TAYLOR'S CLINICAL NURSING SKILLS
EXAM QUESTIONS WITH CORRECT
ANSWERS
The nurse returns to a client's room after the infusion of IV pain medication via a
volume control administration set has been completed. Which sequence would the
nurse now perform?
Recheck the flow rate of the primary infusion, close the roller clamp, turn off the
pump, remove the volume control device and recap it.
Close the roller clamp, turn off the pump, remove the volume control device, recap it,
and recheck the flow rate of the primary infusion.
Open the roller clamp, remove the volume control device, and recheck the flow rate
of the primary infusion.
Remove the volume control device, recap it, close the roller clamp, and recheck the
flow rate of the primary infusion. - ANSWER-Close the roller clamp, turn off the
pump, remove the volume control device, recap it, and recheck the flow rate of the
primary infusion.
Rationale: When removing the equipment following an infusion via a volume control
administration set, the nurse would close the roller clamp, turn off the pump, remove
the volume control device, recap it, and recheck the flow rate of the primary infusion.
The roller clamp is closed to prevent IV leakage. The flow rate of the primary infusion
is rechecked at the end in case it was disturbed during removal of the equipment.
When administering an IV antibiotic to a client, where would the nurse hang the
piggyback container?
On the IV pole, lower than the primary IV solution container.
On the IV pole, at the same height as the primary IV solution container.
On the IV pole, higher than the primary IV solution container.
On a separate IV pole at the same height as the primary IV solution container. -
ANSWER-On the IV pole, higher than the primary IV solution container.
Rationale: The nurse would hang the piggyback container on the same IV pole,
positioning it higher than the primary IV solution according to manufacturer's
recommendations. The position of containers influences the flow of IV fluid into the
primary setup.
While receiving a medication IV piggyback, the client reports discomfort at the IV
site. Upon assessment, the site is cool to the touch and slightly swollen. What is the
best action by the nurse?
Monitor the site closely for any signs of complications.
Apply a cool moist compress for 20 minutes.
Slow the rate of infusion until client reports relief.
Discontinue the IV site and restart IV in a new location. - ANSWER-Discontinue the
IV site and restart IV in a new location.
Rationale: The assessment reveals the IV has infiltrated. The nurse should stop the
IV fluid and remove the IV from the extremity, then restart the IV in a different
,location. Applying a cool moist compress or slowing the rate will not address the
problem of the IV fluid going into the surrounding tissue instead of the vein.
Monitoring the site is not appropriate, because there is already a complication
present that requires action by the nurse.
After setting up a piggyback IV infusion of antibiotics for a client, the nurse notices
that the solution is not infusing. Which should the nurse do first?
Adjust the roller clamp.
Adjust the infusion rate if necessary.
Notify the health care provider.
Check the tubing for kinks and pressure points. - ANSWER-Check the tubing for
kinks and pressure points.
Rationale: The nurse would first check the tubing for kinks, blockages, and pressure
points. The nurse would then adjust the roller clamp and the infusion rate, if
necessary. The health care provider would not be notified in this situation.
A client has been receiving an IV piggyback medication via gravity. On assessment
the nurse notes that the infusion has not completed but is no longer dripping in the
drip chamber. What action should the nurse perform first?
Hang the IV piggyback medication higher on the IV pole.
Using a sterile syringe, flush the site with 10 mL of sterile saline.
Assess the client's IV site for infiltration or other complication.
Obtain a sterile syringe and attempt to get a blood return from the site. - ANSWER-
Assess the client's IV site for infiltration or other complication.
Rationale: When an IV infusion is not dripping or infusing, the nurse should first
assess the client's IV site to ensure there are no complications. After ensuring the IV
site is safe to continue using, the nurse may try troubleshooting such as flushing it
with sterile saline or hanging the IV bag a little higher and see if it will begin infusing.
A blood return does not ensure that the IV is not infiltrated and should not be the
nurse's first action.
