NU 311 CLINICAL NURSING SKILLS
FINAL EXAM QUESTIONS WITH
CORRECT ANSWERS
Insertion of a Short-Peripheral Intravenous Device Pre-assessments - Answer-1.
Review accuracy of health care provider's order: date and time, IV solution, route of
administration, volume, rate, duration, and signature of ordering health care
practitioner. Follow rights of medication administration.
a. Check approved online database, drug reference book, or pharmacist about IV
solution composition, purpose, potential incompatibilities, adverse reactions, and
side effects.
3.Check patient's knowledge of procedure, reason for prescribed therapy, and arm
placement preference.
4. Check for clinical factors/conditions that will respond to or be affected by
administration of IV solutions.
a. Body weight
b. Clinical markers of vascular volume
c. Clinical markers of interstitial volume
d. Thirst
e. Behavior and level of consciousness
4. Determine if patient is to undergo any planned surgeries or procedures.
5. Check available laboratory data (e.g., hematocrit, serum electrolytes, arterial
blood gases, and kidney functions [blood urea nitrogen, urine specific gravity, and
urine osmolality]).
6. Check patient's history of allergies, especially to iodine, adhesive, or latex.
Clinical markers of vascular volume - Answer-(1) Urine output (decreased, dark
yellow)
(2) Vital signs: blood pressure, respirations, pulse, temperature
(3) Distended neck veins (Normally veins are full when person is supine and flat
when person is upright.)
(4) Auscultation of lungs
(5) Capillary refill
Clinical markers of interstitial volume - Answer-(1) Skin turgor (Pinch skin over
sternum or inside of forearm.)
(2) Dependent edema (pitting or nonpitting)
(3) Oral mucous membrane between cheek and gum
Behavior and level of consciousness - Answer-(1) Restlessness and mild confusion
(2) Decreased level of consciousness (lethargy, confusion, coma)
,Insertion of a Short-Peripheral Intravenous Device Post-evaluations - Answer-1.
Observe patient every 1 to 2 hours or at established intervals per agency policy and
procedure for function, intactness, and patency of IV system and for correct infusion
rate and accurate type/amount of IV solution infused by observing level in IV
container.
2. Look at patient to determine response to therapy (e.g., laboratory values, input
and output [I&O]), weights, vital signs, postprocedure assessments).
3. Look at patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications by inspecting and gently palpating skin
around and above IV site over the dressing.
4. Use Teach-Back: "I want to make sure that I explained the problems that can
happen with your IV. Tell me the signs or symptoms that you should tell me or the
other nurses about." Revise your instruction now or develop a plan for revised
patient or family caregiver teaching if patient or family caregiver is not able to teach
back correctly.
Regulating Intravenous Flow Rates Pre-assessments - Answer-1. Review accuracy
and completeness of health care provider order in patient's medical record for patient
name and correct solution: type, volume, additives, infusion rate, and duration of IV
therapy. Follow six rights of drug administration
3. Apply clean gloves; inspect and gently palpate skin around and above IV site over
dressing. Ask patient how IV site feels. Assess VAD for patency and signs and
symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis,
infection, patient complaints of pain, or leaking under dressing). Dispose of gloves;
perform hand hygiene.
4. Check IV system for patency from IV container to insertion site.
5. Identify patient risk for fluid and electrolyte imbalance given type of IV solution
(e.g., neonate, history of cardiac or renal disease).
6. Check patient's knowledge of how positioning of IV site affects flow rate.
Regulating Intravenous Flow Rates Post-evaluations - Answer-1. Observe patient
every 1 to 2 hours (see agency policy), noting volume of IV fluid infused and rate of
infusion.
2. Look at patient's response to therapy (e.g., laboratory values, input and output
[I&O], weights, vital signs, postprocedure assessments).
3. Look at patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
4. Use Teach-Back: "I want to be sure that I explained the importance of your IV
fluids running on time at the rate ordered. Tell me what you think may cause the
pump to alarm and what you would do." Revise your instruction now or develop a
,plan for revised patient or family caregiver teaching if patient or family caregiver is
not able to teach back correctly.
