PNR 202/PNR202 Exam 3 V3 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is preparing to administer a 0.9% Sodium Chloride infusion. Which classification
describes this solution?
A. Isotonic
B. Hypertonic
C. Hypotonic
D. Colloid
Correct Answer: A
Explanation: 0.9% Sodium Chloride is an isotonic solution because it has the same
osmolarity as body fluids. It is used to expand the extracellular fluid volume without
causing a significant shift of water between compartments. This makes it ideal for treating
hypovolemia and maintaining hydration.
2. Which assessment finding indicates that a patient’s IV site has become infiltrated?
A. Redness and warmth along the vein
B. Edema, coolness, and pallor at the site
C. A palpable cord-like vein
D. Purulent drainage from the insertion site
Correct Answer: B
,Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Characteristics of infiltration include localized swelling, coolness to
the touch, and blanched or pale skin. The nurse should immediately stop the infusion and
remove the catheter when these signs are observed.
3. While monitoring a patient receiving IV therapy, the nurse notes redness, warmth, and a
red streak following the vein path. What should the nurse document?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
Correct Answer: B
Explanation: Phlebitis is the inflammation of the inner lining of a vein, often caused by
mechanical or chemical irritation. Common signs include pain, warmth, redness, and
sometimes a palpable cord along the vein. If phlebitis occurs, the IV should be discontinued
and a warm compress may be applied.
4. A patient suddenly develops shortness of breath, cough, and crackles in the lungs during a
rapid IV infusion. Which complication is most likely occurring?
A. Fluid Volume Overload
B. Air Embolism
C. Septicemia
, D. Speed Shock
Correct Answer: A
Explanation: Fluid volume overload occurs when the circulatory system contains more
fluid than it can effectively manage. Symptoms include dyspnea, crackles on auscultation,
and neck vein distention. The nurse must slow the infusion rate and notify the healthcare
provider immediately for further orders.
5. What is the most appropriate nursing action when a vesicant medication has leaked into
the tissue (extravasation)?
A. Increase the flow rate to flush the tissue
B. Apply a tight pressure dressing to the area
C. Stop the infusion and notify the provider
D. Massage the area to promote absorption
Correct Answer: C
Explanation: Extravasation involves the leakage of vesicant medications that can cause
severe tissue damage or necrosis. The first priority is to stop the infusion immediately to
prevent further tissue exposure. The nurse should then follow facility protocol, which may
include aspirating residual drug or administering an antidote.
6. Which gauge size is most appropriate for a patient who requires a blood transfusion in an
emergency?
A. 18-gauge
Therapy Q&A with Rationale | Fortis College
1. A nurse is preparing to administer a 0.9% Sodium Chloride infusion. Which classification
describes this solution?
A. Isotonic
B. Hypertonic
C. Hypotonic
D. Colloid
Correct Answer: A
Explanation: 0.9% Sodium Chloride is an isotonic solution because it has the same
osmolarity as body fluids. It is used to expand the extracellular fluid volume without
causing a significant shift of water between compartments. This makes it ideal for treating
hypovolemia and maintaining hydration.
2. Which assessment finding indicates that a patient’s IV site has become infiltrated?
A. Redness and warmth along the vein
B. Edema, coolness, and pallor at the site
C. A palpable cord-like vein
D. Purulent drainage from the insertion site
Correct Answer: B
,Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue. Characteristics of infiltration include localized swelling, coolness to
the touch, and blanched or pale skin. The nurse should immediately stop the infusion and
remove the catheter when these signs are observed.
3. While monitoring a patient receiving IV therapy, the nurse notes redness, warmth, and a
red streak following the vein path. What should the nurse document?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Hematoma
Correct Answer: B
Explanation: Phlebitis is the inflammation of the inner lining of a vein, often caused by
mechanical or chemical irritation. Common signs include pain, warmth, redness, and
sometimes a palpable cord along the vein. If phlebitis occurs, the IV should be discontinued
and a warm compress may be applied.
4. A patient suddenly develops shortness of breath, cough, and crackles in the lungs during a
rapid IV infusion. Which complication is most likely occurring?
A. Fluid Volume Overload
B. Air Embolism
C. Septicemia
, D. Speed Shock
Correct Answer: A
Explanation: Fluid volume overload occurs when the circulatory system contains more
fluid than it can effectively manage. Symptoms include dyspnea, crackles on auscultation,
and neck vein distention. The nurse must slow the infusion rate and notify the healthcare
provider immediately for further orders.
5. What is the most appropriate nursing action when a vesicant medication has leaked into
the tissue (extravasation)?
A. Increase the flow rate to flush the tissue
B. Apply a tight pressure dressing to the area
C. Stop the infusion and notify the provider
D. Massage the area to promote absorption
Correct Answer: C
Explanation: Extravasation involves the leakage of vesicant medications that can cause
severe tissue damage or necrosis. The first priority is to stop the infusion immediately to
prevent further tissue exposure. The nurse should then follow facility protocol, which may
include aspirating residual drug or administering an antidote.
6. Which gauge size is most appropriate for a patient who requires a blood transfusion in an
emergency?
A. 18-gauge
