Module 3 questions
1. A nurse is caring for a client who has fluid overload during a continuous IV infusion
at 200 mL/hr. Which of the following actions by the nurse is appropriate?
A Reduce the IV fluid rate.
B Place the client in the orthopneic position.
C Remove the IV catheter.
D Place the client in modified Trendelenburg position.
Well done!
Reduce the IV rate and notify the provider immediately. To facilitate breathing, elevate the
head of the bed to the high-Fowler’s position. The client might need intravenous
medications to treat the fluid overload.
2. A nurse is monitoring a client who is receiving an IV medication. The client reports
dizziness and a feeling of chest tightness. The nurse notes that the client’s face is
flushed and warm. These findings indicate which of the following systemic
complications of IV therapy?
A Speed shock
B Extravasation
C Anaphylactic shock
D Fluid overload
Well done!
Speed shock occurs when a client receives an intravenous medication too rapidly, causing
dizziness, chest tightness, flushed and warm face, and other effects related to a toxic level
of medication in the body. Extravasation causes darkening or redness of the skin, swelling,
and pain at the IV site, which can extend to extensive tissue damage over time.
Anaphylactic shock causes bronchospasms, wheezing, shortness of breath, severe
hypotension, tachycardia, and respiratory or cardiac arrest. Fluid overload causes
shortness of breath; increased blood pressure, heart rate, and respiratory rate; crackles in
the lungs; neck vein distention; and edema in the extremities.
3.
A nurse is caring for a client who is receiving norepinephrine by continuous IV
infusion. During a routine assessment of the IV site, the nurse notes that the
catheter is no longer in the vein and the vesicant medication has infused into the
subcutaneous tissue. Which of the following actions should the nurse take?
A Apply a tourniquet proximal to the IV site.
B Call the rapid response team and start oxygen.
C Prepare to administer a diuretic.
D Stop the infusion and prepare to administer an antidote.
Well done!
, Module 3 questions
Stop the IV infusion and prepare to administer phentolamine (an antidote for
extravasation ischemia due to norepinephrine), which prevents damage to the
surrounding tissue. Apply a tourniquet proximal to the IV site if a catheter embolism
is suspected. Call the rapid response team and start oxygen if anaphylactic shock is
suspected. Prepare to administer a diuretic if fluid overload is suspected.
4. A nurse is planning care for a client who is receiving IV therapy. Which of the
following measures should the nurse include to prevent phlebitis?
A Change the IV site weekly.
B Apply a warm compress to IV site.
C Use a clean technique when replacing the transparent dressing over the IV site.
D Use a small-gauge catheter when initiating IV therapy.
Well done!
Use a catheter with the smallest gauge possible to prevent irritation of the vein and
subsequent phlebitis. Change the IV site only as clinically indicated by signs of
phlebitis or infiltration. Use a warm compress to treat phlebitis, not prevent it. Use
sterile technique when replacing the transparent dressing over the IV site.
5. A nurse is caring for a client who is receiving an antibiotic by intermittent IV
infusion. The client reports feeling short of breath and is wheezing. Which of the
following actions should the nurse take?
Select all that apply.
A Initiate oxygen.
B Call the rapid response team.
C Prepare to administer acetylcysteine.
D Remove the IV catheter.
E Elevate the head of the bed to 45°.
Well done!
A client who starts to have shortness of breath and wheezing while receiving an
antibiotic by intermittent bolus is likely experiencing anaphylaxis. First, stop the
infusion. Then initiate oxygen using a nonrebreather mask to treat the dyspnea. Call
the rapid response team for assistance and raise the head of the bed to facilitate gas
exchange. Prepare to administer epinephrine, which reverses manifestations of
anaphylaxis. (Acetylcysteine is the antidote for acetaminophen overdose.) Leave the
catheter in place to facilitate the administration of emergency medications and IV
fluids. Replace the IV tubing and infuse 0.9% NaCl.
