NURS 337 EXAM 1 QUESTIONS WITH VERIFIED
ANSWERS
Isotonic Solutions - Answers - Similar concentration to water and electrolytes to plasma;
ideal for fluid replacement with no shifts in osmosis.
0.9% NaCl (Normal Saline) - Answers - Increases sodium and chloride; good for
patients with fluid volume loss from diarrhea, vomiting, and blood loss; not good for
maintenance fluids.
Hypovolemia - Answers - Decreased blood volume.
Metabolic Alkalosis - Answers - High pH condition.
Hyperkalemia - Answers - Increased potassium levels.
Hyponatremia - Answers - Low sodium levels.
Hypochloremia - Answers - Low chlorine levels.
Lactated Ringer's - Answers - Good for surgery, burns, and GI fluid loss; contains
potassium; not to be given in patients with liver dysfunction, hyperkalemia, and
hypovolemia.
5% Dextrose in Water (D5W) - Answers - Dextrose is sugar; can be isotonic in the bag
but hypotonic in the body; used in fluid loss and dehydration; should not be used in
excessive volumes.
Ringers Solution - Answers - Commonly used for wound irrigation; not often used IV.
Hypotonic Solutions - Answers - Fluid goes into cells causing them to swell; contains
more water than concentrate; used for cell rehydration.
0.45% NaCl - Answers - Used as a basic fluid maintenance; rises total fluid volume; not
good for brain swelling.
0.33% NaCl - Answers - Aids kidneys to eliminate solutes; treats hypernatremia.
Nursing Considerations for Isotonic Solutions - Answers - Monitor for signs of fluid
overload, especially in patients with congestive heart failure and hypertension.
Hypertonic Solutions - Answers - Higher osmotic pressure; very concentrated; good for
patients with hyponatremia, hypovolemia, and trauma.
,Fluid Overload Symptoms - Answers - Crackles, jugular vein distention, edema,
bounding pulses.
Cerebral Edema - Answers - Swelling of the brain; can be worsened by inappropriate IV
fluid use.
Contraindications for Hypotonic Solutions - Answers - Do not give to patients with
increased cranial pressure.
Fluid Maintenance - Answers - Hypotonic solutions are good for maintenance fluids.
Hypernatremia - Answers - High sodium levels; can be treated with certain IV solutions.
D10W - Answers - Used for parenteral nutrition
3.0% Saline - Answers - Used to treat symptomatic hyponatremia and trauma patients
with head injury. Admin slowly. Risk for fluid overload and pulmonary edema.
5% dextrose in 0.45% Saline - Answers - Maintenance fluid. Provides calories- used in
peripheral parenteral nutrition. Most common postop fluid.
5% dextrose in 0.9% Saline - Answers - Used to treat metabolic alkalosis and fluid
volume deficits with hyponatremia. Causes fluid overload, which is swelling, and it can
back up to the heart and lungs.
Nursing Considerations for hypertonic solutions - Answers - Monitor BP, lung sounds,
and sodium levels- risk for fluid volume excess. Monitor for circulatory overload (infused
too quickly).
Circulatory overload signs - Answers - Jugular vein distention, bounding pulse, crackles,
edema.
Irritation to veins - Answers - Can be irritating to veins due to high solute concentration.
Infuse slowly. Risk for cellular dehydration if infused too quickly.
Nursing Responsibilities w/ Mineral Electrolyte Preparations - Answers - NEVER GIVE
POTASSIUM IV PUSH. Assess for adverse effects.
Volume excess signs - Answers - Pitting edema & hypertension.
Volume deficit signs - Answers - Cold clammy skin & hypotension.
IV therapy nurse responsibilities - Answers - Nurse responsible for noting concerns
about ordered meds. Ex. if a patient's K level is elevated you don't wanna give them
lactated ringers.
,LR - Answers - LR contains potassium.
IV placement considerations - Answers - Usually placed on non-dominant hand. Cannot
be placed on the arm if same-sided breast cancer, burns, infection, injury. Commonly do
not use adult legs.