The nurse has just compared the label on the piggyback medication with the
medication administration record (MAR), using the Rights of Medication
Administration for a section check. What is the next step in the process?
Check the medication prescription against the original prescription and check for
allergies.
Use the drug guide to check that the prescribed dose is safe, the administration rate
is correct, and that the client has no contraindications.
Calculate the drip rate for the prescribed infusion time.
Choose the correct medication piggyback set from the client's medication drawer and
check the expiration date. - ANSWER-Calculate the drip rate for the prescribed
infusion time.
Rationale: The correct procedure is to (1) check the medication prescription against
the original prescription and check for allergies; (2) use the drug guide to check that
the prescription dose is safe, the administration rate is correct, and that the client has
no contraindications; (3) choose the correct medication piggyback set from the
client's medication drawer and check the expiration date; (4) compare the label on
the piggyback medication with the MAR; (5) calculate the drip rate.
,After injecting the medication into the injection port of a volume control administration
set, what would the nurse do with the volume control chamber to mix the
medications?
Invert it.
Inject air into it.
No action is needed.
Agitate it gently. - ANSWER-Agitate it gently.
Rationale: The nurse would rotate or gently agitate the volume control chamber to
ensure that the medication is evenly mixed with the solution. Air would not be
injected into the chamber.
The nurse is preparing to administer medication to a client using a piggyback IV
infusion. The client is receiving a continuous IV infusion of dextrose 5% and water
(D5W). Which would be most important for the nurse to do before administering the
medication?
Readjust the flow rate of the continuous infusion.
Ask the pharmacy about the medication's adverse effects.
Put on sterile gloves to set up the piggyback infusion.
Check the compatibility of the medication with the IV solution. - ANSWER-Check the
compatibility of the medication with the IV solution.
Rationale: When administering a piggyback IV medication, it is imperative that the
nurse check to make sure that the prescribed medication is compatible with the
continuous infusion to prevent the risk of injury. There is no need to readjust the flow
rate of the continuous infusion. Rather the nurse would ensure that the piggyback
medication is infusing at the correct rate. The nurse should be knowledgeable about
the medication to be administered and any potential adverse effects. The nurse
would typically consult a drug reference. If additional information is needed, the
nurse could check with the pharmacy. Clean, disposable gloves, not sterile gloves,
are used.
The nurse is attaching the infusion tubing to the medication container when
administering a piggyback IV infusion of medication. What motion would the nurse
use when inserting the tubing spike into the port?
Firm pushing and twisting motion.
Gentle pushing motion.
Gentle twisting motion.
Firm pulling and twisting motion. - ANSWER-Firm pushing and twisting motion.
Rationale: When administering a piggyback infusion, the nurse would attach the
infusion tubing to the medication container by inserting the tubing spike into the port
with a firm pushing and twisting motion, taking care to avoid contaminating either
end.
The nurse is administering a prescribed antibiotic to a client via a piggyback IV
infusion. After hanging the piggyback solution container on the IV pole and labeling
it, what would the nurse do next?
Squeeze the drip chamber of the tubing and release.
Open the clamp and prime the tubing.
Clean the access port above the roller clamp on the primary IV tubing.
Close the clamp and place a needleless connector on the end of the tubing. -
ANSWER-Squeeze the drip chamber of the tubing and release.
, Rationale: The correct order for these procedure steps is (1) squeeze the drip
chamber of the tubing and release, (2) open the clamp and prime the tubing, (3)
close the clamp and place a needleless connector on end of the tubing, and (4) use
an antimicrobial swab to clean the access port or stopcock above the roller clamp on
the primary IV tubing.
After mixing medication with the solution in the volume control chamber, what would
be the nurse's next step?
Clean the injection port on the primary IV infusion tubing closest to the client with an
antimicrobial swab.
Use an alcohol swab to clean the injection port on the primary IV infusion tubing
furthest away from the client.
Insert the tubing into the administration chamber.
