PNR 202/PNR202 Exam 2 V2 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient’s IV site and notes coolness, pallor, and swelling. What is the
most likely complication occurring?
A. Phlebitis
B. Thrombophlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Explanation: Infiltration is the leakage of non-vesicant IV fluid into the surrounding
subcutaneous tissue, characterized by coolness, swelling, and pallor. The nurse should
immediately stop the infusion and remove the catheter. Elevating the extremity and
applying a warm or cold compress based on the fluid type is the standard intervention.
2. Which intravenous fluid is considered isotonic and is frequently used for fluid resuscitation
in trauma patients?
A. 0.9% Sodium Chloride
B. 3% Sodium Chloride
C. 0.45% Sodium Chloride
D. D5W in 0.45% Sodium Chloride
,Correct Answer: A
Explanation: 0.9% Sodium Chloride, also known as Normal Saline, is an isotonic solution
that stays within the intravascular space to expand volume. It is the only fluid used in
conjunction with blood product administration to prevent hemolysis. Nurses must monitor
for signs of fluid volume excess, especially in patients with heart or renal failure.
3. A patient complains of sudden chest pain and dyspnea while the nurse is changing an IV
tubing set. What is the priority nursing action?
A. Administer a rescue inhaler
B. Place the patient in Trendelenburg on their left side
C. Place the patient in the high-Fowler’s position
D. Slow the IV rate to a keep-vein-open (KVO) rate
Correct Answer: B
Explanation: These symptoms are indicative of an air embolism, which is a medical
emergency. Placing the patient in the left lateral Trendelenburg position helps trap the air
in the apex of the right ventricle, preventing it from entering the pulmonary artery. The
nurse should also administer oxygen and notify the healthcare provider immediately.
4. Which assessment finding is indicative of phlebitis at a peripheral IV site?
A. Coolness to the touch and damp dressing
B. Erythema, warmth, and a palpable cord
, C. Numbness and tingling in the fingers
D. Decreased blood pressure and tachycardia
Correct Answer: B
Explanation: Phlebitis is the inflammation of the inner layer of a vein, often characterized
by pain, warmth, and a red streak following the vein’s path. A palpable cord may develop in
advanced stages, indicating significant irritation. Proper management includes removing
the IV and applying warm, moist compresses to the affected area.
5. When preparing to administer IV potassium chloride (KCl), which action by the nurse is
essential for safety?
A. Administer the medication via rapid IV push
B. Ensure the potassium is diluted in a large volume of fluid
C. Limit fluid intake to prevent fluid overload
D. Use a 24-gauge needle to minimize vein irritation
Correct Answer: B
Explanation: Potassium chloride must always be diluted and administered using an
infusion pump to ensure a controlled rate. Giving KCl via IV push can cause immediate
cardiac arrest and is never an acceptable practice. The nurse must also assess renal
function and urinary output before and during administration.
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient’s IV site and notes coolness, pallor, and swelling. What is the
most likely complication occurring?
A. Phlebitis
B. Thrombophlebitis
C. Extravasation
D. Infiltration
Correct Answer: D
Explanation: Infiltration is the leakage of non-vesicant IV fluid into the surrounding
subcutaneous tissue, characterized by coolness, swelling, and pallor. The nurse should
immediately stop the infusion and remove the catheter. Elevating the extremity and
applying a warm or cold compress based on the fluid type is the standard intervention.
2. Which intravenous fluid is considered isotonic and is frequently used for fluid resuscitation
in trauma patients?
A. 0.9% Sodium Chloride
B. 3% Sodium Chloride
C. 0.45% Sodium Chloride
D. D5W in 0.45% Sodium Chloride
,Correct Answer: A
Explanation: 0.9% Sodium Chloride, also known as Normal Saline, is an isotonic solution
that stays within the intravascular space to expand volume. It is the only fluid used in
conjunction with blood product administration to prevent hemolysis. Nurses must monitor
for signs of fluid volume excess, especially in patients with heart or renal failure.
3. A patient complains of sudden chest pain and dyspnea while the nurse is changing an IV
tubing set. What is the priority nursing action?
A. Administer a rescue inhaler
B. Place the patient in Trendelenburg on their left side
C. Place the patient in the high-Fowler’s position
D. Slow the IV rate to a keep-vein-open (KVO) rate
Correct Answer: B
Explanation: These symptoms are indicative of an air embolism, which is a medical
emergency. Placing the patient in the left lateral Trendelenburg position helps trap the air
in the apex of the right ventricle, preventing it from entering the pulmonary artery. The
nurse should also administer oxygen and notify the healthcare provider immediately.
4. Which assessment finding is indicative of phlebitis at a peripheral IV site?
A. Coolness to the touch and damp dressing
B. Erythema, warmth, and a palpable cord
, C. Numbness and tingling in the fingers
D. Decreased blood pressure and tachycardia
Correct Answer: B
Explanation: Phlebitis is the inflammation of the inner layer of a vein, often characterized
by pain, warmth, and a red streak following the vein’s path. A palpable cord may develop in
advanced stages, indicating significant irritation. Proper management includes removing
the IV and applying warm, moist compresses to the affected area.
5. When preparing to administer IV potassium chloride (KCl), which action by the nurse is
essential for safety?
A. Administer the medication via rapid IV push
B. Ensure the potassium is diluted in a large volume of fluid
C. Limit fluid intake to prevent fluid overload
D. Use a 24-gauge needle to minimize vein irritation
Correct Answer: B
Explanation: Potassium chloride must always be diluted and administered using an
infusion pump to ensure a controlled rate. Giving KCl via IV push can cause immediate
cardiac arrest and is never an acceptable practice. The nurse must also assess renal
function and urinary output before and during administration.