Infusion rate monitoring - Answers - CHECK INFUSION RATE EVERY HOUR OR
MORE FREQ.
Infiltration - Answers - Leakage of intravenous solution into surrounding tissue
(NONVESICANT- not irritating). Cool skin indicates infiltration.
Infiltration signs and symptoms - Answers - Swelling, pallor, coldness, or pain around
the infusion site. Significant decrease in the flow rate.
Infiltration nursing considerations - Answers - Check the infusion site every hour for
signs and symptoms. Discontinue the infusion if symptoms occur. Restart the infusion at
a different site.
Infiltration scale - Answers - 0= no symptoms; 1= skin blanched, edema <1 inch in any
direction, cool to touch, with or without pain; 2= skin blanched, edema 1-6 inch in any
direction, cool to touch, with or without pain; 3= skin clanched, translucent, gross edema
>6 inch in any direction, cool to touch, mild-mod pain, possible numbness; 4= skin
blanched, translucent, skin-tight, leaking, skin discolored, bruised, swollen, gross
edema >6 inch in any direction, circulatory impairment, mod-severe pain.
Phlebitis - Answers - Inflammation/irritation of a vein (vesicant). Mechanical trauma from
needle or catheter. Chemical trauma from the solution.
Phlebitis signs and symptoms - Answers - Redness, tenderness, slight edema of a vein
above the site, warm skin. Severe cases: red streak along the vein, vein distention,
purulent drainage.
Phlebitis nursing considerations - Answers - Discontinue iv immediately, apply a warm
moist compress to the affected site, restart IV in another vein in another arm, if not go
above the bad site.
Phlebitis scale - Answers - 0= no symptoms; 1= erythema at access site with or without
pain; 2=pain at access site with erythema and/or edema; 3= pain at access site with
erythema and/or edema, streak formation, palpable venous cord; 4= pain at access site
with erythema and/or edema, streak formation, palpable venous cord >1 inch in length,
purulent drainage.
Thrombus - Answers - Blood clot in the vein that causes inflammation (tissue trauma
from needle/catheter).
, Thrombus signs and symptoms - Answers - Redness, tenderness, slight edema, IV fluid
flow may stop if clot obstructs needle.
Thrombus nursing consideration - Answers - Stop infusion immediately - restart at
another site, do not rub/massage the affected area.
Speed shock - Answers - the body's reaction to a substance that is injected rapidly into
the circulatory system
Signs and symptoms of speed shock - Answers - pounding headache, rapid pulse,
fainting, back pains, dyspnea, apprehension, chills
Nursing considerations for speed shock - Answers - Use the proper IV tubing, carefully
monitor the rate of fluid flow, check the rate and frequency for accuracy.
Extravasation - Answers - Inadvertent leakage of vesicant intravenous solution into
surrounding tissue
Consequences of extravasation - Answers - Leaking of highly irritating IV solution or
medication into the tissue causing blisters, tissue damage, necrosis
Vesicants - Answers - These highly caustic/irritating solutions are called vesicants,
including chemotherapy, vasoconstriction (vasopressin), diltiazem, potassium, propofol.
Fluid Overload - Answers - too large a volume of fluid infuses into the circulatory system
Signs and symptoms of fluid overload - Answers - engorged neck veins, increased
blood pressure, edema, dyspnea - can result in cardiac/resp failure!
Nursing considerations for fluid overload - Answers - slow rate of infusion, monitor
vitals, call doctor, carefully monitor the rate of fluid flow.
Air embolus - Answers - air in the circulatory system, break in the IV system above the
heart level allowing air in
Signs and symptoms of air embolus - Answers - Respiratory distress, increased heart
rate, cyanosis, decreased bp, change LOC
Nursing considerations for air embolus - Answers - pinch off catheter or secure system
to prevent the entry of air, place pt in left side Trendelenburg position, call for help,
monitor vitals and pulse ox.
Venous access device signs and symptoms - Answers - Erythema and edema
Nursing considerations for venous access device - Answers - Perform hand hygiene
before and after palpating the catheter inserting site; assess catheter site at least daily.
