PNR 202/PNR202 Final Exam V1 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient for signs of fluid volume excess. Which clinical finding is most
characteristic of this condition?
A. Dry mucous membranes
B. Orthostatic hypotension
C. Decreased skin turgor
D. Distended neck veins
Correct Answer: D
Explanation: Distended neck veins (JVD) occur when the venous system is overloaded
with fluid, increasing central venous pressure. This is a primary indicator of fluid volume
excess along with crackles in the lungs and peripheral edema. Dry mucous membranes and
poor skin turgor are instead associated with fluid volume deficit.
2. Which intravenous solution is considered isotonic and is commonly used for fluid
resuscitation?
A. 0.45% Normal Saline
B. 3% Sodium Chloride
C. Dextrose 10% in Water
D. 0.9% Normal Saline
,Correct Answer: D
Explanation: 0.9% Normal Saline has an osmolarity similar to that of blood plasma,
making it an isotonic solution. It is used to expand the extracellular fluid volume without
causing a fluid shift between compartments. This makes it ideal for treating hypovolemia
and shock in clinical settings.
3. A patient’s IV site is cool to the touch, swollen, and the infusion has slowed. Which
complication should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Septicemia
D. Extravasation
Correct Answer: A
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness of the skin, edema, and dampened
flow rates of the infusion. The nurse must stop the infusion immediately and elevate the
extremity to promote fluid reabsorption.
4. What is the most appropriate nursing intervention when a phlebitis grade of 2 is identified
at an IV site?
A. Slow the infusion rate and monitor
B. Apply a cold compress and document
, C. Discontinue the IV and apply a warm compress
D. Flush the line with heparin to clear the vein
Correct Answer: C
Explanation: A phlebitis grade of 2 is characterized by pain, erythema, and edema at the
access site. The priority intervention is to remove the catheter to stop the source of
irritation to the vein wall. Applying a warm compress helps increase circulation and
alleviate the discomfort associated with inflammation.
5. When a patient is receiving a hypertonic solution like D5NS, the nurse knows that fluid will
shift in which direction?
A. From the intracellular space to the intravascular space
B. From the intravascular space to the intracellular space
C. Equally between all fluid compartments
D. Into the interstitial space exclusively
Correct Answer: A
Explanation: Hypertonic solutions have a higher osmolarity than blood plasma, creating
an osmotic pull. This causes water to leave the cells and enter the intravascular space to
balance the concentration levels. Nurses must monitor for signs of circulatory overload
when administering these types of fluids.
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient for signs of fluid volume excess. Which clinical finding is most
characteristic of this condition?
A. Dry mucous membranes
B. Orthostatic hypotension
C. Decreased skin turgor
D. Distended neck veins
Correct Answer: D
Explanation: Distended neck veins (JVD) occur when the venous system is overloaded
with fluid, increasing central venous pressure. This is a primary indicator of fluid volume
excess along with crackles in the lungs and peripheral edema. Dry mucous membranes and
poor skin turgor are instead associated with fluid volume deficit.
2. Which intravenous solution is considered isotonic and is commonly used for fluid
resuscitation?
A. 0.45% Normal Saline
B. 3% Sodium Chloride
C. Dextrose 10% in Water
D. 0.9% Normal Saline
,Correct Answer: D
Explanation: 0.9% Normal Saline has an osmolarity similar to that of blood plasma,
making it an isotonic solution. It is used to expand the extracellular fluid volume without
causing a fluid shift between compartments. This makes it ideal for treating hypovolemia
and shock in clinical settings.
3. A patient’s IV site is cool to the touch, swollen, and the infusion has slowed. Which
complication should the nurse suspect?
A. Infiltration
B. Phlebitis
C. Septicemia
D. Extravasation
Correct Answer: A
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness of the skin, edema, and dampened
flow rates of the infusion. The nurse must stop the infusion immediately and elevate the
extremity to promote fluid reabsorption.
4. What is the most appropriate nursing intervention when a phlebitis grade of 2 is identified
at an IV site?
A. Slow the infusion rate and monitor
B. Apply a cold compress and document
, C. Discontinue the IV and apply a warm compress
D. Flush the line with heparin to clear the vein
Correct Answer: C
Explanation: A phlebitis grade of 2 is characterized by pain, erythema, and edema at the
access site. The priority intervention is to remove the catheter to stop the source of
irritation to the vein wall. Applying a warm compress helps increase circulation and
alleviate the discomfort associated with inflammation.
5. When a patient is receiving a hypertonic solution like D5NS, the nurse knows that fluid will
shift in which direction?
A. From the intracellular space to the intravascular space
B. From the intravascular space to the intracellular space
C. Equally between all fluid compartments
D. Into the interstitial space exclusively
Correct Answer: A
Explanation: Hypertonic solutions have a higher osmolarity than blood plasma, creating
an osmotic pull. This causes water to leave the cells and enter the intravascular space to
balance the concentration levels. Nurses must monitor for signs of circulatory overload
when administering these types of fluids.
