PNR 202/PNR202 Exam 3 V2 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is preparing to administer an isotonic intravenous solution. Which of the following
solutions should the nurse select?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 10% Dextrose in water
D. 0.9% Sodium Chloride
Correct Answer: D
Explanation: Isotonic solutions have the same osmolarity as body fluids and are used to
expand the extracellular fluid volume. Normal saline (0.9% NaCl) is the most common
isotonic solution used for resuscitation and general hydration. Solutions like 0.45% NaCl
are hypotonic, while 3% NaCl and D10W are hypertonic.
2. Which assessment finding is most indicative of phlebitis at a peripheral IV site?
A. Erythema and a palpable cord along the vein
B. Coolness of the skin around the insertion site
C. Dampness of the dressing over the site
D. Painless edema above the insertion site
Correct Answer: A
,Explanation: Phlebitis is characterized by inflammation of the vein wall, often resulting in
pain, warmth, and redness. A palpable venous cord is a classic sign of advanced phlebitis.
The nurse must discontinue the IV and apply a warm compress according to facility
protocol.
3. A patient receiving IV therapy reports pain and swelling at the insertion site. The nurse
notes the skin is cool to the touch and the infusion has slowed. What is the priority nursing
action?
A. Apply a warm compress immediately
B. Flush the catheter with normal saline
C. Stop the infusion and remove the catheter
D. Slow the infusion rate and reassess in one hour
Correct Answer: C
Explanation: The clinical manifestations described—cool skin, swelling, and slowed
infusion—are indicative of infiltration. Infiltration occurs when non-vesicant fluid leaks
into the surrounding tissue. The primary action is to stop the infusion and remove the IV
device to prevent further tissue damage.
4. What is the recommended gauge size for a peripheral IV catheter intended for a routine
blood transfusion in an adult?
A. 18 gauge
B. 22 gauge
, C. 20 gauge
D. 24 gauge
Correct Answer: A
Explanation: An 18-gauge catheter is preferred for blood transfusions to allow for rapid
infusion and to prevent hemolysis of red blood cells. While a 20-gauge may be acceptable in
some clinical settings, the 18-gauge is the standard for trauma or major surgery involving
blood. Smaller gauges like 22 or 24 can increase the risk of blood cell damage.
5. A nurse is monitoring a patient for fluid volume excess. Which of the following symptoms
should the nurse expect to find?
A. Flat neck veins when supine
B. Crackles upon lung auscultation
C. Decreased central venous pressure
D. Dry mucous membranes
Correct Answer: B
Explanation: Fluid volume excess leads to an accumulation of fluid in the lungs,
manifesting as crackles or rales. Other signs include jugular venous distention, bounding
pulses, and peripheral edema. Nurses must monitor patients on IV therapy closely to
prevent this complication.
Therapy Q&A with Rationale | Fortis College
1. A nurse is preparing to administer an isotonic intravenous solution. Which of the following
solutions should the nurse select?
A. 0.45% Sodium Chloride
B. 3% Sodium Chloride
C. 10% Dextrose in water
D. 0.9% Sodium Chloride
Correct Answer: D
Explanation: Isotonic solutions have the same osmolarity as body fluids and are used to
expand the extracellular fluid volume. Normal saline (0.9% NaCl) is the most common
isotonic solution used for resuscitation and general hydration. Solutions like 0.45% NaCl
are hypotonic, while 3% NaCl and D10W are hypertonic.
2. Which assessment finding is most indicative of phlebitis at a peripheral IV site?
A. Erythema and a palpable cord along the vein
B. Coolness of the skin around the insertion site
C. Dampness of the dressing over the site
D. Painless edema above the insertion site
Correct Answer: A
,Explanation: Phlebitis is characterized by inflammation of the vein wall, often resulting in
pain, warmth, and redness. A palpable venous cord is a classic sign of advanced phlebitis.
The nurse must discontinue the IV and apply a warm compress according to facility
protocol.
3. A patient receiving IV therapy reports pain and swelling at the insertion site. The nurse
notes the skin is cool to the touch and the infusion has slowed. What is the priority nursing
action?
A. Apply a warm compress immediately
B. Flush the catheter with normal saline
C. Stop the infusion and remove the catheter
D. Slow the infusion rate and reassess in one hour
Correct Answer: C
Explanation: The clinical manifestations described—cool skin, swelling, and slowed
infusion—are indicative of infiltration. Infiltration occurs when non-vesicant fluid leaks
into the surrounding tissue. The primary action is to stop the infusion and remove the IV
device to prevent further tissue damage.
4. What is the recommended gauge size for a peripheral IV catheter intended for a routine
blood transfusion in an adult?
A. 18 gauge
B. 22 gauge
, C. 20 gauge
D. 24 gauge
Correct Answer: A
Explanation: An 18-gauge catheter is preferred for blood transfusions to allow for rapid
infusion and to prevent hemolysis of red blood cells. While a 20-gauge may be acceptable in
some clinical settings, the 18-gauge is the standard for trauma or major surgery involving
blood. Smaller gauges like 22 or 24 can increase the risk of blood cell damage.
5. A nurse is monitoring a patient for fluid volume excess. Which of the following symptoms
should the nurse expect to find?
A. Flat neck veins when supine
B. Crackles upon lung auscultation
C. Decreased central venous pressure
D. Dry mucous membranes
Correct Answer: B
Explanation: Fluid volume excess leads to an accumulation of fluid in the lungs,
manifesting as crackles or rales. Other signs include jugular venous distention, bounding
pulses, and peripheral edema. Nurses must monitor patients on IV therapy closely to
prevent this complication.
