NURS 3320 Test Bank Intravenous Therapy Questions and Answers and Rationale,100% CORRECT

NURS 3320 Test Bank Intravenous Therapy Questions and Answers and Rationale 1. You are training nurses at your hospital to insert midline catheters. What would you teach the nurses about how many inches of the catheter should be inserted into the required site and for how long can it be used? A) 1 to 3 inches, used for up to 3 weeks B) 3 to 6 inches, used for up to 4 weeks C) 7 to 8 inches, used for up to 5 weeks D) 8 to 9 inches, used for up to 6 weeks Ans: B Feedback: A midline catheter is 7 to 8 inches long, but only 3 to 6 inches of the catheter are inserted. This type of catheter can be used for up to 4 weeks before it requires replacement. Therefore, the other options are incorrect. 2. Your client is going out on pass for the afternoon with his family. The physician has ordered that his venipuncture device needs to be temporarily capped. How will you ensure that the vein remains patent? A) Flush the lock with potassium chloride. B) Flush the lock with saline or heparinized saline. C) Flush the lock with cyclical total parenteral nutrition (TPN). D) Flush the lock with colloid solutions. Ans: B Feedback: When a venipuncture device is temporarily capped, the vein is kept patent by flushing the lock with saline or heparinized saline. Deaths have occurred when potassium chloride has been used incorrectly to flush a lock. TPN solutions are used to provide nutrition, and colloid solutions are used to replace circulating blood volume; these solutions are not used to flush locks. 3. You are the emergency department nurse caring for a client who has just been admitted by ambulance for a suspected myocardial infarction. The physician orders IV fluids of normal saline to be hung at 100 mL/hr. You know that this is what type of IV solution? A) Crystalloid B) Colloid C) Hypertonic D) Hypotonic Ans: A Feedback: The two types of IV solutions are crystalloid and colloid solutions. Crystalloid solutions consist of water and uniformly dissolved crystals such as salt (sodium chloride) or sugar (glucose, dextrose). Normal saline is an isotonic crystalloid solution. Colloid solutions are used to replace blood. Hypertonic solutions are rarely used. Hypotonic solutions contain fewer dissolved substances compared with plasma. 4. The nursing instructor is discussing the different types of IV fluids with the nursing students. What type of fluid would the instructor tell the students is used to replace circulating blood? A) Hypertonic solutions B) Crystalloid solutions C) Hypotonic solutions D) Colloid solutions Ans: D Feedback: Colloid solutions are used to replace circulating blood volume because the suspended molecules in the solutions pull fluid from other fluid compartments in the body. Colloids contain blood cells such as RBCs. Crystalloid solutions are made from water and sodium chloride or sugar. Hypotonic solutions contain more dissolved substances compared with plasma. Hypertonic solutions pull fluids into plasma but do not assist with replacement of cells. 5. You are caring for a client who has an order to receive Hespan IV. The client asks you what this solution is for. What would be your response? A) “This solution pulls fluid into the vascular space.” B) “This is a colloid solution used to replace blood.” C) “Hespan is a solution used instead of a transfusion.” D) “Hespan is an artificial blood replacement product.” Ans: A, B, C Feedback: Plasma expanders are nonblood solutions, such as dextran 40 (Rheomacrodex) and hetastarch (Hespan), that pull fluid into the vascular space. Options B and C are also correct. Hespan is not artificial blood. 6. The nurse caring for a client with an intravenous infusion is looking up her institution's policy on changing IV equipment used in a venipuncture. When is most IV tubing changed? A) Every 12 hours B) Every 24 hours C) Every 48 hours D) Every 72 hours Ans: D Feedback: Most IV tubing is changed every 72 hours, but the exact parameters depend on agency policy. Some exceptions include tubing used to administer TPN and intermittent secondary infusions. Therefore, options A, B, and C are incorrect. 7. You are caring for an older adult client with an IV infusing at 100 mL/hr. What should you monitor this client for? A) Urinary retention B) Circulatory overload C) Pulmonary embolism D) Incontinence Ans: B Feedback: Circulatory overload can develop if the volume of infusing solution exceeds the heart's ability to circulate it effectively. The scenario does not indicate that the client is at risk for urinary retention or incontinence. IV fluids infusing at 100 mL/hr do not put the client at risk for a pulmonary embolism. 