ANSWERS
Isotonic Solutions - Answers - Similar concentration to water and electrolytes to plasma;
ideal for fluid replacement with no shifts in osmosis.
0.9% NaCl (Normal Saline) - Answers - Increases sodium and chloride; good for
patients with fluid volume loss from diarrhea, vomiting, and blood loss; not good for
maintenance fluids.
Hypovolemia - Answers - Decreased blood volume.
Metabolic Alkalosis - Answers - High pH condition.
Hyperkalemia - Answers - Increased potassium levels.
Hyponatremia - Answers - Low sodium levels.
Hypochloremia - Answers - Low chlorine levels.
Lactated Ringer's - Answers - Good for surgery, burns, and GI fluid loss; contains
potassium; not to be given in patients with liver dysfunction, hyperkalemia, and
hypovolemia.
5% Dextrose in Water (D5W) - Answers - Dextrose is sugar; can be isotonic in the bag
but hypotonic in the body; used in fluid loss and dehydration; should not be used in
excessive volumes.
Ringers Solution - Answers - Commonly used for wound irrigation; not often used IV.
Hypotonic Solutions - Answers - Fluid goes into cells causing them to swell; contains
more water than concentrate; used for cell rehydration.
0.45% NaCl - Answers - Used as a basic fluid maintenance; rises total fluid volume; not
good for brain swelling.
0.33% NaCl - Answers - Aids kidneys to eliminate solutes; treats hypernatremia.
Nursing Considerations for Isotonic Solutions - Answers - Monitor for signs of fluid
overload, especially in patients with congestive heart failure and hypertension.
Hypertonic Solutions - Answers - Higher osmotic pressure; very concentrated; good for
patients with hyponatremia, hypovolemia, and trauma.
,Fluid Overload Symptoms - Answers - Crackles, jugular vein distention, edema,
bounding pulses.
Cerebral Edema - Answers - Swelling of the brain; can be worsened by inappropriate IV
fluid use.
Contraindications for Hypotonic Solutions - Answers - Do not give to patients with
increased cranial pressure.
Fluid Maintenance - Answers - Hypotonic solutions are good for maintenance fluids.
Hypernatremia - Answers - High sodium levels; can be treated with certain IV solutions.
D10W - Answers - Used for parenteral nutrition
3.0% Saline - Answers - Used to treat symptomatic hyponatremia and trauma patients
with head injury. Admin slowly. Risk for fluid overload and pulmonary edema.
5% dextrose in 0.45% Saline - Answers - Maintenance fluid. Provides calories- used in
peripheral parenteral nutrition. Most common postop fluid.
5% dextrose in 0.9% Saline - Answers - Used to treat metabolic alkalosis and fluid
volume deficits with hyponatremia. Causes fluid overload, which is swelling, and it can
back up to the heart and lungs.
Nursing Considerations for hypertonic solutions - Answers - Monitor BP, lung sounds,
and sodium levels- risk for fluid volume excess. Monitor for circulatory overload (infused
too quickly).
Circulatory overload signs - Answers - Jugular vein distention, bounding pulse, crackles,
edema.
Irritation to veins - Answers - Can be irritating to veins due to high solute concentration.
Infuse slowly. Risk for cellular dehydration if infused too quickly.
Nursing Responsibilities w/ Mineral Electrolyte Preparations - Answers - NEVER GIVE
POTASSIUM IV PUSH. Assess for adverse effects.
Volume excess signs - Answers - Pitting edema & hypertension.
Volume deficit signs - Answers - Cold clammy skin & hypotension.
IV therapy nurse responsibilities - Answers - Nurse responsible for noting concerns
about ordered meds. Ex. if a patient's K level is elevated you don't wanna give them
lactated ringers.
,LR - Answers - LR contains potassium.
IV placement considerations - Answers - Usually placed on non-dominant hand. Cannot
be placed on the arm if same-sided breast cancer, burns, infection, injury. Commonly do
not use adult legs.
