IV THERAPY NCLEX PRACTICE
QUESTIONS & ANSWERS 100%
CORRECT (FULLY SOLVED)
A client has a saline lock. How should the nurse maintain
the patency of the saline lock?
A) Flush it with heparin every 2 hours
B) Flush it with normal saline every 8 hours
C) Use sterile water for irrigation
D) Administer continuous fluids through it - correct
answer- B) Flush it with normal saline every 8 hours
Rationale: Flushing the saline lock with normal saline
helps maintain patency and prevent clot formation.
A client receiving IV fluids at 125 mL/hr is at risk for fluid
overload. Which assessment finding would indicate this
complication?
A) Clear breath sounds
B) Low urine output
,C) Bounding pulse and dyspnea
D) Hypotension - correct answer- C) Bounding
pulse and dyspnea
Rationale: Fluid overload can cause a bounding pulse,
dyspnea, and crackles in the lungs due to excess fluid in
the body.
A client receiving IV fluids begins to complain of pain at
the insertion site. What is the nurse's initial action?
A) Slow down the infusion rate
B) Discontinue the IV site
C) Assess the site for signs of complications
D) Elevate the extremity - correct answer- C)
Assess the site for signs of complications
Rationale: Pain at the insertion site could indicate
infiltration or phlebitis; assessing the site helps determine
the appropriate response.
,A client receiving IV therapy is experiencing dyspnea,
jugular vein distension, and increased weight. What
should the nurse suspect?
A) Fluid overload
B) Infiltration
C) Phlebitis
D) Extravasation - correct answer- A) Fluid
overload
Rationale: Symptoms such as dyspnea, jugular vein
distension, and weight gain are associated with fluid
overload, a common IV therapy complication.
A client with a central line develops jugular vein distention
and hypotension. The nurse suspects an air embolism.
What is the immediate intervention?
A) Place the client in the Trendelenburg position on the
left side
B) Elevate the head of the bed
C) Clamp the central line
, D) Administer oxygen at 2 L/min - correct answer-
A) Place the client in the Trendelenburg position on the
left side
Rationale: This position helps trap the air embolus in the
right atrium and prevents it from moving into the
pulmonary circulation, which can be life-saving.
A client with a central venous catheter is at risk for air
embolism. Which intervention should the nurse perform
to prevent this complication?
A) Use a small syringe for injections
B) Place the client in Trendelenburg position when
changing caps
C) Administer medications rapidly
D) Flush the catheter every hour - correct answer-
B) Place the client in Trendelenburg position when
changing caps
QUESTIONS & ANSWERS 100%
CORRECT (FULLY SOLVED)
A client has a saline lock. How should the nurse maintain
the patency of the saline lock?
A) Flush it with heparin every 2 hours
B) Flush it with normal saline every 8 hours
C) Use sterile water for irrigation
D) Administer continuous fluids through it - correct
answer- B) Flush it with normal saline every 8 hours
Rationale: Flushing the saline lock with normal saline
helps maintain patency and prevent clot formation.
A client receiving IV fluids at 125 mL/hr is at risk for fluid
overload. Which assessment finding would indicate this
complication?
A) Clear breath sounds
B) Low urine output
,C) Bounding pulse and dyspnea
D) Hypotension - correct answer- C) Bounding
pulse and dyspnea
Rationale: Fluid overload can cause a bounding pulse,
dyspnea, and crackles in the lungs due to excess fluid in
the body.
A client receiving IV fluids begins to complain of pain at
the insertion site. What is the nurse's initial action?
A) Slow down the infusion rate
B) Discontinue the IV site
C) Assess the site for signs of complications
D) Elevate the extremity - correct answer- C)
Assess the site for signs of complications
Rationale: Pain at the insertion site could indicate
infiltration or phlebitis; assessing the site helps determine
the appropriate response.
,A client receiving IV therapy is experiencing dyspnea,
jugular vein distension, and increased weight. What
should the nurse suspect?
A) Fluid overload
B) Infiltration
C) Phlebitis
D) Extravasation - correct answer- A) Fluid
overload
Rationale: Symptoms such as dyspnea, jugular vein
distension, and weight gain are associated with fluid
overload, a common IV therapy complication.
A client with a central line develops jugular vein distention
and hypotension. The nurse suspects an air embolism.
What is the immediate intervention?
A) Place the client in the Trendelenburg position on the
left side
B) Elevate the head of the bed
C) Clamp the central line
, D) Administer oxygen at 2 L/min - correct answer-
A) Place the client in the Trendelenburg position on the
left side
Rationale: This position helps trap the air embolus in the
right atrium and prevents it from moving into the
pulmonary circulation, which can be life-saving.
A client with a central venous catheter is at risk for air
embolism. Which intervention should the nurse perform
to prevent this complication?
A) Use a small syringe for injections
B) Place the client in Trendelenburg position when
changing caps
C) Administer medications rapidly
D) Flush the catheter every hour - correct answer-
B) Place the client in Trendelenburg position when
changing caps
