PNR 202/PNR202 Final Exam V2 |
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is monitoring a patient receiving an IV infusion of 0.9% normal saline. The nurse
notes that the IV site is swollen, cool to the touch, and the patient reports discomfort. Which
complication is most likely occurring?
A. Phlebitis
B. Air Embolism
C. Infection
D. Infiltration
Correct Answer: D
Expert Explanation: Infiltration occurs when IV fluid leaks into the surrounding
subcutaneous tissue instead of staying in the vein. The presence of swelling and coolness is
a classic indicator that the fluid is no longer entering the vascular space correctly. The
nurse must stop the infusion immediately and remove the catheter to prevent further
tissue damage.
2. When preparing to administer a blood transfusion, which gauge of peripheral IV catheter is
the minimum size recommended to prevent hemolysis of red blood cells?
A. 24-gauge
,B. 22-gauge
C. 26-gauge
D. 20-gauge
Correct Answer: D
Expert Explanation: An 18 to 20-gauge catheter is typically preferred for blood
transfusions to allow the cells to flow freely without being damaged. Using a smaller gauge,
such as a 22 or 24, increases the risk of lysing the red blood cells during administration.
Proper catheter selection is a critical safety step in blood product therapy for PNR 202
students.
3. A patient complains of sudden shortness of breath, chest pain, and lightheadedness shortly
after an IV catheter was discontinued. The nurse suspects an air embolism. What is the
priority nursing action?
A. Place the patient in High-Fowler’s position.
B. Administer a bolus of normal saline.
C. Encourage the patient to cough and deep breathe.
D. Place the patient in Trendelenburg position on the left side.
Correct Answer: D
Expert Explanation: Placing the patient in the left-lateral Trendelenburg position helps
trap the air in the apex of the right atrium, preventing it from entering the pulmonary
, artery. This is a life-saving maneuver that minimizes the risk of a pulmonary embolism. The
nurse should also immediately notify the healthcare provider and initiate oxygen therapy.
4. Which clinical manifestation is most indicative of fluid volume excess in a patient receiving
IV therapy?
A. Increased skin turgor
B. Sunken eyeballs
C. Orthostatic hypotension
D. Crackles on lung auscultation
Correct Answer: D
Expert Explanation: Crackles in the lungs suggest that fluid is backing up into the
pulmonary system, which is a hallmark sign of fluid volume excess. This condition often
occurs if the IV infusion rate is too high for the patient’s cardiac or renal status. Monitoring
lung sounds is an essential assessment for nurses managing intravenous fluids.
5. A nurse is preparing to hang a new bag of Total Parenteral Nutrition (TPN). If the TPN
solution is not available from the pharmacy when the current bag runs out, which solution
should the nurse hang?
A. 0.9% Normal Saline
B. 10% Dextrose in Water
C. 5% Dextrose in Water
Intravenous Therapy Q&A with Rationale |
Fortis College
1. A nurse is monitoring a patient receiving an IV infusion of 0.9% normal saline. The nurse
notes that the IV site is swollen, cool to the touch, and the patient reports discomfort. Which
complication is most likely occurring?
A. Phlebitis
B. Air Embolism
C. Infection
D. Infiltration
Correct Answer: D
Expert Explanation: Infiltration occurs when IV fluid leaks into the surrounding
subcutaneous tissue instead of staying in the vein. The presence of swelling and coolness is
a classic indicator that the fluid is no longer entering the vascular space correctly. The
nurse must stop the infusion immediately and remove the catheter to prevent further
tissue damage.
2. When preparing to administer a blood transfusion, which gauge of peripheral IV catheter is
the minimum size recommended to prevent hemolysis of red blood cells?
A. 24-gauge
,B. 22-gauge
C. 26-gauge
D. 20-gauge
Correct Answer: D
Expert Explanation: An 18 to 20-gauge catheter is typically preferred for blood
transfusions to allow the cells to flow freely without being damaged. Using a smaller gauge,
such as a 22 or 24, increases the risk of lysing the red blood cells during administration.
Proper catheter selection is a critical safety step in blood product therapy for PNR 202
students.
3. A patient complains of sudden shortness of breath, chest pain, and lightheadedness shortly
after an IV catheter was discontinued. The nurse suspects an air embolism. What is the
priority nursing action?
A. Place the patient in High-Fowler’s position.
B. Administer a bolus of normal saline.
C. Encourage the patient to cough and deep breathe.
D. Place the patient in Trendelenburg position on the left side.
Correct Answer: D
Expert Explanation: Placing the patient in the left-lateral Trendelenburg position helps
trap the air in the apex of the right atrium, preventing it from entering the pulmonary
, artery. This is a life-saving maneuver that minimizes the risk of a pulmonary embolism. The
nurse should also immediately notify the healthcare provider and initiate oxygen therapy.
4. Which clinical manifestation is most indicative of fluid volume excess in a patient receiving
IV therapy?
A. Increased skin turgor
B. Sunken eyeballs
C. Orthostatic hypotension
D. Crackles on lung auscultation
Correct Answer: D
Expert Explanation: Crackles in the lungs suggest that fluid is backing up into the
pulmonary system, which is a hallmark sign of fluid volume excess. This condition often
occurs if the IV infusion rate is too high for the patient’s cardiac or renal status. Monitoring
lung sounds is an essential assessment for nurses managing intravenous fluids.
5. A nurse is preparing to hang a new bag of Total Parenteral Nutrition (TPN). If the TPN
solution is not available from the pharmacy when the current bag runs out, which solution
should the nurse hang?
A. 0.9% Normal Saline
B. 10% Dextrose in Water
C. 5% Dextrose in Water
