NURS-242 Final Exam Study Guide
Questions With Complete Solutions
/. Tolerance of IV infusion therapy - Answer-No edema, no changes in LOC, increase in
urine output, no crackles upon lung auscultation, no change in VS
/.Subcutaneous butterfly label - Answer-Name of drug, date, time, drug concentration,
signature/initials
/.Administering drugs in subcutaneous butterfly site - Answer-Only one drug and one
concentration per butterfly
/.PVAD site assessment - Phlebitis - Answer-Red and tender site, warm with erythema
along the path of the vein
/.PVAD site assessment - Infiltration - Answer-Cool, pale, and painful site; edema at
site; IV bag not running by gravity or more volume than expected remains in the IV bag
/.PVAD site assessment - Hematoma - Answer-Change of color as healing occurs,
painful, increase in size
/.PVAD site assessment - Extravasation - Answer-Pain, redness, burning; no blood
return; edema is noted
/.PVAD site assessment - Infection - Answer-Warm site with swelling, spreading with
localized pain, no drainage noted
/.Grade 4 phlebitis - Answer-Pain at access site with erythema, streak formation,
palpable venous cord, purulent drainage
/.Calculating time for a bag to finish draining - Answer-Divide volume by infusion rate to
determine hours
/.Calculating daily fluid intake - Answer-Not provided in notes
/.Minimum hourly urine output - Answer-30 ml per hour
/.Calculating gtts/min for 100mL/hr tube (10gtt/mL) - Answer-Rate x drop factor / time
(mins) = 17 gtts/min
/.Calculating gtts/min for 100mL/hr tube (15gtt/mL) - Answer-Rate x drop factor / time
(mins) = 25 gtts/min
, /.Recommended hourly fluid intake for an adult - Answer-Not provided in notes
/.Teaching for patient using an IV pole - Answer-Use opposite arm to push the pole to
avoid kinking the line
/.PIV not running or beeping - Answer-Flush the PIV and check for occlusions
/.Dropping IV line on floor or contaminated surface - Answer-Get a new IV tube, prime
new line
/.Risk of hypertonic solutions - Answer-They can further exacerbate heart failure
/.Crystalloid fluids vs Colloidal fluids - Answer-We use Crystalloid fluids more than
Colloidal fluids
/.Gauze dressing for PVAD - Answer-Used when patients cannot tolerate transparent
tegaderm dressing
/.Changing gauze PVAD dressing - Answer-Change after 3 days or if it is coming loose,
remove dressing, assess the site, clean, and apply another gauze dressing
/.Performing a PVAD dressing change - Answer-Stabilize the wings when removing the
dressing, remove by loosening the edges
/.Changing intermittent IV line - Answer-Change every 24 hours
/.Changing continuous IV line - Answer-Change every 96 hours
/.Flushing an IV properly - Answer-Use start-stop/turbulent flush technique, leave a
small amount of fluid in the syringe
/.Output vs input - Answer-Output will be 500ml less than input due to insensible loss
/.Factors that influence wound healing - Answer-Adequate perfusion and oxygenation,
chronic moisture, nutrition and hydration, comorbidities, pressure offloading, infection,
advanced age, MRDPIs, corticosteroid therapy/immunosuppressants, metabolic control,
alcohol/smoking/drug use
/.Principles of a sterile field - Answer-Fluid flows in the direction of gravity, 2.5 inch
border is considered contaminated, wet surface means field is contaminated, prolonged
exposure to airflow contaminates sterile field, objects out of sight or below waist are
considered contaminated, only sterile objects may be placed on the sterile field, integrity
of sterile field packaging is intact, sterile objects only remain sterile when touched by
other sterile objects
Questions With Complete Solutions
/. Tolerance of IV infusion therapy - Answer-No edema, no changes in LOC, increase in
urine output, no crackles upon lung auscultation, no change in VS
/.Subcutaneous butterfly label - Answer-Name of drug, date, time, drug concentration,
signature/initials
/.Administering drugs in subcutaneous butterfly site - Answer-Only one drug and one
concentration per butterfly
/.PVAD site assessment - Phlebitis - Answer-Red and tender site, warm with erythema
along the path of the vein
/.PVAD site assessment - Infiltration - Answer-Cool, pale, and painful site; edema at
site; IV bag not running by gravity or more volume than expected remains in the IV bag
/.PVAD site assessment - Hematoma - Answer-Change of color as healing occurs,
painful, increase in size
/.PVAD site assessment - Extravasation - Answer-Pain, redness, burning; no blood
return; edema is noted
/.PVAD site assessment - Infection - Answer-Warm site with swelling, spreading with
localized pain, no drainage noted
/.Grade 4 phlebitis - Answer-Pain at access site with erythema, streak formation,
palpable venous cord, purulent drainage
/.Calculating time for a bag to finish draining - Answer-Divide volume by infusion rate to
determine hours
/.Calculating daily fluid intake - Answer-Not provided in notes
/.Minimum hourly urine output - Answer-30 ml per hour
/.Calculating gtts/min for 100mL/hr tube (10gtt/mL) - Answer-Rate x drop factor / time
(mins) = 17 gtts/min
/.Calculating gtts/min for 100mL/hr tube (15gtt/mL) - Answer-Rate x drop factor / time
(mins) = 25 gtts/min
, /.Recommended hourly fluid intake for an adult - Answer-Not provided in notes
/.Teaching for patient using an IV pole - Answer-Use opposite arm to push the pole to
avoid kinking the line
/.PIV not running or beeping - Answer-Flush the PIV and check for occlusions
/.Dropping IV line on floor or contaminated surface - Answer-Get a new IV tube, prime
new line
/.Risk of hypertonic solutions - Answer-They can further exacerbate heart failure
/.Crystalloid fluids vs Colloidal fluids - Answer-We use Crystalloid fluids more than
Colloidal fluids
/.Gauze dressing for PVAD - Answer-Used when patients cannot tolerate transparent
tegaderm dressing
/.Changing gauze PVAD dressing - Answer-Change after 3 days or if it is coming loose,
remove dressing, assess the site, clean, and apply another gauze dressing
/.Performing a PVAD dressing change - Answer-Stabilize the wings when removing the
dressing, remove by loosening the edges
/.Changing intermittent IV line - Answer-Change every 24 hours
/.Changing continuous IV line - Answer-Change every 96 hours
/.Flushing an IV properly - Answer-Use start-stop/turbulent flush technique, leave a
small amount of fluid in the syringe
/.Output vs input - Answer-Output will be 500ml less than input due to insensible loss
/.Factors that influence wound healing - Answer-Adequate perfusion and oxygenation,
chronic moisture, nutrition and hydration, comorbidities, pressure offloading, infection,
advanced age, MRDPIs, corticosteroid therapy/immunosuppressants, metabolic control,
alcohol/smoking/drug use
/.Principles of a sterile field - Answer-Fluid flows in the direction of gravity, 2.5 inch
border is considered contaminated, wet surface means field is contaminated, prolonged
exposure to airflow contaminates sterile field, objects out of sight or below waist are
considered contaminated, only sterile objects may be placed on the sterile field, integrity
of sterile field packaging is intact, sterile objects only remain sterile when touched by
other sterile objects