Infusion rate monitoring - Answers - CHECK INFUSION RATE EVERY HOUR OR
MORE FREQ.
Infiltration - Answers - Leakage of intravenous solution into surrounding tissue
(NONVESICANT- not irritating). Cool skin indicates infiltration.
Infiltration signs and symptoms - Answers - Swelling, pallor, coldness, or pain around
the infusion site. Significant decrease in the flow rate.
Infiltration nursing considerations - Answers - Check the infusion site every hour for
signs and symptoms. Discontinue the infusion if symptoms occur. Restart the infusion at
a different site.
Infiltration scale - Answers - 0= no symptoms; 1= skin blanched, edema <1 inch in any
direction, cool to touch, with or without pain; 2= skin blanched, edema 1-6 inch in any
direction, cool to touch, with or without pain; 3= skin clanched, translucent, gross edema
>6 inch in any direction, cool to touch, mild-mod pain, possible numbness; 4= skin
blanched, translucent, skin-tight, leaking, skin discolored, bruised, swollen, gross
edema >6 inch in any direction, circulatory impairment, mod-severe pain.
Phlebitis - Answers - Inflammation/irritation of a vein (vesicant). Mechanical trauma from
needle or catheter. Chemical trauma from the solution.
Phlebitis signs and symptoms - Answers - Redness, tenderness, slight edema of a vein
above the site, warm skin. Severe cases: red streak along the vein, vein distention,
purulent drainage.
Phlebitis nursing considerations - Answers - Discontinue iv immediately, apply a warm
moist compress to the affected site, restart IV in another vein in another arm, if not go
above the bad site.
Phlebitis scale - Answers - 0= no symptoms; 1= erythema at access site with or without
pain; 2=pain at access site with erythema and/or edema; 3= pain at access site with
erythema and/or edema, streak formation, palpable venous cord; 4= pain at access site
with erythema and/or edema, streak formation, palpable venous cord >1 inch in length,
purulent drainage.
Thrombus - Answers - Blood clot in the vein that causes inflammation (tissue trauma
from needle/catheter).
, Thrombus signs and symptoms - Answers - Redness, tenderness, slight edema, IV fluid
flow may stop if clot obstructs needle.
Thrombus nursing consideration - Answers - Stop infusion immediately - restart at
another site, do not rub/massage the affected area.
Speed shock - Answers - the body's reaction to a substance that is injected rapidly into
the circulatory system
Signs and symptoms of speed shock - Answers - pounding headache, rapid pulse,
fainting, back pains, dyspnea, apprehension, chills
Nursing considerations for speed shock - Answers - Use the proper IV tubing, carefully
monitor the rate of fluid flow, check the rate and frequency for accuracy.
Extravasation - Answers - Inadvertent leakage of vesicant intravenous solution into
surrounding tissue
Consequences of extravasation - Answers - Leaking of highly irritating IV solution or
medication into the tissue causing blisters, tissue damage, necrosis
Vesicants - Answers - These highly caustic/irritating solutions are called vesicants,
including chemotherapy, vasoconstriction (vasopressin), diltiazem, potassium, propofol.
Fluid Overload - Answers - too large a volume of fluid infuses into the circulatory system
Signs and symptoms of fluid overload - Answers - engorged neck veins, increased
blood pressure, edema, dyspnea - can result in cardiac/resp failure!
Nursing considerations for fluid overload - Answers - slow rate of infusion, monitor
vitals, call doctor, carefully monitor the rate of fluid flow.
Air embolus - Answers - air in the circulatory system, break in the IV system above the
heart level allowing air in
Signs and symptoms of air embolus - Answers - Respiratory distress, increased heart
rate, cyanosis, decreased bp, change LOC
Nursing considerations for air embolus - Answers - pinch off catheter or secure system
to prevent the entry of air, place pt in left side Trendelenburg position, call for help,
monitor vitals and pulse ox.
Venous access device signs and symptoms - Answers - Erythema and edema
Nursing considerations for venous access device - Answers - Perform hand hygiene
before and after palpating the catheter inserting site; assess catheter site at least daily.