8. You are caring for a client who has just had total parenteral nutrition (TPN) ordered. The LPN is correct when informing the client that TPN is used for what? A) To meet the client's need for protein B) To provide calories and prevent weight loss C) To provide glucose to the client and prevent weight loss D) To meet the client's caloric and nutritional needs Ans: D Feedback: TPN uses a solution of nutrients to meet the client's caloric and nutritional needs. TPN does provide calories and glucose to the client, but it does not prevent weight loss. TPN does include protein, but it usually does not meet the total protein requirement of the adult client. 9. Your client has just had a transfusion ordered for severe anemia. You are gathering the supplies that you need in order to transfuse the client. What kind of tubing do you know that you need to infuse blood or blood products? A) Y-administration tubing B) Macrodrip tubing C) Minidrip tubing D) Primary tubing Ans: A Feedback: Blood is administered through Y-administration tubing. Blood is never infused through any tubing except Y-administration tubing, which makes options B, C, and D incorrect. 10. The nursing instructor is teaching student nurses about venipuncture techniques and possible complications from the procedure. What can happen if the venipuncture device is left in the clients' vein too long? A) Phlebitis can develop. B) Gangrene can set in. C) Necrosis of the skin will develop. D) Cold packs will need to be used to reduce the pain. Ans: A Feedback: Because the venous access device traumatizes the vein wall and disturbs the flow of blood cells in the vein, there is a potential for phlebitis, inflammation of the vein, and thrombus formation (development of a clot). Gangrene is not an issue; necrosis of the skin depends on the fluid being infused and if it has infiltrated; and warm compresses are used, not cold packs. 11. Which of the following provides the best practice for the graduate nurse in the administration and regulation of intravenous fluids to clients? A) Nursing supervisor B) The physician C) Nursing instructor D) State licensing board Ans: D Feedback: The state nurse practice act specifies the qualifications and regulations for scope of practice of nurses. In addition, the nurse must follow the policies/procedures of the institution in which presently employed. The nursing supervisor should be able to provide guidance to a new employee but is not the ultimate authority. The nursing instructor prepares the educational track for learning but does not provide guidance in employment situations. The physician initiates the orders for IV therapy but does not provide nursing guidance. 12. The nurse would expect to hang which of the following intravenous (IV) solution to a client with ascites? A) Isotonic solution B) Low osmolarity solution C) Hypotonic solution D) Hypertonic solution Ans: D Feedback: With ascites, minimizing the fluid in the cells can be accomplished with the use of hypertonic solutions. Hypertonic solutions act by pulling the fluid from the cells to the blood vessels. Isotonic solutions stay within the blood vessels and do not minimize ascites. Hypotonic solutions are lower in osmolarity and shift fluids from the blood vessels to the cells. 13. A client is brought to the emergency department with full-thickness burns to 27% of the body. The nurse knows to prepare intravenous (IV) fluid administration from which solution group? A) Isotonic B) Hypertonic C) Lower osmolarity solution D) Higher osmolarity solution Ans: C Feedback: Lower osmolarity solutions are hypotonic solutions and will shift fluid from the blood vessels to the cells (where damage has occurred). Isotonic solutions will assist in preventing hypovolemia but will not rescue the damaged cells and prevent further dehydration. Higher osmolarity solutions are hypertonic and will pull fluid from the cells to the blood vessels. 14. A client is scheduled for a test that requires an NPO status and has been ordered 5% dextrose in water (D5W). The nurse understands which of the following to be the best rationale for this action? A) Isotonic solutions maintain body fluid balance. B) Hypotonic solutions replenish the cells. C) Hypotonic solutions reduce need for circulatory fluids. D) Hypertonic solutions replace lost fluids. Ans: A Feedback: Isotonic solutions, such as D5W, are administered for maintenance of fluid balance. Hypotonic solutions do provide fluid to the cells, but this is not the purpose for D5W. Hypertonic solutions are used to pull fluid into the blood vessels and are not used to replace lost fluids. 