.
2
This is incorrect. There is no need to discontinue the IV site.
3
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This is incorrect. There is no need to place meperidine on hold.
4
This is incorrect. Notifying the supervisor is not necessary.
PTS: 1
CON: Patient-Centered Care
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2. ANS: 2
Chapter: Chapter 38, Intravenous Therapy
Objective: 13. Summarize how to prepare, initiate, and monitor infusion of blood and blood products. | 14.
Apply knowledge of IV therapy in specific scenarios.
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Page: 884
Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
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Feedback
1
This is incorrect. These vital signs are significantly increased, and further investigation
is needed.
2
This is correct. Elevated BP, P, and R are symptoms of fluid abirb.com/test
overload, and the most
appropriate action is to listen to breath sounds.
3
This is incorrect. Further assessment is needed before notifying the physician would be
appropriate.
4
This is incorrect. It is best to stop the infusion if the client hasabirb.com/test
symptoms of distress.
The nurse should then fully assess the client and proceed by continuing or
discontinuing the transfusion.
PTS: 1
3. ANS: 2
CON: Patient-Centered Care
Copyright © 2019 F. A. Davis Company
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Chapter: Chapter 38, Intravenous Therapy
Objective: 2. Identify the purposes and benefits of peripheral IV therapy.
Page: 856
Heading: Purposes of IV Therapy > Maintaining Fluids and Electrolytes
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Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
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Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
This is incorrect. Medication may be administered via IV, but it is not classified as a
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maintenance fluid.
2
This is correct. Water is a key component of maintenance fluid because it maintains
hydration.
3
This is incorrect. Plasma may be administered via IV, but separately
from maintenance
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fluids.
4
This is incorrect. Blood transfusions are administered via IV, but separately from
maintenance fluids.
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PTS: 1
CON: Patient-Centered Care
4. ANS: 2
Chapter: Chapter 38, Intravenous Therapy
Objective: 6. Discuss the importance of asepsis during IV therapy.abirb.com/test
| 7. Relate possible complications of IV
therapy, their causes, prevention, and treatment.
Page: 881, 882
Heading: Complications of Peripheral IV Therapy
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Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Moderate
Feedback
1
This is incorrect. When fluids and electrolytes are lost in balanced proportions from
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extracellular spaces, the decrease in blood volume is called hypovolemia.
signs and symptoms of a different condition.
2
This is correct. These signs and symptoms indicate phlebitis.
3
This is incorrect. Extravasation refers to leakage of vesicant IV fluid or medication into
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the tissue surrounding the IV insertion site, which causes blistering,
necrosis, and
sloughing of tissue.
4
This is incorrect. Signs and symptoms of infiltration include edema around or
dependent to the site, cool or taut skin around the site, and absence
of or decrease in
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blood return.
PTS: 1
CON: Safety
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5. ANS: 4
Chapter: Chapter 38, Intravenous Therapy
Objective: 4. Compare the effects of infusing hypotonic, isotonic, and hypertonic IV solutions.
Page: 861
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Heading: IV Solutions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Copyright © 2019 F. A. Davis Company
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Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
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Feedback
1
This is incorrect. Although this is true, this does not show an understanding of safety
issues surrounding use of LR.
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2
This is incorrect. This statement refers to safety concerns of using
Dextrose 5% in
water (D5W), not LR.
3
This is incorrect. This shows an understanding of safety concerns when administering
3% to 5% sodium chloride.
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4
This is correct. LR has some incompatibilities with medications. The nurse should
check for compatibility before administering.
PTS: 1
CON: Safety
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6. ANS: 3
Chapter: Chapter 38, Intravenous Therapy
Objective: 7. Relate possible complications of IV therapy, as well as their causes, prevention, and treatment.
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Page: 881
Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
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Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback
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1
This is incorrect. These are not signs of an air embolism.
2
This is incorrect. These are not signs of fluid overload.
