PNR 202/PNR202 Exam 2 V1 | Intravenous
Therapy Q&A with Rationale | Fortis College
1. A nurse observes that a patient’s peripheral IV site is cool to the touch, swollen, and the
infusion rate has slowed. Which complication is the patient likely experiencing?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Thrombophlebitis
Correct Answer: A
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, characterized by coolness, swelling, and pallor. Phlebitis would
present with warmth and redness rather than coolness. The nurse must immediately stop
the infusion and remove the catheter to prevent further tissue damage.
2. Which of the following intravenous solutions is classified as hypotonic?
A. 0.9% Sodium Chloride
B. Lactated Ringer’s
C. 0.45% Sodium Chloride
D. 5% Dextrose in 0.9% Sodium Chloride
Correct Answer: C
,Explanation: 0.45% Sodium Chloride (half-normal saline) is a hypotonic solution because
it has a lower osmolarity than plasma. This type of fluid causes water to move from the
extracellular space into the intracellular space to rehydrate cells. In contrast, 0.9% NaCl
and Lactated Ringer’s are isotonic solutions commonly used for volume expansion.
3. When initiating a blood transfusion, what is the most critical action the nurse must take
during the first 15 minutes of the infusion?
A. Document the patient’s intake and output
B. Infuse the blood at a rapid rate to ensure completion
C. Stay with the patient and monitor for adverse reactions
D. Check the IV site for signs of infiltration every 30 minutes
Correct Answer: C
Explanation: The first 15 minutes are the most critical period for the occurrence of severe
hemolytic or allergic reactions. The nurse must stay at the bedside to monitor vital signs
and identify immediate distress. If a reaction is suspected, the infusion must be stopped
immediately to protect the patient.
4. A patient receiving IV therapy develops sudden shortness of breath, crackles in the lungs,
and an increased blood pressure. Which condition should the nurse suspect?
A. Septicemia
B. Air Embolism
C. Catheter Embolism
, D. Circulatory Overload
Correct Answer: D
Explanation: Circulatory overload, or fluid volume excess, occurs when fluids are
administered faster than the cardiovascular system can manage. Symptoms include
hypertension, dyspnea, and pulmonary crackles due to fluid backing up into the lungs. The
nurse should slow the infusion rate to KVO (Keep Vein Open) and notify the provider
immediately.
5. What is the standard drop factor for a microdrip administration set?
A. 10 gtt/mL
B. 15 gtt/mL
C. 20 gtt/mL
D. 60 gtt/mL
Correct Answer: D
Explanation: Microdrip tubing is designed to deliver small, precise amounts of fluid and
always has a drop factor of 60 gtt/mL. This makes the math simple as the number of drops
per minute equals the number of milliliters per hour. Macrodrip sets usually vary between
10, 15, or 20 gtt/mL depending on the manufacturer.
6. A nurse is preparing to administer a vesicant medication. Which complication must the
nurse be most vigilant in preventing?
A. Infiltration
Therapy Q&A with Rationale | Fortis College
1. A nurse observes that a patient’s peripheral IV site is cool to the touch, swollen, and the
infusion rate has slowed. Which complication is the patient likely experiencing?
A. Infiltration
B. Phlebitis
C. Extravasation
D. Thrombophlebitis
Correct Answer: A
Explanation: Infiltration occurs when non-vesicant IV fluid leaks into the surrounding
subcutaneous tissue, characterized by coolness, swelling, and pallor. Phlebitis would
present with warmth and redness rather than coolness. The nurse must immediately stop
the infusion and remove the catheter to prevent further tissue damage.
2. Which of the following intravenous solutions is classified as hypotonic?
A. 0.9% Sodium Chloride
B. Lactated Ringer’s
C. 0.45% Sodium Chloride
D. 5% Dextrose in 0.9% Sodium Chloride
Correct Answer: C
,Explanation: 0.45% Sodium Chloride (half-normal saline) is a hypotonic solution because
it has a lower osmolarity than plasma. This type of fluid causes water to move from the
extracellular space into the intracellular space to rehydrate cells. In contrast, 0.9% NaCl
and Lactated Ringer’s are isotonic solutions commonly used for volume expansion.
3. When initiating a blood transfusion, what is the most critical action the nurse must take
during the first 15 minutes of the infusion?
A. Document the patient’s intake and output
B. Infuse the blood at a rapid rate to ensure completion
C. Stay with the patient and monitor for adverse reactions
D. Check the IV site for signs of infiltration every 30 minutes
Correct Answer: C
Explanation: The first 15 minutes are the most critical period for the occurrence of severe
hemolytic or allergic reactions. The nurse must stay at the bedside to monitor vital signs
and identify immediate distress. If a reaction is suspected, the infusion must be stopped
immediately to protect the patient.
4. A patient receiving IV therapy develops sudden shortness of breath, crackles in the lungs,
and an increased blood pressure. Which condition should the nurse suspect?
A. Septicemia
B. Air Embolism
C. Catheter Embolism
, D. Circulatory Overload
Correct Answer: D
Explanation: Circulatory overload, or fluid volume excess, occurs when fluids are
administered faster than the cardiovascular system can manage. Symptoms include
hypertension, dyspnea, and pulmonary crackles due to fluid backing up into the lungs. The
nurse should slow the infusion rate to KVO (Keep Vein Open) and notify the provider
immediately.
5. What is the standard drop factor for a microdrip administration set?
A. 10 gtt/mL
B. 15 gtt/mL
C. 20 gtt/mL
D. 60 gtt/mL
Correct Answer: D
Explanation: Microdrip tubing is designed to deliver small, precise amounts of fluid and
always has a drop factor of 60 gtt/mL. This makes the math simple as the number of drops
per minute equals the number of milliliters per hour. Macrodrip sets usually vary between
10, 15, or 20 gtt/mL depending on the manufacturer.
6. A nurse is preparing to administer a vesicant medication. Which complication must the
nurse be most vigilant in preventing?
A. Infiltration
