NURS 3270 Fundamentals Evolve -- Module 11 Questions
With Complete Solutions
A confused elderly 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. Manipulation of the IV catheter by the patient
B. The patient's dehydration and anemia
C. Viscosity (thickness) and temperature of the infusion
D. Improperly placed restraints
E. The electronic infusion device (EID) being plugged into the
wall outlet
F. The patient's age Correct Answer A, C, D
A nurse working in the emergency room has selected to use
macrodrip IV tubing. For which patient would this be most
appropriate?
A. A child who has experienced nausea and vomiting for the last
24 hours
B. A hypotensive adult trauma victim with cool, clammy skin
C. An older adult who is being treated for congestive heart
failure
D. A young adult being treated for asthma with an order for
D5W at 60 mL/hr Correct Answer D. A young adult being
treated for asthma with an order for D5W at 60 mL/hr
, A nursing instructor is assisting a student nurse to change the
peripheral IV dressing on a patient. Which action, if made by the
nursing student, indicates further teaching is necessary? (Select
all that apply.)
A. The student nurse applies sterile gloves and removes the old
dressing, being careful to avoid dislodging the catheter.
B. After completing the dressing change, the student nurse
documents in the patient's chart the presence of swelling,
coolness, blanching, and complaints of pain at the insertion site.
C. The student stabilizes the IV, cleans the insertion site with
antiseptic swab using friction in a horizontal plane, then vertical
plane, followed by a circular motion.
D. The student nurse cleans the site with an antiseptic swab and
immediately applies a new dressing to protect against infection.
E. The student nurse labels the dressing with date and time of
insertion, date and time of dressing change, Correct Answer
A, B, D
A patient has an order for the administration of 1000 mL of
0.9% normal saline at 100 mL/hr. The nurse begins the infusion
at 0900. At noon the nurse notices that 500 mL has infused. Of
the following options, which should be the nurse's highest
priority action?
A. Determine if there is a kink in the tubing or if the IV is
positional.
B. Determine if the electronic infusion device is plugged in or if
the "low battery" signal is displayed.
C. Assess the site for complications such as infiltration,
phlebitis, or clotting of the catheter.
With Complete Solutions
A confused elderly 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. Manipulation of the IV catheter by the patient
B. The patient's dehydration and anemia
C. Viscosity (thickness) and temperature of the infusion
D. Improperly placed restraints
E. The electronic infusion device (EID) being plugged into the
wall outlet
F. The patient's age Correct Answer A, C, D
A nurse working in the emergency room has selected to use
macrodrip IV tubing. For which patient would this be most
appropriate?
A. A child who has experienced nausea and vomiting for the last
24 hours
B. A hypotensive adult trauma victim with cool, clammy skin
C. An older adult who is being treated for congestive heart
failure
D. A young adult being treated for asthma with an order for
D5W at 60 mL/hr Correct Answer D. A young adult being
treated for asthma with an order for D5W at 60 mL/hr
, A nursing instructor is assisting a student nurse to change the
peripheral IV dressing on a patient. Which action, if made by the
nursing student, indicates further teaching is necessary? (Select
all that apply.)
A. The student nurse applies sterile gloves and removes the old
dressing, being careful to avoid dislodging the catheter.
B. After completing the dressing change, the student nurse
documents in the patient's chart the presence of swelling,
coolness, blanching, and complaints of pain at the insertion site.
C. The student stabilizes the IV, cleans the insertion site with
antiseptic swab using friction in a horizontal plane, then vertical
plane, followed by a circular motion.
D. The student nurse cleans the site with an antiseptic swab and
immediately applies a new dressing to protect against infection.
E. The student nurse labels the dressing with date and time of
insertion, date and time of dressing change, Correct Answer
A, B, D
A patient has an order for the administration of 1000 mL of
0.9% normal saline at 100 mL/hr. The nurse begins the infusion
at 0900. At noon the nurse notices that 500 mL has infused. Of
the following options, which should be the nurse's highest
priority action?
A. Determine if there is a kink in the tubing or if the IV is
positional.
B. Determine if the electronic infusion device is plugged in or if
the "low battery" signal is displayed.
C. Assess the site for complications such as infiltration,
phlebitis, or clotting of the catheter.