Changing Intravenous Solutions Pre-assessments - Answer-1. Review accuracy and
completeness of health care provider's order in patient's medical record for patient
name and correct solution: type, volume, additives, rate, and duration of IV therapy.
Follow rights of drug administration
2. Note date and time when IV tubing and solution were last changed.
3. Determine patient understanding of need for continued IV therapy.
4. Perform hand hygiene and apply clean gloves; inspect and gently palpate skin
around and above IV site over dressing. Assess VAD for patency and signs and
symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis,
infection, patient complaints of pain, or leaking under dressing).
5. Check infusion system from solution container down to VAD insertion site for
integrity, including but not limited to discoloration, cloudiness, leakage, expiration
date. Determine compatibility of all IV solutions and additives by consulting approved
online database, drug reference, or pharmacist. Discard gloves and perform hand
hygiene.
6. Check pertinent laboratory data such as potassium level.
Changing Intravenous Solutions Post-evaluations - Answer-1. Observe patient every
1 to 2 hours or at established intervals per agency policy and procedure for function,
intactness, and patency of IV system; correct infusion rate; and type/amount of IV
solution infused.
2. Evaluate patient to determine response to therapy (e.g., laboratory values, input
and output [I&O], weights, vital signs, postprocedure assessments).
3. Monitor patient for signs of fluid volume excess (FVE), fluid volume deficit (FVD),
or signs and symptoms of electrolyte imbalances.
4. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
5. Use Teach-Back: "We talked about the importance of your IV solutions running
continuously. I want to be sure I explained this clearly. Tell me in your own words
what you should do if you notice that the IV is not dripping." Revise your instruction
now or develop a plan for revised patient or family caregiver teaching if patient or
family caregiver is not able to teach back correctly.
Changing Infusion Tubing Pre-assessments - Answer-1. Note date and time when IV
tubing was last changed
2. Perform hand hygiene. Assess IV tubing for puncture, contamination, or occlusion
that requires immediate change.
, 3. Determine patient understanding of need for continued IV therapy.
Changing Infusion Tubing Post-evaluations - Answer-1. Observe patient every 1 to 2
hours or at established intervals per agency policy and procedure for function,
intactness, and patency of IV system and leaking at connection sites.
2. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
3. Use Teach-Back: "Let's go over what we talked about earlier regarding the
problems that can occur with your IV line. Tell me how you can prevent the tubing
from being pinched off and which signs and symptoms you would report to me or
another nurse." Revise your instruction now or develop a plan for revised patient or
family caregiver teaching if patient or family caregiver is not able to teach back
correctly.
Changing a Short-Peripheral Intravenous Dressing Pre-assessments - Answer-1.
Determine when dressing was last changed. Dressing should be labeled to include
date and time applied, size and type of vascular access device (VAD) insertion date.
2. Perform hand hygiene and apply clean gloves. Observe present dressing for
moisture and intactness. Determine if moisture is from site leakage or external
source.
3. Inspect and gently palpate skin around and above IV site over dressing. Assess
VAD for patency and signs and symptoms of IV-related complications (e.g.,
infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or
leaking under dressing). Remove and discard gloves.
4. Assess patient's understanding of need for continued IV infusion.
Changing a Short-Peripheral Intravenous Dressing Post-evaluations - Answer-1.
Evaluate function, patency of IV system, and flow rate after changing dressing.
2. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV line-related complications.
3. Use Teach-Back: "I want to be sure that I explained reasons for why we change
the IV dressing. Tell me in your own words the problems that you would report that
would require us to change the dressing." Revise your instruction now or develop a
plan for revised patient or family caregiver teaching if patient or family caregiver is
not able to teach back correctly.
Insertion of a Short-Peripheral Intravenous Device Pediatric Considerations -
Answer-• Perform venipuncture in a neutral space to allow the child's room to be a
safe place.
• In addition to the usual venipuncture sites, the four scalp veins are used in infants
and toddlers and, if not walking, the dorsum of the foot.
FINAL EXAM QUESTIONS WITH
CORRECT ANSWERS
Insertion of a Short-Peripheral Intravenous Device Pre-assessments - Answer-1.