15. The nurse receives an order for a client to be given a colloid solution. Which is the likely reason for the use of this type of solution? A) Dependent edema B) Increased blood loss C) Skin turgor is decreased. D) The blood pressure has increased. Ans: B Feedback: Colloid solutions create oncotic pressure that pulls fluid into the blood vessels and expands the space. Common colloid products are blood products. Dependent edema would be remedied by careful use of hypertonic (crystalloid solution). Increased blood pressure can be caused by hypertonic solutions or use of colloid solutions. Decreased skin turgor is caused by dehydration not blood loss. 16. A client with severe malnutrition is ordered intravenous (IV) albumin. Which is the primary assessment in providing nursing care for this client? A) Monitor hematocrit and hemoglobin (H&H). B) Monitor for fluid overload. C) Assess for thrombocytopenia. D) Assess for elevation of white blood cells (WBCs). Ans: B Feedback: Albumin attracts fluid so care is taken to monitor clients for signs of fluid overload during and after albumin administration. Albumin is a plasma protein and should not affect H&H. Albumin does not lower thrombocytes or elevate WBCs. 17. A client is brought to the emergency department with a diagnosis of possible cerebral vascular accident (CVA) and is being typed and crossmatched for fresh frozen plasma (FFP). Which is the best nursing understanding for this action? A) Best treatment for embolus causing stroke B) The stroke is still evolving. C) Client is experiencing a hemorrhagic stroke. D) The client is experiencing hypervolemia. Ans: C Feedback: FFP contains fibrinogen and components for coagulation and is used to treat clotting disorders and/or hemorrhage. An embolus is not treated with FFP. An evolving stroke is a stroke in which the symptoms are still changing and does not define the cause of the stroke. Hypervolemia means intravascular overload, which is not usually associated with a stroke. 18. Which is the best option for raising the white blood cell count in a cancer client who is at risk for congestive failure? A) Granulocyte transfusion B) Packed red blood cells (PRBCs) C) Whole blood D) Injection of filgrastim (Neupogen) Ans: D Feedback: Neupogen stimulates bone marrow production of granulocytes and is used in clients with cancer. Neupogen is given as a 0.6-mL injection. Granulocyte transfusions are usually 400 mL units and will add to fluid in the intravascular fluid space. One unit of whole blood will add 500 mL, whereas PRBCs add 250 mL of added fluid. 19. A client is ordered an intravenous (IV) solution of Ringer's lactate 1000 mL to infuse at 40 mL/hr. What is the maximum amount of time the nurse should allow this IV to hang? A) 22 hours B) 23 hours C) 24 hours D) 25 hours Ans: C Feedback: Although the 1000-mL bag can deliver 25 hours of infusion (at the rate of 40 mL/hr) the nurse knows that once the IV solution bag is spiked, the bag cannot hang for more than 24 hours. 20. Thirty minutes after hanging a glass intravenous bottle of total parenteral nutrition (TPN), the nurse notices the solution has stopped dripping. Which is the best troubleshooting action of the nurse? A) Restart the IV. B) Hang vented tubing. C) Turn off infusion pump. D) Hang in-line filtered tubing. Ans: B Feedback: Vented tubing draws air into the container and must be used with glass bottles. Restarting the IV is unnecessary and places the client at risk for further complications. Turning off the pump will not correct the problem. In-line filtered tubing should always be used with TPN but will not correct the problem. 21. There are limited infusion pumps available on the nursing unit. Which client has the greatest need for accurate fluid monitoring? Select all that apply. A) Young adult with pneumonia B) Adolescent with knee infection C) Older adult receiving potassium chloride in the solution D) Middle-aged adult receiving medication for congestive failure Ans: C, D Feedback: A client with congestive failure should be monitored closely for signs of worsening fluid overload and is at great risk. Young adult and adolescent would need monitoring but not at greatest risk. Potassium chloride can cause extravasation if not monitored closely and is also at great risk. 22. A central venous catheter has been inserted in the right subclavian vein of the client. Which of the following would be the priority nursing action before total parenteral nutrition (TPN) can be started? A) Assess for