Invasive - IV Therapy Exam
A nurse finds a patient's IV insertion site red, warm, and slightly edematous. Which of
the following actions should the nurse perform first?
1 - Check for a blood return.
2 - Elevate the extremity.
3 - Discontinue the IV line.
4 - Apply warm, moist heat.
3 - Discontinue the IV line.
Rationale
1 - Even if the line is patent, the patient has still developed a complication. This action
will not promote resolution of the problem.
2 -Elevation of the extremity can help promote venous drainage and reduce swelling,
but it will not promote resolution of the problem.
3 - The patient has classic signs of phlebitis, an inflammation of the vein. The IV line
must be discontinued immediately to reduce the risk of thrombophlebitis and embolism.
4 - Heat application can help relieve the patient's symptoms, but it alone will not
promote resolution of the problem.
A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for
continuous infusion. How often should the nurse plan to replace the primary infusion
tubing?
1 - Every 24 hours
2 - Every 48 hours
3 - Every 72 hours
4 - Every 96 hours
Rationale
1 - Tubing should be replaced every 24 hours if it is used to administer blood, blood
products, or lipid emulsions.
2 - Unless the solution is changed to one that is incompatible with the current infusate or
there is some compromise to the tubing, replacing the tubing 48 hours after initiation
would be inappropriate.
3 - Unless the infusion system has been compromised in some way, changing the
administration set 72 hours after initiating the IV would be inappropriate.
4 - The Centers for Disease Control and Prevention and the Infusion Nurses' Society
recommend changing the IV tubing no more than every 96 hours unless the tubing has
been contaminated, punctured, or obstructed.
,A nurse has just inserted a peripheral IV catheter for a continuous infusion. To secure
the catheter, the nurse should
1 - leave the connection between the hub and the tubing uncovered.
2 - wrap tape around the circumference of the patient's arm.
3 - tape the IV catheter's hub securely to the patient's skin.
4 - place a piece of paper tape over the insertion site.
Rationale
1- This makes it possible to replace the tubing without removing the dressing.
2 - This can impair circulation, especially if the arm swells.
3 - This can exert pressure on the skin. It is better to place a small gauze pad under the
hub of the IV catheter to elevate it and thus avoid direct pressure.
4 - This blocks visibility of the insertion site.
Which of the following is an important nursing action when concerting an IV infusion to a
saline lock?
1 - Open the roller clamp of the primary infusion to prime the saline lock.
2 - Apply pressure with a syringe to clear resistance in the IV catheter.
3 - Attach secondary tubing to allow mobility.
4 - Flush the IV catheter to confirm patency.
Rationale
1 - The tubing of a saline lock is primed separately using a syringe. It is not primed from
the existing infusion.
2 - If resistance is encountered in an IV line, it should not be flushed. That would place
the patient at risk for embolism.
3 - Secondary tubing is used to administer IV medications via piggyback. A saline lock
attaches to extension tubing, not to secondary tubing.
4 - It is essential to attach the primed saline lock adapter to the extension tubing and to
flush the tubing with normal saline to confirm patency.
A nurse who has just initiated an IV infusion explains to the patient that complications
are possible and that she will monitor the infusion regularly. The nurse should teach the
patient that which of the following findings is an indication of early infiltration?
1 - Moisture
2 - Bruising
3 - Tingling
4 - Coolness
Rationale
1 - A damp or wet dressing or other evidence of moisture typically indicates that the hub
is loose or has become detached from the tubing or that the site itself is leaking IV
solution. If all connections are secure, moisture could be a late sign of infiltration, not an
,early sign.
2 -Bruising at the infusion site is likely to be a result of trauma to tiny blood vessels
during insertion. Bruising is not uncommon after a venipuncture.
3 - Tingling is generally a sign of nerve irritation or compromise. An infiltration would
have to be severe to affect neurological function.
4 - Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly
tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment
into the surrounding tissue.