Connect the tubing to the injection port. - ANSWER-Clean the injection port on the
primary IV infusion tubing closest to the client with an antimicrobial swab.
Rationale: After mixing the medication with the solution in a volume control chamber,
the nurse would use an antimicrobial swab to clean the injection port on the primary
IV infusion tubing closest to the client. This deters the entry of microorganisms into
the chamber.
The nurse is administering a medication to a client by piggyback IV infusion. Which
accurately describes a step in this procedure?
After assessing the IV site, close the clamp on the long, primary infusion tubing.
After assessing the IV site, open the clamp on the short, secondary infusion tubing.
Attach the infusion tubing spike into the port of the medication container.
Using clean technique, remove the cap on the tubing spike and port of medication
container. - ANSWER-Attach the infusion tubing spike into the port of the medication
container.
Rationale: The nurse administering an IV medication via piggyback infusion would
assess the IV site, close the clamp on the short, secondary infusion tubing, use
aseptic technique to remove the cap on the tubing spike and the port of the
medication container, and attach the infusion tubing to the medication container by
inserting the tubing spike into the port of the medication container.
The nurse is preparing to backprime by gravity. Place in order, from first to last, the
actions the nurse will perform. Use all options. - ANSWER-1)Close the roller clamp
on the tubing.
2)Spike the new bag.
3)Hang the spiked bag on the IV pole.
4)Compress the drip chamber and allow it to fill about halfway full.
5)Connect the secondary bag to the primary bag at the appropriate port.
Rationale: When preparing to backprime a secondary tubing by gravity, the nurse
should first close the roller clamp on the tubing to prevent any accidental loss of
medication, then spike the new bag and hang it on the IV pole. Then the nurse
should compress the drip chamber and allow the drip chamber to become about half
full. The nurse should then open the roller clamp carefully and prime the rest of the
tubing, close the clamp again, connect the tubing to the appropriate port, and then
unclamp the roller clamp and begin the infusion at the prescribed rate.
EXAM QUESTIONS WITH CORRECT
ANSWERS
The nurse returns to a client's room after the infusion of IV pain medication via a
volume control administration set has been completed. Which sequence would the
nurse now perform?
Recheck the flow rate of the primary infusion, close the roller clamp, turn off the
pump, remove the volume control device and recap it.
Close the roller clamp, turn off the pump, remove the volume control device, recap it,
and recheck the flow rate of the primary infusion.
Open the roller clamp, remove the volume control device, and recheck the flow rate
of the primary infusion.
Remove the volume control device, recap it, close the roller clamp, and recheck the
flow rate of the primary infusion. - ANSWER-Close the roller clamp, turn off the
pump, remove the volume control device, recap it, and recheck the flow rate of the
primary infusion.
Rationale: When removing the equipment following an infusion via a volume control
administration set, the nurse would close the roller clamp, turn off the pump, remove
the volume control device, recap it, and recheck the flow rate of the primary infusion.
The roller clamp is closed to prevent IV leakage. The flow rate of the primary infusion
is rechecked at the end in case it was disturbed during removal of the equipment.
When administering an IV antibiotic to a client, where would the nurse hang the
piggyback container?
On the IV pole, lower than the primary IV solution container.
On the IV pole, at the same height as the primary IV solution container.
On the IV pole, higher than the primary IV solution container.
On a separate IV pole at the same height as the primary IV solution container. -
ANSWER-On the IV pole, higher than the primary IV solution container.
Rationale: The nurse would hang the piggyback container on the same IV pole,
positioning it higher than the primary IV solution according to manufacturer's
recommendations. The position of containers influences the flow of IV fluid into the
primary setup.
While receiving a medication IV piggyback, the client reports discomfort at the IV
site. Upon assessment, the site is cool to the touch and slightly swollen. What is the
best action by the nurse?
Monitor the site closely for any signs of complications.
Apply a cool moist compress for 20 minutes.
