PNR 202/PNR202 Exam 2 V3 | Intravenous
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s IV site and notes that the area is swollen, cool to the touch,
and the patient reports discomfort. What is the most likely complication?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombosis
Correct Answer: B
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding tissue. The clinical manifestations include swelling, coolness, and pallor at the
site. The nurse should immediately stop the infusion and remove the catheter to prevent
further tissue damage.
2. Which of the following IV fluids is classified as a hypotonic solution?
A. 0.45% Normal Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. D5W in 0.9% Saline
,Correct Answer: A
Expert Explanation: 0.45% Normal Saline (Half-Normal Saline) is a hypotonic solution
because its osmolarity is lower than that of serum. Hypotonic solutions cause fluid to shift
from the intravascular space into the intracellular space. This type of fluid is typically used
to treat cellular dehydration.
3. A patient receiving IV therapy develops sudden shortness of breath, cough, and crackles in
the lungs. What should be the nurse’s priority action?
A. Increase the IV flow rate
B. Change the IV tubing
C. Administer an antihistamine
D. Slow the IV rate and notify the provider
Correct Answer: D
Expert Explanation: These symptoms are indicative of circulatory overload, where the
patient is receiving fluid faster than the system can manage. The nurse must slow the
infusion rate to a keep-vein-open status and elevate the head of the bed. Prompt
notification of the healthcare provider is essential for potential diuretic orders.
4. When selecting a vein for a peripheral IV line, which site should the nurse prioritize to
preserve future access?
A. The antecubital fossa
B. The back of the hand
, C. The most distal vein on the arm
D. Veins in the lower extremities
Correct Answer: C
Expert Explanation: Starting at the most distal point allows for subsequent proximal
attempts if the initial site fails. Selecting a distal site like the forearm or hand helps
preserve the integrity of the vein higher up the arm. This is a standard practice in
intravenous therapy to maximize the longevity of vascular access.
5. What is the primary characteristic of phlebitis at an IV site?
A. Coolness and blanching
B. Numbness and tingling
C. Redness, warmth, and a palpable cord
D. Dampness of the dressing
Correct Answer: C
Expert Explanation: Phlebitis is the inflammation of the vein wall characterized by pain,
erythema, and warmth at the site. A palpable cord may be felt along the path of the vein as
the inflammation progresses. The nurse should remove the IV and apply warm compresses
to improve circulation and comfort.
Therapy Q&A with Rationale | Fortis
College
1. A nurse is assessing a patient’s IV site and notes that the area is swollen, cool to the touch,
and the patient reports discomfort. What is the most likely complication?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Thrombosis
Correct Answer: B
Expert Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the
surrounding tissue. The clinical manifestations include swelling, coolness, and pallor at the
site. The nurse should immediately stop the infusion and remove the catheter to prevent
further tissue damage.
2. Which of the following IV fluids is classified as a hypotonic solution?
A. 0.45% Normal Saline
B. Lactated Ringer’s
C. 0.9% Normal Saline
D. D5W in 0.9% Saline
,Correct Answer: A
Expert Explanation: 0.45% Normal Saline (Half-Normal Saline) is a hypotonic solution
because its osmolarity is lower than that of serum. Hypotonic solutions cause fluid to shift
from the intravascular space into the intracellular space. This type of fluid is typically used
to treat cellular dehydration.
3. A patient receiving IV therapy develops sudden shortness of breath, cough, and crackles in
the lungs. What should be the nurse’s priority action?
A. Increase the IV flow rate
B. Change the IV tubing
C. Administer an antihistamine
D. Slow the IV rate and notify the provider
Correct Answer: D
Expert Explanation: These symptoms are indicative of circulatory overload, where the
patient is receiving fluid faster than the system can manage. The nurse must slow the
infusion rate to a keep-vein-open status and elevate the head of the bed. Prompt
notification of the healthcare provider is essential for potential diuretic orders.
4. When selecting a vein for a peripheral IV line, which site should the nurse prioritize to
preserve future access?
A. The antecubital fossa
B. The back of the hand
, C. The most distal vein on the arm
D. Veins in the lower extremities
Correct Answer: C
Expert Explanation: Starting at the most distal point allows for subsequent proximal
attempts if the initial site fails. Selecting a distal site like the forearm or hand helps
preserve the integrity of the vein higher up the arm. This is a standard practice in
intravenous therapy to maximize the longevity of vascular access.
5. What is the primary characteristic of phlebitis at an IV site?
A. Coolness and blanching
B. Numbness and tingling
C. Redness, warmth, and a palpable cord
D. Dampness of the dressing
Correct Answer: C
Expert Explanation: Phlebitis is the inflammation of the vein wall characterized by pain,
erythema, and warmth at the site. A palpable cord may be felt along the path of the vein as
the inflammation progresses. The nurse should remove the IV and apply warm compresses
to improve circulation and comfort.