A patient is to receive 1,000 mL of 5% dextrose in lactated Ringer's over 8 hours. Using
tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at
how many drops per minute?
_____________________ gtt/min
31 gtt/min
A nurse initiating a peripheral IV infusion punctures the skin and selected vein and
observes blood return in the flashback chamber of the IV catheter. Which of the
following actions should the nurse perform next?
1 - Secure the catheter to the skin with a transparent dressing.
2 - Lower the catheter until it is almost flush with the skin.
3 - Advance the catheter about 1/4 inch into the vein.
4 - Remove the stylet slowly from the lumen of the catheter
Rationale
1 - This is one of the final steps in the process. Securing the catheter prior to stabilizing
it could, for example, result in dislodgement or injury to the patient.
2 - Lowering the angle and then advancing the catheter slightly facilitates full
penetration of the wall of the vein, thus placing the catheter within the vein's lumen and
making it easy to advance the catheter off the stylet.
3 - Advancing the catheter at this point in the insertion process might puncture the
opposite wall of the vein.
4 - The stylet should remain in place until the catheter is positioned further within the
vein.
A nurse is removing an IV catheter from a patient whose IV infusion has been
discontinued. Which of the following actions is appropriate?
1 - Apply firm pressure over the vein.
2 - Leave the roller clamp slightly open.
3 - Pull the catheter straight back from the insertion site.
4 - Lift the hub slightly upward away from the skin.
Rationale
1 - Firm pressure over the vein can make the procedure unnecessarily painful for the
patient.
, 2 - Moving the roller clamp to the off position is recommended to avoid spilling IV fluid.
3 - With the catheter stabilized and using a slow, steady movement, the nurse should
withdraw the catheter straight back and away from the insertion site, making sure to
keep the hub parallel to the skin.
4 - Changing the angle of the catheter inside the vein, which would result from elevating
the hub, could irritate the vein and put the patient at risk for postinfusion phlebitis.
A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride.
This type of solution is appropriate because it
1 - pulls fluid from the cells and increases vascular volume.
2 - dilutes extracellular fluid and rehydrates the cells.
3 - replaces extracellular volume and maintains intravascular volume.
4 - draws fluid into blood vessels and reduces interstitial compartments.
Rationale
1 - Infusing a hypertonic solution such as 10% dextrose in water pulls fluid from the cells
and increases vascular volume; 0.45% sodium chloride is not a hypertonic solution.
2 - Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the
cells, thus enlarging and rehydrating them.
3 - Infusing an isotonic solution such as 0.9% sodium chloride replaces fluid losses,
usually extracellular losses, and maintains or expands the intravascular volume; 0.45%
sodium chloride is not an isotonic solution.
4 - Infusing a hypertonic solution such as 3% sodium chloride pulls fluid from the cells
and increases vascular volume; 0.45% sodium chloride is not a hypertonic solution.
A nurse is discontinuing an IV infusion. For which of the following reasons is it important
to verify and document the integrity and condition of the IV catheter?
1 - A broken-off catheter tip indicates the risk for an embolus.
2 - Catheter erosion indicates that it was left in place too long.
3 - Blood within the catheter could indicate clot formation.
4 - Discoloration of the catheter could be a sign of phlebitis.
Rationale
1 - The tip of the catheter can break off, thus creating an embolus. To limit the
movement of the embolus, the nurse should apply a tourniquet high on the extremity
where the IV line was located and notify the provider immediately.
2 - This finding is highly unlikely, as IV catheters are made of durable materials that
would not disintegrate during the period of time an IV catheter is in place.
3 - It is typical to find blood inside the catheter on removal. If a clot is observed at the tip
of the catheter, then clotting has taken place.
4 - Phlebitis, the inflammation of a vein, would not cause discoloration of the catheter.
A nurse is preparing to administer diphenhydramine to a client who is to receive a blood
transfusion. The nurse should explain that the purpose of diphenhydramine is to prevent
