NSO- FINAL EXAM WITH COMPLETE SOLUTION
Which of the following is a correct sequence for administering a medication by IV bolus
through a saline lock?
a) Clean injection port with antiseptic swab, insert syringe containing prepared
medication into port, and inject over recommended time period. Remove syringe, clean
port, and flush port with normal saline at same rate as medication administration.
b) Clean injection port with antiseptic swab, insert syringe with normal saline, aspirate
for blood return, and flush with saline. Remove syringe, clean port, administer
medication over recommended time period, withdraw syringe, clean port, discard
gloves, and document.
c) Clean injection port, insert syringe of normal saline, aspirate for blood return, and
flush with saline. Remove syringe, clean port, administer medication over recommended
time period, withdraw syringe, clean port, and flush port with normal saline at same rate
as medication administration.
d) C - ANSWER c) Clean injection port, insert syringe of normal saline, aspirate for blood
return, and flush with saline. Remove syringe, clean port, administer medication over
recommended time period, withdraw syringe, clean port, and flush port with normal
saline at same rate as medication administration.
What additional supplies are required for administering medication by IV bolus through
a saline lock versus an existing infusion of IV fluids?
a) The necessary supplies are the same regardless of whether a medication is
administered by IV bolus through a saline lock or through an existing infusion of IV
fluids.
b) Two syringes with 2 to 3 mL of normal saline.
c) A watch
d) Nonsterile gloves - ANSWER b) Two syringes with 2 to 3 mL of normal saline.
Which of the following situations indicates discontinuation of peripheral IV access?
(Select all that apply.)
a) The patient is being discharged to home on PO medications.
b) The health care provider has ordered normal saline at 100 mL per hour and the
patient's bag of IV fluids is empty.
c) The patient is drinking fluids well postoperatively and has an order for morphine IV
every three hours, as needed.
,d) The electronic infusion pump alarm keeps sounding, indicating "occlusion" on its
screen, and the nurse is unable to flush the IV.
e) The patient's arm is swollen and cool to the touch; the patient complains of pain at the
IV site.
f) The patient's arm appears reddened and is tender to the touch.
g) The IV access site is dated four days ago. - ANSWER a)The patient is being
discharged to home on PO medications.
d)The electronic infusion pump alarm keeps sounding, indicating "occlusion" on its
screen, and the nurse is unable to flush the IV.
e) The patient's arm is swollen and cool to the touch; the patient complains of pain at the
IV site.
f) The patient's arm appears reddened and is tender to the touch.
g) The IV access site is dated four days ago.
The student nurse is watching the staff nurse discontinue a peripheral IV. The staff
nurse removes the catheter and then looks at it. The student asks the nurse what she is
looking for. The correct response by the nurse is which of the following?
a) "I am looking to see if there is any clot formation on the tip."
b) "I am looking for exudate at the catheter tip."
c) "I am noting the gauge of the catheter so I can document removal accurately."
d) "I am inspecting the catheter for intactness." - ANSWER d) "I am inspecting the
catheter for intactness."
What is the primary danger related to a broken catheter tip?
a) Embolus
b) Infection
c) Pain
d) Phlebitis
e) Hematoma formation - ANSWER a) Embolus
The nurse is discontinuing peripheral IV access. Which of the following steps, if
performed by the nurse, requires correction?
a) Explain to the patient that the affected extremity must be held still. Turn the IV roller
clamp to the "off" position. Perform hand hygiene and apply clean gloves. Remove the
,tape securing the tubing. Remove the IV site dressing and tape while stabilizing the
catheter.
b) With dry gauze or an alcohol swab held over the site, apply light pressure and
withdraw the catheter by using a slow, steady movement with the hub at a 10- to a
30-degree angle. Apply pressure to the site for 1 to 2 seconds by using a dry, sterile
gauze pad
c) Inspect the catheter for intactness. Discard used supplies. Remove and discard
gloves, and perform hand hygiene.
d) Instruct the patient to report any redness, pain, drainage, or swelling that may occur
after catheter removal. Document discontinuation of the IV acce - ANSWER b) With dry
gauze or an alcohol swab held over the site, apply light pressure and withdraw the
catheter by using a slow, steady movement with the hub at a 10- to 30-degree angle.
Apply pressure to the site for 1 to 2 seconds by using a dry, sterile gauze pad
Which of the following demonstrates the best documentation of discontinuation of an IV?
a) 2000 hours IV removed and pressure applied for 2 min. Pt tolerated well. S. Chan, RN
b)1030 hours 20-gauge 2.5-cm catheter removed from left forearm. Catheter tip intact.
