PNR 202/PNR202 Exam 4 V1 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient’s intravenous (IV) site and notes localized redness, warmth,
and a palpable cord along the vein. Which complication is most likely occurring?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Circulatory Overload
Correct Answer: A
Explanation: Phlebitis is characterized by inflammation of the vein, often presenting with
redness, warmth, and a palpable cord. The nurse should immediately discontinue the IV
and apply a warm compress to the area. Documenting the findings and reporting the grade
of phlebitis is a standard nursing responsibility.
2. Which of the following IV fluids is classified as an isotonic solution?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. Dextrose 10% in Water
Correct Answer: B
,Explanation: 0.9% Sodium Chloride (Normal Saline) is an isotonic solution because its
osmolarity matches the plasma concentration. Isotonic solutions are used to expand the
extracellular fluid volume without causing a significant shift between compartments. This
solution is commonly used for fluid resuscitation and during blood transfusions.
3. The nurse is preparing to hang a secondary IV piggyback medication. Where should the
secondary bag be placed in relation to the primary bag?
A. Lower than the primary bag
B. At the same level as the primary bag
C. Attached to a different IV pump entirely
D. Higher than the primary bag
Correct Answer: D
Explanation: For gravity-fed secondary infusions, the secondary bag must be hung higher
than the primary bag to ensure the secondary fluid infuses first. The back-check valve on
the primary tubing prevents the secondary medication from flowing into the primary bag.
Once the secondary bag is empty, the primary infusion will automatically resume due to the
height difference.
4. A patient receiving IV therapy complains of sudden shortness of breath, cough, and the
nurse auscultates crackles in the lungs. What is the priority nursing action?
A. Increase the IV rate to maintain patency
B. Place the patient in a Trendelenburg position
, C. Administer an antihistamine immediately
D. Slow the IV rate to a Keep Vein Open (KVO) rate and notify the provider
Correct Answer: D
Explanation: These symptoms are indicative of circulatory overload, also known as fluid
volume excess. The nurse should slow the rate, elevate the head of the bed, and notify the
healthcare provider for further orders such as diuretics. Continuous monitoring of oxygen
saturation and lung sounds is essential for patient safety.
5. What is the primary purpose of a ‘scrub the hub’ protocol when accessing an IV port?
A. To ensure the port is patent
B. To lubricate the connection for the syringe
C. To check for backflow of blood
D. To prevent Central Line-Associated Bloodstream Infections (CLABSI)
Correct Answer: D
Explanation: Scrubbing the hub with an alcohol or chlorhexidine pad for at least 15
seconds significantly reduces the risk of introducing bacteria into the bloodstream. This is a
critical evidence-based practice for preventing catheter-related infections. The nurse must
allow the site to dry completely before attaching any tubing or syringes.
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing a patient’s intravenous (IV) site and notes localized redness, warmth,
and a palpable cord along the vein. Which complication is most likely occurring?
A. Phlebitis
B. Infiltration
C. Extravasation
D. Circulatory Overload
Correct Answer: A
Explanation: Phlebitis is characterized by inflammation of the vein, often presenting with
redness, warmth, and a palpable cord. The nurse should immediately discontinue the IV
and apply a warm compress to the area. Documenting the findings and reporting the grade
of phlebitis is a standard nursing responsibility.
2. Which of the following IV fluids is classified as an isotonic solution?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. Dextrose 10% in Water
Correct Answer: B
,Explanation: 0.9% Sodium Chloride (Normal Saline) is an isotonic solution because its
osmolarity matches the plasma concentration. Isotonic solutions are used to expand the
extracellular fluid volume without causing a significant shift between compartments. This
solution is commonly used for fluid resuscitation and during blood transfusions.
3. The nurse is preparing to hang a secondary IV piggyback medication. Where should the
secondary bag be placed in relation to the primary bag?
A. Lower than the primary bag
B. At the same level as the primary bag
C. Attached to a different IV pump entirely
D. Higher than the primary bag
Correct Answer: D
Explanation: For gravity-fed secondary infusions, the secondary bag must be hung higher
than the primary bag to ensure the secondary fluid infuses first. The back-check valve on
the primary tubing prevents the secondary medication from flowing into the primary bag.
Once the secondary bag is empty, the primary infusion will automatically resume due to the
height difference.
4. A patient receiving IV therapy complains of sudden shortness of breath, cough, and the
nurse auscultates crackles in the lungs. What is the priority nursing action?
A. Increase the IV rate to maintain patency
B. Place the patient in a Trendelenburg position
, C. Administer an antihistamine immediately
D. Slow the IV rate to a Keep Vein Open (KVO) rate and notify the provider
Correct Answer: D
Explanation: These symptoms are indicative of circulatory overload, also known as fluid
volume excess. The nurse should slow the rate, elevate the head of the bed, and notify the
healthcare provider for further orders such as diuretics. Continuous monitoring of oxygen
saturation and lung sounds is essential for patient safety.
5. What is the primary purpose of a ‘scrub the hub’ protocol when accessing an IV port?
A. To ensure the port is patent
B. To lubricate the connection for the syringe
C. To check for backflow of blood
D. To prevent Central Line-Associated Bloodstream Infections (CLABSI)
Correct Answer: D
Explanation: Scrubbing the hub with an alcohol or chlorhexidine pad for at least 15
seconds significantly reduces the risk of introducing bacteria into the bloodstream. This is a
critical evidence-based practice for preventing catheter-related infections. The nurse must
allow the site to dry completely before attaching any tubing or syringes.