Review accuracy of health care provider's order: date and time, IV solution, route of
administration, volume, rate, duration, and signature of ordering health care
practitioner. Follow rights of medication administration.
a. Check approved online database, drug reference book, or pharmacist about IV
solution composition, purpose, potential incompatibilities, adverse reactions, and
side effects.
3.Check patient's knowledge of procedure, reason for prescribed therapy, and arm
placement preference.
4. Check for clinical factors/conditions that will respond to or be affected by
administration of IV solutions.
a. Body weight
b. Clinical markers of vascular volume
c. Clinical markers of interstitial volume
d. Thirst
e. Behavior and level of consciousness
4. Determine if patient is to undergo any planned surgeries or procedures.
5. Check available laboratory data (e.g., hematocrit, serum electrolytes, arterial
blood gases, and kidney functions [blood urea nitrogen, urine specific gravity, and
urine osmolality]).
6. Check patient's history of allergies, especially to iodine, adhesive, or latex.
Clinical markers of vascular volume - Answer-(1) Urine output (decreased, dark
yellow)
(2) Vital signs: blood pressure, respirations, pulse, temperature
(3) Distended neck veins (Normally veins are full when person is supine and flat
when person is upright.)
(4) Auscultation of lungs
(5) Capillary refill
Clinical markers of interstitial volume - Answer-(1) Skin turgor (Pinch skin over
sternum or inside of forearm.)
(2) Dependent edema (pitting or nonpitting)
(3) Oral mucous membrane between cheek and gum
Behavior and level of consciousness - Answer-(1) Restlessness and mild confusion
(2) Decreased level of consciousness (lethargy, confusion, coma)
,Insertion of a Short-Peripheral Intravenous Device Post-evaluations - Answer-1.
Observe patient every 1 to 2 hours or at established intervals per agency policy and
procedure for function, intactness, and patency of IV system and for correct infusion
rate and accurate type/amount of IV solution infused by observing level in IV
container.
2. Look at patient to determine response to therapy (e.g., laboratory values, input
and output [I&O]), weights, vital signs, postprocedure assessments).
3. Look at patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications by inspecting and gently palpating skin
around and above IV site over the dressing.
4. Use Teach-Back: "I want to make sure that I explained the problems that can
happen with your IV. Tell me the signs or symptoms that you should tell me or the
other nurses about." Revise your instruction now or develop a plan for revised
patient or family caregiver teaching if patient or family caregiver is not able to teach
back correctly.
Regulating Intravenous Flow Rates Pre-assessments - Answer-1. Review accuracy
and completeness of health care provider order in patient's medical record for patient
name and correct solution: type, volume, additives, infusion rate, and duration of IV
therapy. Follow six rights of drug administration
3. Apply clean gloves; inspect and gently palpate skin around and above IV site over
dressing. Ask patient how IV site feels. Assess VAD for patency and signs and
symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis,
infection, patient complaints of pain, or leaking under dressing). Dispose of gloves;
perform hand hygiene.
4. Check IV system for patency from IV container to insertion site.
5. Identify patient risk for fluid and electrolyte imbalance given type of IV solution
(e.g., neonate, history of cardiac or renal disease).
6. Check patient's knowledge of how positioning of IV site affects flow rate.
Regulating Intravenous Flow Rates Post-evaluations - Answer-1. Observe patient
every 1 to 2 hours (see agency policy), noting volume of IV fluid infused and rate of
infusion.
2. Look at patient's response to therapy (e.g., laboratory values, input and output
[I&O], weights, vital signs, postprocedure assessments).
3. Look at patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
4. Use Teach-Back: "I want to be sure that I explained the importance of your IV
fluids running on time at the rate ordered. Tell me what you think may cause the
pump to alarm and what you would do." Revise your instruction now or develop a
,plan for revised patient or family caregiver teaching if patient or family caregiver is
not able to teach back correctly.
Changing Intravenous Solutions Pre-assessments - Answer-1. Review accuracy and
completeness of health care provider's order in patient's medical record for patient
name and correct solution: type, volume, additives, rate, and duration of IV therapy.