Site without redness, swelling, or bleeding. T. Rodriguez, RN
c) 1300 hours 22-gauge 2.5-cm catheter removed due to complaints of pain and signs of
infiltration. New 22-gauge 2.5-cm catheter inserted in right forearm x1 attempt. 0.45%
sodium chloride infusing at 50 mL/hr without difficulty. P. Gonzalez, RN
d) 1445 hours 21-gauge, 2.5-cm catheter removed from right hand. Catheter intact.
Pressure applied for 5 minutes due to anticoagulant therapy. Gauze dressing and tape
applied. Pt states is ready to go home. L. Castello, RN - ANSWER b) 1030 hours
20-gauge 2.5-cm catheter removed from left forearm. Catheter tip intact. Site without
redness, swelling, or bleeding. T. Rodriguez, RN
Maintenance care of a peripheral intravenous site includes which of the following:
(Select all that apply.)
a) Changing IV fluids
b) Changing the IV dressing
c) Initiating blood therapy
d) Ongoing assessment
e) Inserting a peripherally inserted central catheter
f) Changing IV tubing
g) Regulating the IV flow rate - ANSWER a) Changing IV fluids
, b) Changing the IV dressing
d) Ongoing assessment
f) Changing IV tubing
g) Regulating the IV flow rate
A confused older adult patient has pulled out her IV twice. The health care provider has
ordered restraints and that the IV be restarted for the transfusion of packed red blood
cells (PRBCs). Which factors in this situation may alter the rate of infusion? (Select all
that apply.)
a) The patient's age
b) The patient's dehydration and anemia
c) The electronic infusion device (EID) being plugged into the wall outlet
d) Manipulation of the IV catheter by the patient
e) Improperly placed restraints
f) Viscosity (thickness) and temperature of the infusion - ANSWER d) Manipulation of the
IV catheter by the patient
e) Improperly placed restraints
f) Viscosity (thickness) and temperature of the infusion
The unregulated care provider turned and repositioned the patient as requested.
However, now the alarm on the electronic infusion device is sounding. Which of the
following situations is most likely to have set off the alarm?
a) The patient is lying on the tubing.
b) The patient is probably developing phlebitis.
c) The rate of infusion has increased.
d) There is now air in the tubing. - ANSWER a)The patient is lying on the tubing.
Which of the following is an acceptable IV site ina child but not a routine site in adults?
a) Hand
b) Forearm
c) Foot
d) Scalp - ANSWER c) Foot
Which of the following is a correct sequence for administering a medication by IV bolus
through a saline lock?
a) Clean injection port with antiseptic swab, insert syringe containing prepared
medication into port, and inject over recommended time period. Remove syringe, clean
port, and flush port with normal saline at same rate as medication administration.
b) Clean injection port with antiseptic swab, insert syringe with normal saline, aspirate
for blood return, and flush with saline. Remove syringe, clean port, administer
medication over recommended time period, withdraw syringe, clean port, discard
gloves, and document.
c) Clean injection port, insert syringe of normal saline, aspirate for blood return, and
flush with saline. Remove syringe, clean port, administer medication over recommended
time period, withdraw syringe, clean port, and flush port with normal saline at same rate
as medication administration.
d) C - ANSWER c) Clean injection port, insert syringe of normal saline, aspirate for blood
return, and flush with saline. Remove syringe, clean port, administer medication over
recommended time period, withdraw syringe, clean port, and flush port with normal
saline at same rate as medication administration.
What additional supplies are required for administering medication by IV bolus through
a saline lock versus an existing infusion of IV fluids?
a) The necessary supplies are the same regardless of whether a medication is
administered by IV bolus through a saline lock or through an existing infusion of IV
fluids.
b) Two syringes with 2 to 3 mL of normal saline.
c) A watch
d) Nonsterile gloves - ANSWER b) Two syringes with 2 to 3 mL of normal saline.
Which of the following situations indicates discontinuation of peripheral IV access?
(Select all that apply.)
a) The patient is being discharged to home on PO medications.
b) The health care provider has ordered normal saline at 100 mL per hour and the
patient's bag of IV fluids is empty.
c) The patient is drinking fluids well postoperatively and has an order for morphine IV
every three hours, as needed.
,d) The electronic infusion pump alarm keeps sounding, indicating "occlusion" on its
screen, and the nurse is unable to flush the IV.
e) The patient's arm is swollen and cool to the touch; the patient complains of pain at the
IV site.
f) The patient's arm appears reddened and is tender to the touch.
g) The IV access site is dated four days ago. - ANSWER a)The patient is being
discharged to home on PO medications.
d)The electronic infusion pump alarm keeps sounding, indicating "occlusion" on its
screen, and the nurse is unable to flush the IV.
e) The patient's arm is swollen and cool to the touch; the patient complains of pain at the
IV site.
f) The patient's arm appears reddened and is tender to the touch.
g) The IV access site is dated four days ago.