6. Which of the following is a common name for the IV solution 0.9% sodium chloride?
1. A nurse is caring for a client who has fluid overload during a continuous IV infusion
at 200 mL/hr. Which of the following actions by the nurse is appropriate?
A Reduce the IV fluid rate.
B Place the client in the orthopneic position.
C Remove the IV catheter.
D Place the client in modified Trendelenburg position.
Well done!
Reduce the IV rate and notify the provider immediately. To facilitate breathing, elevate the
head of the bed to the high-Fowler’s position. The client might need intravenous
medications to treat the fluid overload.
2. A nurse is monitoring a client who is receiving an IV medication. The client reports
dizziness and a feeling of chest tightness. The nurse notes that the client’s face is
flushed and warm. These findings indicate which of the following systemic
complications of IV therapy?
A Speed shock
B Extravasation
C Anaphylactic shock
D Fluid overload
Well done!
Speed shock occurs when a client receives an intravenous medication too rapidly, causing
dizziness, chest tightness, flushed and warm face, and other effects related to a toxic level
of medication in the body. Extravasation causes darkening or redness of the skin, swelling,
and pain at the IV site, which can extend to extensive tissue damage over time.
Anaphylactic shock causes bronchospasms, wheezing, shortness of breath, severe
hypotension, tachycardia, and respiratory or cardiac arrest. Fluid overload causes
shortness of breath; increased blood pressure, heart rate, and respiratory rate; crackles in
the lungs; neck vein distention; and edema in the extremities.
3.
A nurse is caring for a client who is receiving norepinephrine by continuous IV
infusion. During a routine assessment of the IV site, the nurse notes that the
catheter is no longer in the vein and the vesicant medication has infused into the
subcutaneous tissue. Which of the following actions should the nurse take?
A Apply a tourniquet proximal to the IV site.
B Call the rapid response team and start oxygen.
C Prepare to administer a diuretic.
D Stop the infusion and prepare to administer an antidote.
Well done!
, Module 3 questions
Stop the IV infusion and prepare to administer phentolamine (an antidote for
extravasation ischemia due to norepinephrine), which prevents damage to the
surrounding tissue. Apply a tourniquet proximal to the IV site if a catheter embolism
is suspected. Call the rapid response team and start oxygen if anaphylactic shock is
suspected. Prepare to administer a diuretic if fluid overload is suspected.
4. A nurse is planning care for a client who is receiving IV therapy. Which of the
following measures should the nurse include to prevent phlebitis?
A Change the IV site weekly.
B Apply a warm compress to IV site.
C Use a clean technique when replacing the transparent dressing over the IV site.
D Use a small-gauge catheter when initiating IV therapy.
Well done!
Use a catheter with the smallest gauge possible to prevent irritation of the vein and
subsequent phlebitis. Change the IV site only as clinically indicated by signs of
phlebitis or infiltration. Use a warm compress to treat phlebitis, not prevent it. Use
sterile technique when replacing the transparent dressing over the IV site.
5. A nurse is caring for a client who is receiving an antibiotic by intermittent IV
infusion. The client reports feeling short of breath and is wheezing. Which of the
following actions should the nurse take?
Select all that apply.
A Initiate oxygen.
B Call the rapid response team.
C Prepare to administer acetylcysteine.
D Remove the IV catheter.
E Elevate the head of the bed to 45°.
Well done!
A client who starts to have shortness of breath and wheezing while receiving an
antibiotic by intermittent bolus is likely experiencing anaphylaxis. First, stop the
infusion. Then initiate oxygen using a nonrebreather mask to treat the dyspnea. Call
the rapid response team for assistance and raise the head of the bed to facilitate gas
exchange. Prepare to administer epinephrine, which reverses manifestations of
anaphylaxis. (Acetylcysteine is the antidote for acetaminophen overdose.) Leave the
catheter in place to facilitate the administration of emergency medications and IV
fluids. Replace the IV tubing and infuse 0.9% NaCl.
6. Which of the following is a common name for the IV solution 0.9% sodium chloride?