3
This is correct. This is the absence of a blood return (or a decreased blood return) upon
lowering the solution bag below the level of the insertion site,abirb.com/test
or when aspirating with a
syringe at an injection port close to the IV site.
4
This is incorrect. These are not signs of thrombophlebitis.
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PTS: 1
CON: Safety
7. ANS: 4
Chapter: Chapter 38, Intravenous Therapy
Objective: 7. Relate possible complications of IV therapy, as well abirb.com/test
as their causes, prevention, and treatment. |
14. Apply knowledge of IV therapy in specific scenarios.
Page: 883, 884
Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
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Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Moderate
Feedback
1
This is incorrect. This is not the correct position for a client with a suspected air
embolism.
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2
This is incorrect. Telemetry monitoring will not help determine whether the client has
Copyright © 2019 F. A. Davis Company
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3
4
experienced an air embolism.
This is incorrect. This action will not help the client who has a suspected air embolism.
This is correct. If the nurse suspects an air embolism, he or she should call for help to
notify the physician and bring the crash cart. The nurse should
place the client on his or
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her left side in the Trendelenburg position.
PTS: 1
CON: Safety
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8. ANS: 1
Chapter: Chapter 38, Intravenous Therapy
Objective: 13. Summarize how to prepare, initiate, and monitor infusion of blood and blood products.
Page: 888
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Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Analysis [Analyzing]
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Concept: Safety
Difficulty: Difficult
Feedback
abirb.com/test because it is
1
This is correct. After 4 hours, the unit of blood is at risk for contamination
the perfect medium for bacterial growth, so the rate should be increased to ensure that
the entire unit is transfused within that time frame.
2
This is incorrect. There is no need to stop the infusion.
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3
This is incorrect. The infusion must be completed within a 4-hour time frame;
increasing the rate is the priority.
4
This is incorrect. There is no need to notify the charge nurses.
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PTS: 1
CON: Safety
9. ANS: 3
Chapter: Chapter 38, Intravenous Therapy
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Objective: 4. Compare the effects of infusing hypotonic, isotonic, and
hypertonic IV solutions.
Page: 859
Heading: IV Solutions
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
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Feedback
1
This is incorrect. An isotonic solution administered via IV does not cause water to
move into dehydrated tissues.
2
This is incorrect. A hypertonic solution administered via IV causes
water to move out
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of the tissues and into the vascular area, so it could actually cause more dehydration.
3
This is correct. A hypotonic solution administered via IV causes water to move out of
the vascular area and into tissues, thus rehydrating cells. This makes it the best option
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for simple water replacement.
4
This is incorrect. Never administer plain water via IV.
PTS: 1
CON: Patient-Centered Care
Copyright © 2019 F. A. Davis Company
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MULTIPLE RESPONSE
10. ANS: 2, 3, 4
Chapter: Chapter 38, Intravenous Therapy
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Objective: 11. Discuss peripheral IV therapy nursing care.
Page: 881, 882
Heading: Complications of Peripheral IV Therapy
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Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Difficult
1
2
3
4
5
Feedback
This is incorrect. Of the listed agents, potassium chloride, promethazine, and
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vancomycin are classified as vesicants.
This is correct. Potassium chloride is classified as a vesicant.
This is correct. Of the listed agents, potassium chloride, promethazine, and vancomycin
are classified as vesicants.
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This is correct. Promethazine is classified as a vesicant.
This is incorrect. Gentamicin sulfate (gentamicin) is not classified as a vesicant.
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PTS: 1
CON: Safety
11. ANS: 1, 2, 3, 4
Chapter: Chapter 38, Intravenous Therapy
Objective: 13. Summarize how to prepare, initiate, and monitor infusion
of blood and blood products.
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Page: 888, 889
Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Difficult
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1
2
3
4
5
Feedback
This is correct. The nurse should remain with the client for the first 15 minutes to assess
for reactions. The nurse should assess vital signs every 5 minutes during this time and
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monitor for signs and symptoms of reactions.