swelling, redness, and drainage of the site. B) Allow the TPN solution warm to room temperature. C) Call for portable chest x-ray. D) Assess blood sugar via glucometer. Ans: C Feedback: Insertion of a central venous access device in the subclavian can result in an accidental puncture of the pleural membrane, resulting in a pneumothorax. Verification of the insertion site is completed before TPN is started. Swelling, redness, and drainage are symptoms of infection which would not be present immediately following insertion. Hyperglycemia is a common occurrence with the use of hypertonic solutions such as found in TPN, but because the TPN has not been started, this is not a priority assessment. Cold solutions can result in venous spasms but not the priority. 23. The client complains that the intravenous (IV) site is stinging. No signs of infiltration or inflammation are assessed, but the nurse notices the rate is running faster than ordered. Which action should the nurse take first? A) Stop the infusion. B) Reset the drip rate. C) Document the findings. D) Assess the vital signs. Ans: B Feedback: Decreasing the rate of flow and reassessing the symptoms is the priority. If no adverse symptoms are noted, stopping the infusion would not be indicated. Assessing the vital signs during IV infusion is a routine part of nursing care of clients with IV therapy but not a priority for this complaint. Documentation is not the first action to be taken. 24. The nurse is preparing an intravenous partial bottle (IVPB) of anti-infective as ordered. Which is the best method of delivery for a client with a history of congestive failure? A) IV push B) Continuous IV infusion C) Intermittent infusion via medication lock D) Infusion via midline catheter Ans: C Feedback: A medication lock provides a route for intermittent infusion of medications/solutions that limits the amount of solution given. IV push is not the preferred route for administration of anti-infective and is not an approved route for the LPN/VPN. Midline catheter is used for long-term peripheral IV therapy is not indicated. Continuous IV infusion would place the client at greater risk for fluid over load. 25. Which isotonic solution is often used in providing a source of energy to clients receiving total parenteral nutrition (TPN)? A) Lipid emulsions B) Normal saline solution (NSS) C) Dextrose 5% in water (D5W) D) Ringer's lactate (RL) Ans: A Feedback: A lipid emulsions prevent and treat essential fatty acid deficiencies and provide a major source of energy. NSS, D5W, and RL are all isotonic solutions but are not used in addition to TPN and do not a good source of energy. 26. When flushing an intravenous (IV) lock with saline, the nurse avoids forcing the injection into the client. Which is the best rationale for this action? A) Prevents IV infiltration B) Minimizes discomfort/burning C) Minimizes potential for clot release D) Prevents dislodging the venous access device Ans: C Feedback: Forcing the solution through a resistant lock may dislodge a clot into the client's circulation. The risk of IV infiltration and dislodgement is not a priority. Discomfort and burning associated with lock flushing is related to the rate of infusion not force. 27. To avoid complications of blood transfusion reaction, which nursing action is most important? A) Matching numbers on blood bag to client bracelet B) Making sure IV catheter size is 20 gauge or larger C) Hanging normal saline before and after blood infusion D) Only allowing the registered nurse to initiate, maintain, and discontinue the blood Ans: A Feedback: When the laboratory draws a sample of blood for typing and crossmatching, an identification bracelet is attached to the client and must match to confirm the correct blood at time of administration. A 20-gauge needle or greater is preferred for administration of blood but not a priority for avoiding transfusion reaction. Normal saline is the isotonic solution used with transfusions but not indicated for prevention of reactions. Registered nurses are required to initiate blood transfusions, but the scope of practice is changing in some states for the LPN/VPN to maintain and/or discontinue the transfusion after the initial assessment period. 