A patient was admitted to the hospital for same day surgery and has orders for continuous IV
therapy. Before performing a venipuncture, the nurse should
a. place a cold compress over the vein
b. inspect the IV solution for fluid color, clarity, and expiration date
c. apply a tourniquet 1 to 2 inches above selected insertion site
d. secure an armboard to the joint b. inspect the IV solution for fluid color, clarity, and
expiration date
A patient is to receive 1g of ceftriaxone (Rocephin) in 100 mL over 30 minutes. The tubing drip
rate is 10 gtt/mL. The nurse should adjust the flow rate to what infusion rate? 33 gtt/min
A nurse is assessing a patient receiving IV normal saline at 125 mL/hr. Which of the following
should the nurse recognize as a possible complication related to the intravenous therapy?
a. Petechiae over the IV site.
b. The skin is cool over the IV site.
c. patient reports cough and shortness of breath.
d. patient's blood pressure is lower than normal. c. patient reports cough and shortness of
breath.
A nurse is caring for a patient who is receiving D5 with 20 mEq of KCl at 75 mL/hr. The provider
has prescribed 1g of ceftriaxone (Rocephin) IV. When preparing to administer this medication
by IV piggyback, which of the following data is the highest priority for the nurse to collect?
a. The patient's vital signs
,b. The patient's level of consciousness
c. The medication's compatibility with the primary IV solution
d. The amount of IV solution in the primary bag c. The medication's compatibility with the
primary IV solution
A nurse is caring for a patient receiving 0.9% sodium chloride (normal saline) at 75 mL/hr
through a triple lumen central venous catheter. The pump is alarming that there is an occlusion.
Which of the following is the first thing the nurse should do?
a. Call the provider who inserted the catheter
b. Flush the line with a 10-mL syringe of heparin
c. Check the line at or above the hub for kinked tubing that is creating a resistance to flow
d. Reposition the patient. c. Check the line at or above the hub for kinked tubing that is
creating a resistance to flow
A nurse is removing an IV catheter from a patient whose IV infusion has been discontinued.
Which of the following actions is appropriate?
a. apply firm pressure over the vein
b. leave the roller clamp slightly open
c. pull the catheter straight back from the insertion site
d. lift the hub slightly upward away from the skin c. pull the catheter straight back from the
insertion site
A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This
type of solution is appropriate because it
a. pulls fluid from the cells and increases vascular volume
, b. dilutes extracellular fluid rehydrates the cells
c. replaces extracellular volume and maintains intravascular volume
d. draws fluid into blood vessels and reduces interstitial compartments b. dilutes
extracellular fluid rehydrates the cells
A nurse is discontinuing an IV infusion. For which of the following reasons is it important to
verify and document the integrity and condition of the IV catheter?
a. A broken-off catheter tip indicates the risk for an embolus
b. Catheter erosion indicates that it was left in place too long
c. Blood within the catheter could indicate clot formation
d. discoloration of the catheter could be a sign of phlebitis a. A broken-off catheter tip
indicates the risk for an embolus
A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes
blood return in the flashback chamber of the IV catheter. Which of the following actions should
the nurse perform next?
a. secure the catheter to the skin with a transparent dressing.
b. lower the catheter until it is almost flush with the skin
c. advance the catheter about 1/4 inch into the vein
d. remove the stylet slowly from the lumen of the catheter b. lower the catheter until it is
almost flush with the skin
A patient is to receive 1,000 mL of 5% dextrose in lactated Ringers over 8 hours. Using tubing
with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops
per minute? 31 gtt/min