The student nurse is watching the staff nurse discontinue a peripheral IV. The staff
nurse removes the catheter and then looks at it. The student asks the nurse what she is
looking for. The correct response by the nurse is which of the following?
a) "I am looking to see if there is any clot formation on the tip."
b) "I am looking for exudate at the catheter tip."
c) "I am noting the gauge of the catheter so I can document removal accurately."
d) "I am inspecting the catheter for intactness." - ANSWER d) "I am inspecting the
catheter for intactness."
What is the primary danger related to a broken catheter tip?
a) Embolus
b) Infection
c) Pain
d) Phlebitis
e) Hematoma formation - ANSWER a) Embolus
The nurse is discontinuing peripheral IV access. Which of the following steps, if
performed by the nurse, requires correction?
a) Explain to the patient that the affected extremity must be held still. Turn the IV roller
clamp to the "off" position. Perform hand hygiene and apply clean gloves. Remove the
,tape securing the tubing. Remove the IV site dressing and tape while stabilizing the
catheter.
b) With dry gauze or an alcohol swab held over the site, apply light pressure and
withdraw the catheter by using a slow, steady movement with the hub at a 10- to a
30-degree angle. Apply pressure to the site for 1 to 2 seconds by using a dry, sterile
gauze pad
c) Inspect the catheter for intactness. Discard used supplies. Remove and discard
gloves, and perform hand hygiene.
d) Instruct the patient to report any redness, pain, drainage, or swelling that may occur
after catheter removal. Document discontinuation of the IV acce - ANSWER b) With dry
gauze or an alcohol swab held over the site, apply light pressure and withdraw the
catheter by using a slow, steady movement with the hub at a 10- to 30-degree angle.
Apply pressure to the site for 1 to 2 seconds by using a dry, sterile gauze pad
Which of the following demonstrates the best documentation of discontinuation of an IV?
a) 2000 hours IV removed and pressure applied for 2 min. Pt tolerated well. S. Chan, RN
b)1030 hours 20-gauge 2.5-cm catheter removed from left forearm. Catheter tip intact.
Site without redness, swelling, or bleeding. T. Rodriguez, RN
c) 1300 hours 22-gauge 2.5-cm catheter removed due to complaints of pain and signs of
infiltration. New 22-gauge 2.5-cm catheter inserted in right forearm x1 attempt. 0.45%
sodium chloride infusing at 50 mL/hr without difficulty. P. Gonzalez, RN
d) 1445 hours 21-gauge, 2.5-cm catheter removed from right hand. Catheter intact.
Pressure applied for 5 minutes due to anticoagulant therapy. Gauze dressing and tape
applied. Pt states is ready to go home. L. Castello, RN - ANSWER b) 1030 hours
20-gauge 2.5-cm catheter removed from left forearm. Catheter tip intact. Site without
redness, swelling, or bleeding. T. Rodriguez, RN
Maintenance care of a peripheral intravenous site includes which of the following:
(Select all that apply.)
a) Changing IV fluids
b) Changing the IV dressing
c) Initiating blood therapy
d) Ongoing assessment
e) Inserting a peripherally inserted central catheter
f) Changing IV tubing
g) Regulating the IV flow rate - ANSWER a) Changing IV fluids
, b) Changing the IV dressing
d) Ongoing assessment
f) Changing IV tubing
g) Regulating the IV flow rate
A confused older adult patient has pulled out her IV twice. The health care provider has
ordered restraints and that the IV be restarted for the transfusion of packed red blood
cells (PRBCs). Which factors in this situation may alter the rate of infusion? (Select all
that apply.)
a) The patient's age
b) The patient's dehydration and anemia
c) The electronic infusion device (EID) being plugged into the wall outlet
d) Manipulation of the IV catheter by the patient
e) Improperly placed restraints
f) Viscosity (thickness) and temperature of the infusion - ANSWER d) Manipulation of the
IV catheter by the patient
e) Improperly placed restraints
f) Viscosity (thickness) and temperature of the infusion
The unregulated care provider turned and repositioned the patient as requested.
However, now the alarm on the electronic infusion device is sounding. Which of the
following situations is most likely to have set off the alarm?
a) The patient is lying on the tubing.
b) The patient is probably developing phlebitis.
c) The rate of infusion has increased.
d) There is now air in the tubing. - ANSWER a)The patient is lying on the tubing.
Which of the following is an acceptable IV site ina child but not a routine site in adults?
a) Hand
b) Forearm
c) Foot
d) Scalp - ANSWER c) Foot