This is correct. If any signs and symptoms are experienced by the client, the nurse
should stop the transfusion immediately, open the roller clamp to begin infusion of
normal saline (NS), perform appropriate nursing interventions
(refer back to Table
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38.4), and notify the physician STAT.
This is correct. The nurse should save the Y-set tubing, the unit of blood, and bag of NS
for return to the laboratory for testing, leaving the Y-set attached to the blood bag and
NS.
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This is correct. The nurse should also obtain a urine specimen from the client and
deliver it to the laboratory.
This is incorrect. The client needs IV access; there is no need to discontinue the site.
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PTS: 1
CON: Safety
Copyright © 2019 F. A. Davis Company
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12. ANS: 1, 3, 5
Chapter: Chapter 38, Intravenous Therapy
Objective: 2. Identify the purposes and benefits of peripheral IV therapy.
Page: 857
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Heading: Purposes of IV Therapy > Infusion of IV Medications
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
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Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
1
2
3
4
5
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Feedback
This is correct. The prescriber orders the correct dosage.
This is incorrect. The nurse or pharmacist calculates the amount of drug to add to a
specific volume of IV solution.
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This is correct. The volume of solution may vary from 250 to 1,000 mL.
This is incorrect. The physician will determine whether a medication should be
delivered via IV infusion and, therefore, whether it is compatible with an IV solution.
This is correct. The nurse must monitor the IV solution carefully
to maintain the desired
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rate of IV infusion.
PTS: 1
CON: Patient-Centered Care
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13. ANS: 1, 5
Chapter: Chapter 38, Intravenous Therapy
Objective: 12. Discuss the components and uses of various blood products.
Page: 886
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Heading: Blood and Blood Products
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
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Concept: Patient-Centered Care
Difficulty: Difficult
1
2
3
4
5
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Feedback
This is correct. Cryoprecipitate replaces coagulation factors I, VII, and XIII.
This is incorrect. Fresh frozen plasma replaces coagulation factors V and XI and is a
drug reversal of warfarin (Coumadin).
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This is incorrect. Platelets may be given to those with acute leukemia to help prevent
and control bleeding related to low platelet count.
This is incorrect. Albumin increases plasma volume.
This is correct. Packed red blood cells may be used in clientsabirb.com/test
with symptomatic anemia.
PTS: 1
CON: Patient-Centered Care
14. ANS: 1, 3, 4
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Chapter: Chapter 38, Intravenous Therapy
Objective: 17. Identify specific safety features.
Page: 884
Heading: Initiating Peripheral Venipuncture > Monitoring IV Infusions
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Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Copyright © 2019 F. A. Davis Company
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Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
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1
2
3
4
5
Feedback
This is correct. The nurse should perform this monitoring and assessment once every
hour for children.
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This is incorrect. The nurse should perform this monitoring and
assessment once every
2 hours for adults.
This is correct. The nurse should perform this monitoring and assessment once every 1
hour for the elderly.
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This is correct. The nurse should perform this monitoring and assessment once every
hour for clients prone to circulatory fluid overload.
This is incorrect. The nurse should perform this monitoring for clients prone to
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PTS: 1
CON: Patient-Centered Care
15. ANS: 1, 3
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Chapter: Chapter 38, Intravenous Therapy
Objective: 17. Identify specific safety features.
Page: 862, 871
Heading: Asepsis and IV Therapy > Patient’s Skin
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Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Difficult
1
2
3
4
5
Feedback
This is correct. Before using any skin-cleansing solution containing
povidone-iodine,
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the nurse should ask if the client has any allergies to iodine or shellfish.
This is incorrect. Before using any skin-cleansing solution containing povidone-iodine,
the nurse should ask if the client has any allergies to iodine or shellfish. This is not
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generally an issue with a 2% tincture of iodine.
This is correct. The client who is allergic to corn should not be given dextrose.
This is incorrect. Before using any skin-cleansing solution containing povidone-iodine,
the nurse should ask if the client has any allergies to iodine or shellfish. However, it
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should be safe to use isopropyl alcohol with the client.