Slow the rate of infusion until client reports relief.
Discontinue the IV site and restart IV in a new location. - ANSWER-Discontinue the
IV site and restart IV in a new location.
Rationale: The assessment reveals the IV has infiltrated. The nurse should stop the
IV fluid and remove the IV from the extremity, then restart the IV in a different
,location. Applying a cool moist compress or slowing the rate will not address the
problem of the IV fluid going into the surrounding tissue instead of the vein.
Monitoring the site is not appropriate, because there is already a complication
present that requires action by the nurse.
After setting up a piggyback IV infusion of antibiotics for a client, the nurse notices
that the solution is not infusing. Which should the nurse do first?
Adjust the roller clamp.
Adjust the infusion rate if necessary.
Notify the health care provider.
Check the tubing for kinks and pressure points. - ANSWER-Check the tubing for
kinks and pressure points.
Rationale: The nurse would first check the tubing for kinks, blockages, and pressure
points. The nurse would then adjust the roller clamp and the infusion rate, if
necessary. The health care provider would not be notified in this situation.
A client has been receiving an IV piggyback medication via gravity. On assessment
the nurse notes that the infusion has not completed but is no longer dripping in the
drip chamber. What action should the nurse perform first?
Hang the IV piggyback medication higher on the IV pole.
Using a sterile syringe, flush the site with 10 mL of sterile saline.
Assess the client's IV site for infiltration or other complication.
Obtain a sterile syringe and attempt to get a blood return from the site. - ANSWER-
Assess the client's IV site for infiltration or other complication.
Rationale: When an IV infusion is not dripping or infusing, the nurse should first
assess the client's IV site to ensure there are no complications. After ensuring the IV
site is safe to continue using, the nurse may try troubleshooting such as flushing it
with sterile saline or hanging the IV bag a little higher and see if it will begin infusing.
A blood return does not ensure that the IV is not infiltrated and should not be the
nurse's first action.
The nurse has just compared the label on the piggyback medication with the
medication administration record (MAR), using the Rights of Medication
Administration for a section check. What is the next step in the process?
Check the medication prescription against the original prescription and check for
allergies.
Use the drug guide to check that the prescribed dose is safe, the administration rate
is correct, and that the client has no contraindications.
Calculate the drip rate for the prescribed infusion time.
Choose the correct medication piggyback set from the client's medication drawer and
check the expiration date. - ANSWER-Calculate the drip rate for the prescribed
infusion time.
Rationale: The correct procedure is to (1) check the medication prescription against
the original prescription and check for allergies; (2) use the drug guide to check that
the prescription dose is safe, the administration rate is correct, and that the client has
no contraindications; (3) choose the correct medication piggyback set from the
client's medication drawer and check the expiration date; (4) compare the label on
the piggyback medication with the MAR; (5) calculate the drip rate.
,After injecting the medication into the injection port of a volume control administration
set, what would the nurse do with the volume control chamber to mix the
medications?
Invert it.
Inject air into it.
No action is needed.
Agitate it gently. - ANSWER-Agitate it gently.
Rationale: The nurse would rotate or gently agitate the volume control chamber to
ensure that the medication is evenly mixed with the solution. Air would not be
injected into the chamber.
The nurse is preparing to administer medication to a client using a piggyback IV
infusion. The client is receiving a continuous IV infusion of dextrose 5% and water
(D5W). Which would be most important for the nurse to do before administering the
medication?
Readjust the flow rate of the continuous infusion.
Ask the pharmacy about the medication's adverse effects.
Put on sterile gloves to set up the piggyback infusion.
Check the compatibility of the medication with the IV solution. - ANSWER-Check the
compatibility of the medication with the IV solution.
