PNR 202/PNR202 Exam 3 V1 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing an IV site and finds the area is cool, pale, and edematous. Which
complication should the nurse suspect?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Systemic infection
Correct Answer: C
Explanation: Infiltration occurs when non-vesicant fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness to the touch, skin pallor, and localized
swelling around the insertion site. The nurse should stop the infusion immediately and
elevate the extremity to promote fluid reabsorption.
2. When administering a blood transfusion, which IV solution is the only one compatible with
blood products?
A. Lactated Ringer’s
B. 5% Dextrose in Water (D5W)
C. 0.45% Sodium Chloride
D. 0.9% Sodium Chloride
,Correct Answer: D
Explanation: Normal Saline or 0.9% Sodium Chloride is the only fluid used to prime blood
tubing and co-administer with blood. Other solutions like D5W can cause hemolysis of the
red blood cells due to their osmotic properties. Using incompatible fluids can lead to life-
threatening transfusion reactions and clotting in the tubing.
3. A patient receiving IV therapy reports sudden shortness of breath, cough, and the nurse
notes crackles in the lungs. What is the priority nursing action?
A. Administer an antihistamine immediately
B. Increase the IV rate to flush the line
C. Place the patient in a flat supine position
D. Slow the IV rate to Keep Vein Open (KVO) and notify the provider
Correct Answer: D
Explanation: These symptoms are indicative of Circulatory Overload, which occurs when
fluid is infused too rapidly for the patient’s system to handle. The nurse must reduce the
infusion rate to KVO to maintain access while preventing further fluid intake. Raising the
head of the bed is also a critical intervention to ease respiratory effort while waiting for the
provider’s orders.
4. Which of the following is a classic sign of phlebitis at an IV insertion site?
A. Cool skin temperature
B. Dampness of the dressing
, C. Numbness in the fingers
D. A palpable cord along the vein
Correct Answer: D
Explanation: Phlebitis is the inflammation of the inner lining of a vein, often characterized
by redness, warmth, and tenderness. A palpable venous cord may develop as the
inflammation progresses along the path of the vein. The IV must be discontinued
immediately to prevent further vessel damage or thrombus formation.
5. A nurse is preparing to administer a hypertonic IV solution. What is the primary mechanism
of action for this type of fluid?
A. It shifts fluid from the intracellular space to the intravascular space
B. It causes cells to swell by moving fluid into the intracellular space
C. It maintains an equal balance between the fluid compartments
D. It is used primarily for simple hydration without electrolyte shifts
Correct Answer: A
Explanation: Hypertonic solutions have a higher osmolarity than serum, which creates an
osmotic pressure gradient that pulls water out of the cells. This increases the volume of the
intravascular space and is often used to treat cerebral edema or severe hyponatremia.
Patients must be monitored closely for signs of pulmonary edema and fluid overload due to
this rapid shift.
Therapy Q&A with Rationale | Fortis College
1. A nurse is assessing an IV site and finds the area is cool, pale, and edematous. Which
complication should the nurse suspect?
A. Phlebitis
B. Extravasation
C. Infiltration
D. Systemic infection
Correct Answer: C
Explanation: Infiltration occurs when non-vesicant fluid leaks into the surrounding
subcutaneous tissue. Common signs include coolness to the touch, skin pallor, and localized
swelling around the insertion site. The nurse should stop the infusion immediately and
elevate the extremity to promote fluid reabsorption.
2. When administering a blood transfusion, which IV solution is the only one compatible with
blood products?
A. Lactated Ringer’s
B. 5% Dextrose in Water (D5W)
C. 0.45% Sodium Chloride
D. 0.9% Sodium Chloride
,Correct Answer: D
Explanation: Normal Saline or 0.9% Sodium Chloride is the only fluid used to prime blood
tubing and co-administer with blood. Other solutions like D5W can cause hemolysis of the
red blood cells due to their osmotic properties. Using incompatible fluids can lead to life-
threatening transfusion reactions and clotting in the tubing.
3. A patient receiving IV therapy reports sudden shortness of breath, cough, and the nurse
notes crackles in the lungs. What is the priority nursing action?
A. Administer an antihistamine immediately
B. Increase the IV rate to flush the line
C. Place the patient in a flat supine position
D. Slow the IV rate to Keep Vein Open (KVO) and notify the provider
Correct Answer: D
Explanation: These symptoms are indicative of Circulatory Overload, which occurs when
fluid is infused too rapidly for the patient’s system to handle. The nurse must reduce the
infusion rate to KVO to maintain access while preventing further fluid intake. Raising the
head of the bed is also a critical intervention to ease respiratory effort while waiting for the
provider’s orders.
4. Which of the following is a classic sign of phlebitis at an IV insertion site?
A. Cool skin temperature
B. Dampness of the dressing
, C. Numbness in the fingers
D. A palpable cord along the vein
Correct Answer: D
Explanation: Phlebitis is the inflammation of the inner lining of a vein, often characterized
by redness, warmth, and tenderness. A palpable venous cord may develop as the
inflammation progresses along the path of the vein. The IV must be discontinued
immediately to prevent further vessel damage or thrombus formation.
5. A nurse is preparing to administer a hypertonic IV solution. What is the primary mechanism
of action for this type of fluid?
A. It shifts fluid from the intracellular space to the intravascular space
B. It causes cells to swell by moving fluid into the intracellular space
C. It maintains an equal balance between the fluid compartments
D. It is used primarily for simple hydration without electrolyte shifts
Correct Answer: A
Explanation: Hypertonic solutions have a higher osmolarity than serum, which creates an
osmotic pressure gradient that pulls water out of the cells. This increases the volume of the
intravascular space and is often used to treat cerebral edema or severe hyponatremia.
Patients must be monitored closely for signs of pulmonary edema and fluid overload due to
this rapid shift.