This is incorrect. Although this should be infused only in small volumes, this is because
it irritates veins and may cause circulatory overload.
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PTS: 1
CON: Safety
16. ANS: 2, 3, 5
Chapter: Chapter 38, Intravenous Therapy
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Objective: 2. Identify the purposes and benefits of peripheral IV therapy.
Page: 857
Heading: Purposes of IV Therapy > IV Push
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
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Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
Copyright © 2019 F. A. Davis Company
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Concept: Patient-Centered Care
Difficulty: Difficult
1
2
3
4
5
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Feedback
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This is incorrect. An IV push should be administered slowly to prevent overdose or
adverse reactions.
This is correct. An IV push causes medication to take effect immediately; thus, the risk
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for adverse reaction if it is administered too quickly, so it is crucial
that the nurse
research the length of time over which the medication must be administered.
This is correct. If the client has an intermittent infusion device, also known as a PRN
lock, the medication can be administered IV push via the injection port without having
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the discomfort of another needle stick.
This is incorrect. Some jurisdictions require that only registered nurses administer IV
push medication.
This is correct. Many facilities have policies in place requiring
that all venous access
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devices (VADs) be flushed with 1 to 10 mL of sodium chloride, or normal saline (NS),
prior to administration of IV push medications, and again after the IV push medication,
regardless of compatibility or incompatibility.
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PTS: 1
CON: Patient-Centered Care
17. ANS: 1, 3, 4, 5
Chapter: Chapter 38, Intravenous Therapy
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Objective: 13. Summarize how to prepare, initiate, and monitor infusion
of blood and blood products. |
14. Apply knowledge of IV therapy in specific scenarios.
Page: 887
Heading: Complications of Peripheral IV Therapy
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Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Safety
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Difficulty: Moderate
1
2
3
4
5
Feedback
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This is correct. Just prior to initiating a blood product transfusion,
most facilities
require that two nurses, usually RNs, double-check the physician’s order, comparing it
to the actual blood product to make certain that the correct blood components have been
prepared for transfusion.
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This is incorrect. Blood and blood products are not compatible
with any IV solution
other than 0.9% sodium chloride (NS).
This is correct. Transfusions are generally administered with a special Y-shaped
administration set, often referred to as a Y-set.
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This is correct. A specific identification number is assigned to the blood product and is
used for verification that it is the correct blood product for the specified client.
This is correct. The nurse should assess the client’s vital signs immediately before
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beginning the blood or blood product transfusion. This will serve
as a baseline against
which the nurse can compare vital signs taken during the transfusion.
PTS: 1
CON: Safety
18. ANS: 2, 4, 5
Chapter: Chapter 38, Intravenous Therapy
Copyright © 2019 F. A. Davis Company
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Objective: 6. Discuss the importance of asepsis during IV therapy.
Page: 882
Heading: Complications of Peripheral IV Therapy
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
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Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Difficult
1
2
3
4
5
Feedback
This is incorrect. Applying ice would not help these symptoms.
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flow of the IV fluid and
discontinue the IV cannula.
This is incorrect. This site should be discontinued.
This is correct. The nurse should elevate the affected arm on abirb.com/test
pillows.
This is correct. The nurse should apply warm, moist packs to the site for 20 to 30
minutes every 2 hours until signs of phlebitis are gone.
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PTS: 1
CON: Safety
19. ANS: 2, 3
Chapter: Chapter 38, Intravenous Therapy
Objective: 4. Compare the effects of infusing hypotonic, isotonic, and hypertonic IV solutions.
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Page: 861-863
Heading: IV Solutions
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Difficult
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1
2
3
4
5
Feedback
This is incorrect. An IV fluid with dextrose concentration greater than 10% cannot be
given through peripheral veins. It must be administered via central veins.
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This is correct. An IV fluid with dextrose concentration of 10%
or less can be given
through peripheral veins.