28. Before instilling any additives to a client's medication lock, normal saline is used to flush the device. Which of the following provides the best rationale for this action? A) Prevents drug/solution incompatibilities B) Dilutes the medication for easier administration C) Decreases the drug's irritating effect D) Maintains the serum sodium level and pH balance Ans: A Feedback: To prevent incompatibility between medication doses, the line should be flushed with normal saline. The medication is diluted and mixed in the partial bottle prior to administration. Following the instructions for mixing and preparation of the drug should allow for safe (less irritating) administration of the drug. Saline flush is used in small amounts (approximately 2 to 3 mL) and will not affect the sodium level or pH of the blood. 29. The major advantage for giving a client medication via intravenous (IV) route is which of the following? A) Fewer adverse reactions noted B) Less costly to the client C) Rapid distribution of the drug to all target tissues D) Ease of maintaining drug therapy in the home setting Ans: C Feedback: The IV route produces a rapid drug effect throughout the body. IV administration of drugs can be more costly than the oral route. Adverse reaction toward the medication is not effected by the route. The easiest route for drug therapy in the home is usually oral route. 30. In providing nursing care to a client, which actions should the nurse take to reduce the risk of administering a precipitated intravenous (IV) solution? Select all that apply. A) Use in-line filters on peripheral and central line IV solutions. B) Avoid reconstituting powder drugs when preparing the solution. C) Inspect IV solutions prior to administration. D) Do not use any solution that is expired. Ans: C, D Feedback: Inspecting the solution to make sure the solution is clear, transparent, and does not contain a precipitant is the primary action to be taken prior to any IV administration. In- line filters are not used routinely on peripheral IVs but are used for TPN and blood transfusions. IV drugs are often packaged in the powder form. The nurse should inspect the IV container for expiration date and should not use those solutions that are past the expiration date. 31. The client asks the nurse why it is necessary to prime the intravenous tubing. Which is the best response by the nurse? A) “It eliminates air and potential of complications.” B) “It helps to keep the catheter open and flowing.” C) “It allows for air lock, which ensures the delivery of all the medication.” D) “It adheres to infection control and prevention of infection.” Ans: A Feedback: A bolus of air that is forced into the venous system can result in pulmonary emboli, shock, or death. Priming the tubing does not keep the catheter open and flowing and is not indicated for infection control purposes. An air lock used in intramuscular injections is not indicated for IV administration. 32. The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline. Which is the most likely nursing diagnosis for this client? A) Ineffective Peripheral Tissue Perfusion B) Ineffective Airway Clearance C) Excess Fluid Volume D) Impaired Tissue Integrity Ans: C Feedback: The symptoms the client is experiencing indicated excess fluid volume. If the edema continues in the lower extremities, peripheral tissue perfusion and integrity can become impaired. Ineffective airway associated with the crackles is directly related to the fluid volume overload. 33. The client is receiving total parenteral nutrition (TPN), and the solution bag is almost empty. The nurse discovers there are no containers prepared for use. Which is the immediate action of the nurse? A) Hang dextrose 10% in water (D10W) until new container is ready. B) Hang normal saline solution (NSS). C) Slow the rate to keep vein open (KVO) until new container is ready. D) Stop the infusion and then flush the catheter to maintain patency. Ans: A Feedback: Abruptly stopping the administration of hypertonic, high-glucose solutions will result in a rebound hypoglycemic effect and can be avoided if the approximate glucose concentration can be assessed and added to D10W solution. NSS does not contain glucose. Slowing or stopping the rate of infusion will not prevent rebound hypoglycemia. 34. A postoperative total hip replacement client is to receive salvaged blood through the cell saver system. The nurse is most concerned about which possible transfusion reaction? A) Incompatibility reaction B) Allergic reaction C) Hepatitis B D) Septic reaction Ans: D Feedback: Infusion of blood products that contain microorganisms can result in septic reaction. The cell saver system requires specific guidelines and timelines for safe administration of the salvaged blood. Incompatibility reactions and allergic reactions are associated with mismatched donor and recipient blood, but salvaged blood comes directly from the client. Hepatitis B is not indicated with self-transfusions.