PNR 202/PNR202 Final Exam V3 |
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is preparing to administer 0.9% Normal Saline to a patient with fluid volume
deficit. Which classification does this solution fall under?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Correct Answer: B
Expert Explanation: 0.9% Normal Saline is an isotonic solution because its osmolarity
matches that of human serum. It expands the extracellular fluid volume without causing a
shift of water into or out of the cells. This makes it ideal for replacing fluid lost due to
hemorrhage or severe vomiting.
2. Upon assessment of an IV site, the nurse notes coolness of the skin, edema around the
insertion site, and a slowed infusion rate. What is the most likely complication?
A. Infiltration
B. Phlebitis
C. Thrombosis
,D. Extravasation
Correct Answer: A
Expert Explanation: Infiltration is the leakage of non-vesicant IV fluid into the
surrounding subcutaneous tissue. Common signs include localized swelling, coolness to the
touch, and blanching of the skin. The nurse should immediately discontinue the IV and
elevate the affected limb.
3. When administering a hypertonic solution like 3% Sodium Chloride, the nurse must
monitor for which primary complication?
A. Cellular dehydration
B. Hypovolemia
C. Hypotension
D. Fluid volume excess
Correct Answer: D
Expert Explanation: Hypertonic solutions draw water out of the intracellular space and
into the intravascular space to balance osmolarity. This rapid shift can lead to circulatory
overload and pulmonary edema if not monitored closely. The nurse must assess lung
sounds and blood pressure frequently during administration.
4. According to the Phlebitis Scale, a nurse observes redness at the access site with a palpable
venous cord. How should this be graded?
A. Grade 3
, B. Grade 2
C. Grade 1
D. Grade 4
Correct Answer: A
Expert Explanation: Grade 3 phlebitis is characterized by pain at the access site with
erythema, edema, and a palpable venous cord. Grade 2 only involves pain and erythema
without cord formation, while Grade 4 includes a palpable cord longer than one inch and
purulent drainage. Proper grading is essential for standardized documentation and
intervention.
5. A patient experiences sudden respiratory distress, chest pain, and hypotension shortly
after a central line was opened to air. Which position is most appropriate?
A. High Fowler’s
B. Left side in Trendelenburg
C. Supine
D. Right side semi-Fowler’s
Correct Answer: B
Expert Explanation: The patient is likely experiencing an air embolism, which requires
immediate positioning on the left side in Trendelenburg. This position helps trap the air
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is preparing to administer 0.9% Normal Saline to a patient with fluid volume
deficit. Which classification does this solution fall under?
A. Hypotonic
B. Isotonic
C. Hypertonic
D. Colloid
Correct Answer: B
Expert Explanation: 0.9% Normal Saline is an isotonic solution because its osmolarity
matches that of human serum. It expands the extracellular fluid volume without causing a
shift of water into or out of the cells. This makes it ideal for replacing fluid lost due to
hemorrhage or severe vomiting.
2. Upon assessment of an IV site, the nurse notes coolness of the skin, edema around the
insertion site, and a slowed infusion rate. What is the most likely complication?
A. Infiltration
B. Phlebitis
C. Thrombosis
,D. Extravasation
Correct Answer: A
Expert Explanation: Infiltration is the leakage of non-vesicant IV fluid into the
surrounding subcutaneous tissue. Common signs include localized swelling, coolness to the
touch, and blanching of the skin. The nurse should immediately discontinue the IV and
elevate the affected limb.
3. When administering a hypertonic solution like 3% Sodium Chloride, the nurse must
monitor for which primary complication?
A. Cellular dehydration
B. Hypovolemia
C. Hypotension
D. Fluid volume excess
Correct Answer: D
Expert Explanation: Hypertonic solutions draw water out of the intracellular space and
into the intravascular space to balance osmolarity. This rapid shift can lead to circulatory
overload and pulmonary edema if not monitored closely. The nurse must assess lung
sounds and blood pressure frequently during administration.
4. According to the Phlebitis Scale, a nurse observes redness at the access site with a palpable
venous cord. How should this be graded?
A. Grade 3
, B. Grade 2
C. Grade 1
D. Grade 4
Correct Answer: A
Expert Explanation: Grade 3 phlebitis is characterized by pain at the access site with
erythema, edema, and a palpable venous cord. Grade 2 only involves pain and erythema
without cord formation, while Grade 4 includes a palpable cord longer than one inch and
purulent drainage. Proper grading is essential for standardized documentation and
intervention.
5. A patient experiences sudden respiratory distress, chest pain, and hypotension shortly
after a central line was opened to air. Which position is most appropriate?
A. High Fowler’s
B. Left side in Trendelenburg
C. Supine
D. Right side semi-Fowler’s
Correct Answer: B
Expert Explanation: The patient is likely experiencing an air embolism, which requires
immediate positioning on the left side in Trendelenburg. This position helps trap the air
