PNR 202/PNR202 Exam 4 V3 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse is monitoring a patient receiving an isotonic intravenous solution. Which of the
following fluids is classified as isotonic?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. 10% Dextrose in Water
Correct Answer: B
Explanation: Isotonic solutions like 0.9% Sodium Chloride have the same osmolarity as
serum and do not cause fluid shifts between compartments. They are primarily used to
expand the extracellular fluid volume in patients with dehydration or hypovolemia. The
nurse must monitor for signs of fluid volume overload when administering these solutions
at high rates.
2. Upon assessment of an IV site, the nurse notes redness, warmth, and a palpable cord along
the vein. Which complication is the patient likely experiencing?
A. Infiltration
B. Extravasation
C. Circulatory Overload
,D. Phlebitis
Correct Answer: D
Explanation: Phlebitis is defined as the inflammation of the inner lining of the vein, often
characterized by pain, warmth, and a red streak. A palpable cord indicates a more severe
inflammatory response or thrombus formation. Immediate intervention involves
discontinuing the IV and applying warm compresses to the affected area.
3. Which electrolyte should never be administered via IV push under any circumstances?
A. Sodium Chloride
B. Calcium Gluconate
C. Magnesium Sulfate
D. Potassium Chloride
Correct Answer: D
Explanation: Potassium Chloride must always be diluted and administered via an infusion
pump to prevent cardiac arrest. Giving potassium as an IV bolus or push is lethal and will
lead to immediate dysrhythmias. The nurse must also ensure the patient has adequate
renal output before starting a potassium infusion.
4. A patient’s IV site is cool to the touch, pale, and swollen. What is the priority nursing
action?
A. Stop the infusion and remove the catheter
, B. Slow the infusion rate and notify the physician
C. Apply a warm compress to the site immediately
D. Flush the line with 10 mL of normal saline
Correct Answer: A
Explanation: Coolness, pallor, and edema are classic signs of infiltration, which occurs
when non-vesicant fluid enters the subcutaneous tissue. The nurse must first stop the
infusion to prevent further tissue damage. Following removal, the extremity should be
elevated to encourage the reabsorption of the fluid.
5. When priming a secondary IV tubing (piggyback), the nurse uses the ‘back-prime’ method.
What is the main advantage of this technique?
A. It prevents the loss of medication from the secondary bag
B. It allows the nurse to use a smaller gauge needle
C. It eliminates the need for an infusion pump
D. It increases the rate of the primary infusion
Correct Answer: A
Explanation: Back-priming allows the nurse to clear air from the secondary tubing using
fluid from the primary bag. This method ensures that the secondary medication dose
remains intact and is not wasted during the manual priming process. It also reduces the
risk of contamination by maintaining a closed system.
Therapy Q&A with Rationale | Fortis College
1. A nurse is monitoring a patient receiving an isotonic intravenous solution. Which of the
following fluids is classified as isotonic?
A. 0.45% Sodium Chloride
B. 0.9% Sodium Chloride
C. 3% Sodium Chloride
D. 10% Dextrose in Water
Correct Answer: B
Explanation: Isotonic solutions like 0.9% Sodium Chloride have the same osmolarity as
serum and do not cause fluid shifts between compartments. They are primarily used to
expand the extracellular fluid volume in patients with dehydration or hypovolemia. The
nurse must monitor for signs of fluid volume overload when administering these solutions
at high rates.
2. Upon assessment of an IV site, the nurse notes redness, warmth, and a palpable cord along
the vein. Which complication is the patient likely experiencing?
A. Infiltration
B. Extravasation
C. Circulatory Overload
,D. Phlebitis
Correct Answer: D
Explanation: Phlebitis is defined as the inflammation of the inner lining of the vein, often
characterized by pain, warmth, and a red streak. A palpable cord indicates a more severe
inflammatory response or thrombus formation. Immediate intervention involves
discontinuing the IV and applying warm compresses to the affected area.
3. Which electrolyte should never be administered via IV push under any circumstances?
A. Sodium Chloride
B. Calcium Gluconate
C. Magnesium Sulfate
D. Potassium Chloride
Correct Answer: D
Explanation: Potassium Chloride must always be diluted and administered via an infusion
pump to prevent cardiac arrest. Giving potassium as an IV bolus or push is lethal and will
lead to immediate dysrhythmias. The nurse must also ensure the patient has adequate
renal output before starting a potassium infusion.
4. A patient’s IV site is cool to the touch, pale, and swollen. What is the priority nursing
action?
A. Stop the infusion and remove the catheter
, B. Slow the infusion rate and notify the physician
C. Apply a warm compress to the site immediately
D. Flush the line with 10 mL of normal saline
Correct Answer: A
Explanation: Coolness, pallor, and edema are classic signs of infiltration, which occurs
when non-vesicant fluid enters the subcutaneous tissue. The nurse must first stop the
infusion to prevent further tissue damage. Following removal, the extremity should be
elevated to encourage the reabsorption of the fluid.
5. When priming a secondary IV tubing (piggyback), the nurse uses the ‘back-prime’ method.
What is the main advantage of this technique?
A. It prevents the loss of medication from the secondary bag
B. It allows the nurse to use a smaller gauge needle
C. It eliminates the need for an infusion pump
D. It increases the rate of the primary infusion
Correct Answer: A
Explanation: Back-priming allows the nurse to clear air from the secondary tubing using
fluid from the primary bag. This method ensures that the secondary medication dose
remains intact and is not wasted during the manual priming process. It also reduces the
risk of contamination by maintaining a closed system.