Follow rights of drug administration
2. Note date and time when IV tubing and solution were last changed.
3. Determine patient understanding of need for continued IV therapy.
4. Perform hand hygiene and apply clean gloves; inspect and gently palpate skin
around and above IV site over dressing. Assess VAD for patency and signs and
symptoms of IV-related complications (e.g., infiltration, occlusion of VAD, phlebitis,
infection, patient complaints of pain, or leaking under dressing).
5. Check infusion system from solution container down to VAD insertion site for
integrity, including but not limited to discoloration, cloudiness, leakage, expiration
date. Determine compatibility of all IV solutions and additives by consulting approved
online database, drug reference, or pharmacist. Discard gloves and perform hand
hygiene.
6. Check pertinent laboratory data such as potassium level.
Changing Intravenous Solutions Post-evaluations - Answer-1. Observe patient every
1 to 2 hours or at established intervals per agency policy and procedure for function,
intactness, and patency of IV system; correct infusion rate; and type/amount of IV
solution infused.
2. Evaluate patient to determine response to therapy (e.g., laboratory values, input
and output [I&O], weights, vital signs, postprocedure assessments).
3. Monitor patient for signs of fluid volume excess (FVE), fluid volume deficit (FVD),
or signs and symptoms of electrolyte imbalances.
4. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
5. Use Teach-Back: "We talked about the importance of your IV solutions running
continuously. I want to be sure I explained this clearly. Tell me in your own words
what you should do if you notice that the IV is not dripping." Revise your instruction
now or develop a plan for revised patient or family caregiver teaching if patient or
family caregiver is not able to teach back correctly.
Changing Infusion Tubing Pre-assessments - Answer-1. Note date and time when IV
tubing was last changed
2. Perform hand hygiene. Assess IV tubing for puncture, contamination, or occlusion
that requires immediate change.
, 3. Determine patient understanding of need for continued IV therapy.
Changing Infusion Tubing Post-evaluations - Answer-1. Observe patient every 1 to 2
hours or at established intervals per agency policy and procedure for function,
intactness, and patency of IV system and leaking at connection sites.
2. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV-related complications.
3. Use Teach-Back: "Let's go over what we talked about earlier regarding the
problems that can occur with your IV line. Tell me how you can prevent the tubing
from being pinched off and which signs and symptoms you would report to me or
another nurse." Revise your instruction now or develop a plan for revised patient or
family caregiver teaching if patient or family caregiver is not able to teach back
correctly.
Changing a Short-Peripheral Intravenous Dressing Pre-assessments - Answer-1.
Determine when dressing was last changed. Dressing should be labeled to include
date and time applied, size and type of vascular access device (VAD) insertion date.
2. Perform hand hygiene and apply clean gloves. Observe present dressing for
moisture and intactness. Determine if moisture is from site leakage or external
source.
3. Inspect and gently palpate skin around and above IV site over dressing. Assess
VAD for patency and signs and symptoms of IV-related complications (e.g.,
infiltration, occlusion of VAD, phlebitis, infection, patient complaints of pain, or
leaking under dressing). Remove and discard gloves.
4. Assess patient's understanding of need for continued IV infusion.
Changing a Short-Peripheral Intravenous Dressing Post-evaluations - Answer-1.
Evaluate function, patency of IV system, and flow rate after changing dressing.
2. Evaluate patient at established intervals per agency policy and procedure for signs
and symptoms of IV line-related complications.
3. Use Teach-Back: "I want to be sure that I explained reasons for why we change
the IV dressing. Tell me in your own words the problems that you would report that
would require us to change the dressing." Revise your instruction now or develop a
plan for revised patient or family caregiver teaching if patient or family caregiver is
not able to teach back correctly.
Insertion of a Short-Peripheral Intravenous Device Pediatric Considerations -
Answer-• Perform venipuncture in a neutral space to allow the child's room to be a
safe place.
• In addition to the usual venipuncture sites, the four scalp veins are used in infants
and toddlers and, if not walking, the dorsum of the foot.