Rationale: When administering a piggyback IV medication, it is imperative that the
nurse check to make sure that the prescribed medication is compatible with the
continuous infusion to prevent the risk of injury. There is no need to readjust the flow
rate of the continuous infusion. Rather the nurse would ensure that the piggyback
medication is infusing at the correct rate. The nurse should be knowledgeable about
the medication to be administered and any potential adverse effects. The nurse
would typically consult a drug reference. If additional information is needed, the
nurse could check with the pharmacy. Clean, disposable gloves, not sterile gloves,
are used.
The nurse is attaching the infusion tubing to the medication container when
administering a piggyback IV infusion of medication. What motion would the nurse
use when inserting the tubing spike into the port?
Firm pushing and twisting motion.
Gentle pushing motion.
Gentle twisting motion.
Firm pulling and twisting motion. - ANSWER-Firm pushing and twisting motion.
Rationale: When administering a piggyback infusion, the nurse would attach the
infusion tubing to the medication container by inserting the tubing spike into the port
with a firm pushing and twisting motion, taking care to avoid contaminating either
end.
The nurse is administering a prescribed antibiotic to a client via a piggyback IV
infusion. After hanging the piggyback solution container on the IV pole and labeling
it, what would the nurse do next?
Squeeze the drip chamber of the tubing and release.
Open the clamp and prime the tubing.
Clean the access port above the roller clamp on the primary IV tubing.
Close the clamp and place a needleless connector on the end of the tubing. -
ANSWER-Squeeze the drip chamber of the tubing and release.
, Rationale: The correct order for these procedure steps is (1) squeeze the drip
chamber of the tubing and release, (2) open the clamp and prime the tubing, (3)
close the clamp and place a needleless connector on end of the tubing, and (4) use
an antimicrobial swab to clean the access port or stopcock above the roller clamp on
the primary IV tubing.
After mixing medication with the solution in the volume control chamber, what would
be the nurse's next step?
Clean the injection port on the primary IV infusion tubing closest to the client with an
antimicrobial swab.
Use an alcohol swab to clean the injection port on the primary IV infusion tubing
furthest away from the client.
Insert the tubing into the administration chamber.
Connect the tubing to the injection port. - ANSWER-Clean the injection port on the
primary IV infusion tubing closest to the client with an antimicrobial swab.
Rationale: After mixing the medication with the solution in a volume control chamber,
the nurse would use an antimicrobial swab to clean the injection port on the primary
IV infusion tubing closest to the client. This deters the entry of microorganisms into
the chamber.
The nurse is administering a medication to a client by piggyback IV infusion. Which
accurately describes a step in this procedure?
After assessing the IV site, close the clamp on the long, primary infusion tubing.
After assessing the IV site, open the clamp on the short, secondary infusion tubing.
Attach the infusion tubing spike into the port of the medication container.
Using clean technique, remove the cap on the tubing spike and port of medication
container. - ANSWER-Attach the infusion tubing spike into the port of the medication
container.
Rationale: The nurse administering an IV medication via piggyback infusion would
assess the IV site, close the clamp on the short, secondary infusion tubing, use
aseptic technique to remove the cap on the tubing spike and the port of the
medication container, and attach the infusion tubing to the medication container by
inserting the tubing spike into the port of the medication container.
The nurse is preparing to backprime by gravity. Place in order, from first to last, the
actions the nurse will perform. Use all options. - ANSWER-1)Close the roller clamp
on the tubing.
2)Spike the new bag.
3)Hang the spiked bag on the IV pole.
4)Compress the drip chamber and allow it to fill about halfway full.
5)Connect the secondary bag to the primary bag at the appropriate port.
Rationale: When preparing to backprime a secondary tubing by gravity, the nurse
should first close the roller clamp on the tubing to prevent any accidental loss of
medication, then spike the new bag and hang it on the IV pole. Then the nurse
should compress the drip chamber and allow the drip chamber to become about half
full. The nurse should then open the roller clamp carefully and prime the rest of the
tubing, close the clamp again, connect the tubing to the appropriate port, and then
unclamp the roller clamp and begin the infusion at the prescribed rate.
