Question 1
The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is
taken first?
1. Apply a warm, moist compress.
2. Aspirate the infusing fluid from the VAD.
3. Report the situation to the health care provider.
4. Discontinue the intravenous infusion
CORRECT ANSWER
4.
Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the
infusion must be stopped and the VAD removed as the highest priority
Question 2
An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set
correctly. Which factors could cause this slowing? (Select all that apply.)
1. Infiltration at vascular access device (VAD) site
2. Patient lying on tubing
3. Roller clamp wide open
4. Tubing kinked in bedrails
5. Circulatory overload
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,CORRECT ANSWER
1, 2, 4.
Factors that could slow an IV infusion even if the infusion pump is set correctly include
increased pressure at the outflow site (e.g., infiltration) and compression of the tubing
lumen (e.g., patient lying on the tubing or tubing kinked in bedrails)
Question 3
When delegating input and output (I&O) measurement to assistive personnel, the nurse
instructs them to record what information for ice chips?
1. Two-thirds of the volume
2. One-half of the volume
3. One-quarter of the volume
4. Two times the volume
CORRECT ANSWER
2.
When ice chips melt, their water volume is one-half the volume of the ice chips. The
water volume should be recorded as intake.
Question 4
What assessments does a nurse make before hanging an intravenous (IV) fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. Arterial blood gases
2
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, 3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
CORRECT ANSWER
1, 4.
Increased potassium intake when potassium output is decreased or during hyperkalemia
are major risks for hyperkalemia. Before increasing IV potassium intake, check to see that
urine output is normal and that the serum potassium level in the health record is not
above normal.
Question 5
The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which
rate does the nurse program into the infusion pump?
1. 100 mL/hr
2. 125 mL/hr
3. 167 mL/hr
4. 200 mL/hr
CORRECT ANSWER
2.
To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125)
Question 6
An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new
onset of crackles in the lung bases. What is the priority action?
3
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The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is
taken first?
1. Apply a warm, moist compress.
2. Aspirate the infusing fluid from the VAD.
3. Report the situation to the health care provider.
4. Discontinue the intravenous infusion
CORRECT ANSWER
4.
Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the
infusion must be stopped and the VAD removed as the highest priority
Question 2
An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set
correctly. Which factors could cause this slowing? (Select all that apply.)
1. Infiltration at vascular access device (VAD) site
2. Patient lying on tubing
3. Roller clamp wide open
4. Tubing kinked in bedrails
5. Circulatory overload
1
@https://www.stuvia.com/user/thestudyvault
,CORRECT ANSWER
1, 2, 4.
Factors that could slow an IV infusion even if the infusion pump is set correctly include
increased pressure at the outflow site (e.g., infiltration) and compression of the tubing
lumen (e.g., patient lying on the tubing or tubing kinked in bedrails)
Question 3
When delegating input and output (I&O) measurement to assistive personnel, the nurse
instructs them to record what information for ice chips?
1. Two-thirds of the volume
2. One-half of the volume
3. One-quarter of the volume
4. Two times the volume
CORRECT ANSWER
2.
When ice chips melt, their water volume is one-half the volume of the ice chips. The
water volume should be recorded as intake.
Question 4
What assessments does a nurse make before hanging an intravenous (IV) fluid that
contains potassium? (Select all that apply.)
1. Urine output
2. Arterial blood gases
2
@https://www.stuvia.com/user/thestudyvault
, 3. Fullness of neck veins
4. Serum potassium laboratory value in EHR
5. Level of consciousness
CORRECT ANSWER
1, 4.
Increased potassium intake when potassium output is decreased or during hyperkalemia
are major risks for hyperkalemia. Before increasing IV potassium intake, check to see that
urine output is normal and that the serum potassium level in the health record is not
above normal.
Question 5
The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which
rate does the nurse program into the infusion pump?
1. 100 mL/hr
2. 125 mL/hr
3. 167 mL/hr
4. 200 mL/hr
CORRECT ANSWER
2.
To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125)
Question 6
An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new
onset of crackles in the lung bases. What is the priority action?
3
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