This is correct. An IV fluid with dextrose concentration of 3% can be given through
peripheral veins.
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This is incorrect. An IV fluid with sodium chloride concentration of 3% or greater is
potentially dangerous and can only be administered in small doses, but it can be
administered via peripheral veins.
This is incorrect. This will need to be given via central veins.abirb.com/test
PTS: 1
CON: Safety
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ORDER
20. ANS:
413625
Chapter: Chapter 38, Intravenous Therapy
Copyright © 2019 F. A. Davis Company
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Objective: 9. Explain how to prepare, initiate, and maintain a peripheral IV infusion.
Page: 900
Heading: IV Equipment
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
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Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
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Difficulty: Moderate
Feedback: The nurse should assess the client’s IV site for signs of infiltration and phlebitis. If using an IV
pump or controller, the nurse should press the button to stop the infusion, remove the IV solution bag from
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the IV pole, and invert the bag. The nurse should remove the piercing
pin, maintaining its sterility, and insert
the piercing pin into the tubing port on the new bag of IV solution. The nurse should then right the new bag
and hang it on the IV pole.
PTS: 1
CON: Patient-Centered Care
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COMPLETION
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21. ANS:
2
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Chapter: Chapter 38, Intravenous Therapy
Objective: 10. Calculate an infusion rate for a gravity infusion and a pump infusion. |
14. Apply knowledge of IV therapy in specific scenarios.
Page: 871, 872
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Heading: Calculation of Infusion Rate
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
Cognitive Level: Application [Applying]
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Concept: Patient-Centered Care
Difficulty: Moderate
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Feedback: The formula used to determine the drip rate is volume divided
by time. In this case, because the
result is asked for in mL/hr, make sure to convert the time of infusion from minutes to hours: 120 minutes = 2
hours. Then the calculation is 250 mL/2 hr = 125 mL/hr.
PTS: 1
22. ANS:
hypotonic
CON: Patient-Centered Care
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Chapter: Chapter 38, Intravenous Therapy
Objective: 4. Compare the effects of infusing hypotonic, isotonic, and hypertonic IV solutions.
Page: 862
Heading: IV Solutions
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Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
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Difficulty: Moderate
Copyright © 2019 F. A. Davis Company
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Feedback: Excessive infusion of hypotonic solution can cause the movement of an excessive volume fluid
from the vascular spaces into the interstitial spaces, which can lower both blood volume and blood pressure
and cause edema, excessive water movement into the cells, and possible
swelling and rupturing of cells.
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PTS: 1
23. ANS:
20
CON: Safety
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Chapter: Chapter 38, Intravenous Therapy
Objective: 17. Identify specific safety features.
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Page: 873
Heading: Initiating Peripheral Venipuncture > Preparing the Equipment
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies
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Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
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Feedback: The nurse should wash his or her hands for at least 20 seconds.
PTS: 1
24. ANS:
hypertonic solution
CON: Safety
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Objective: 4. Compare the effects of infusing hypotonic, isotonic, and hypertonic IV solutions.
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Page: 862, 863
Heading: IV Solutions
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Reduction of Risk Potential
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Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
Feedback: A hypertonic solution administered via IV causes waterabirb.com/test
to move out of the tissues and into the
vascular area, thus increasing blood volume.
PTS: 1
25. ANS:
larger
CON: Safety
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Chapter: Chapter 38, Intravenous Therapy
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Objective: 8. Contrast IV therapy in children, adults, and older adults.
Page: 864
Heading: IV Equipment > IV Needle Cannula
Integrated Processes: Clinical Problem-Solving Process (Nursing Process)
Client Need: Physiological Integrity: Pharmacological Therapies abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
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Copyright © 2019 F. A. Davis Company
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Feedback: The nurse uses a larger-bore needle when he or she might need to rapidly infuse more fluid into the
client, such as when the client is at risk for hemorrhage.
PTS: 1
CON: Safety
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Copyright © 2019 F. A. Davis Company
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