Question 1

Which medication is added to the client’s central line infusion/flush setup to maintain the patency of the hemodynamic monitoring system?

Accepted Answer

Answer reason: Maintaining patency in hemodynamic monitoring tubing requires prevention of fibrin and microclot formation within the catheter/pressure tubing. Low-dose heparin is commonly added to the pressurized flush solution (heparinized saline) to reduce thrombus formation and keep the system patent. Normal saline alone provides a continuous flush but does not offer anticoagulant effect when clot risk is present in the monitoring setup. Aspirin and ranitidine do not function as line-flush additives for maintaining invasive monitoring system patency.

Question 2

A 12-year-old child with burns over 40% of his body is ordered to receive 1,500 ml of I.V. fluid over 6 hours. At what rate should the nurse set the infusion pump?

Accepted Answer

Answer reason: The order is 1,500 mL over 6 hours, so 1,500 ÷ 6 = 250 mL per hour. This rate is necessary to meet the prescribed resuscitation/maintenance plan in a child with significant burns, where under-infusion risks hypovolemia and shock. A common error is misplacing a decimal or dividing by the wrong time unit, leading to unsafe under- or over-infusion.

Question 3

A client diagnosed with a contusion to the brain has an intravenous line. Which solution should be contraindicated for this client?

Accepted Answer

Answer reason: In clients with traumatic brain injury, hypotonic fluids can worsen cerebral edema by lowering serum osmolality and driving water into brain tissue, increasing intracranial pressure. D5W is effectively hypotonic after the dextrose is metabolized, so it increases free water load and is avoided in head injury/brain contusion. Isotonic crystalloids are preferred to maintain intravascular volume without increasing cerebral swelling. A common pitfall is viewing D5W as “isotonic in the bag,” but its physiologic effect is hypotonic once infused.

Question 4

The client with cellular dehydration is to receive an IV solution that will rehydrate cells. Which solution, if prescribed by the HCP, should the nurse proceed to administer?

Accepted Answer

Answer reason: Cellular dehydration reflects a hypertonic extracellular environment that pulls water out of cells, so a hypotonic IV fluid is used to shift free water back into the intracellular space. This solution is hypotonic relative to plasma and provides water that can move into cells to correct intracellular dehydration. Isotonic fluids like normal saline and lactated Ringer’s primarily expand the intravascular/interstitial spaces and do not effectively rehydrate cells. A dextrose-saline combination listed here is hypertonic and would tend to draw water out of cells, worsening intracellular dehydration.

Question 5

A client is to receive an intravenous line and has requested that lidocaine hydrochloride 1% (Lidocaine) be used to locally anesthetize the area. Which is a potential complication that can occur with the use of this technique?

Accepted Answer

Answer reason: Local intradermal anesthetic injected before IV insertion can compress small superficial veins and may cause local vasoconstriction and tissue swelling, making the vein harder to visualize and cannulate. This mechanical and local tissue effect can lead to partial or complete collapse/closure of the targeted vein, preventing successful cannulation at that site. In contrast, infiltration is a complication of IV catheter malposition or dislodgement after the catheter is placed, not a primary complication of the anesthetic injection technique itself. Phlebitis and thrombosis are more commonly related to catheter dwell time, infusates, and vein trauma from the cannula rather than the small pre-insertion anesthetic wheal.

Question 6

Which nursing action helps to prevent the occurrence of phlebitis due to intravenous line insertion?

Accepted Answer

Answer reason: Phlebitis is inflammation of the vein often triggered by mechanical irritation and chemical irritation from hypertonic/vesicant or otherwise irritating IV solutions. Larger veins have greater blood flow and lumen diameter, which dilutes the medication and reduces endothelial injury, lowering the risk of phlebitis. Rotating sites on a fixed 48-hour schedule is not the primary evidence-based preventive strategy for phlebitis (site changes are generally based on clinical indications). Veins over areas of flexion increase catheter movement and friction against the vessel wall, which can worsen irritation rather than prevent it.

Question 7

A client who takes warfarin sodium (Coumadin) requires blood testing to guide treatment. The client requests the implanted venous access device be utilized. Which test should not be drawn from the device?

Accepted Answer

Answer reason: Coagulation assays used to titrate warfarin (PT/INR) require meticulous specimen integrity because small amounts of heparin or other catheter-related contaminants can falsely prolong clotting times. Implanted venous access devices are commonly flushed/locked with heparinized solutions, and residual anticoagulant can significantly skew coagulation results even after wasting blood. In contrast, CBC, metabolic panel, and lipid testing are generally not meaningfully altered by trace heparin contamination to the same degree as PT/INR assays. Therefore, the safest practice is to obtain coagulation monitoring from a fresh peripheral venipuncture to ensure accurate dosing decisions.

Question 8

The nurse is assessing the veins of the client’s hand and arm prior to inserting an IV catheter for a transfusion of RBCs. Which vein would be best for the nurse to select?

Accepted Answer

Answer reason: A straight dorsal metacarpal vein provides a predictable path and reduces the chance of mechanical irritation and infiltration compared with tortuous segments. Veins at bifurcations increase the likelihood of catheter malposition and obstruction because the catheter tip can abut a branch point or valve. “Nondominant hand” is a comfort/functional consideration, but it does not outweigh the technical requirement for a straight, suitable vein segment for safe infusion.

Question 9

An elderly client who receives intravenous therapy has a history of a fractured femur, acute myocardial infarction, glaucoma, and hypothyroidism. Which of these conditions most likely influences the rate at which fluids should be infused for this client?

Accepted Answer

Answer reason: IV infusion rates must be tailored to the client’s cardiovascular ability to tolerate added intravascular volume. After an MI, ventricular function may be impaired, making the client more susceptible to fluid overload, pulmonary edema, and worsening cardiac workload if fluids are infused too rapidly. Therefore, this history directly drives the need for cautious rate selection and close monitoring of respiratory status, oxygenation, and signs of heart failure. By contrast, a prior femur fracture does not inherently change intravascular volume tolerance, and glaucoma or hypothyroidism are not primary determinants of safe IV fluid infusion rates in routine therapy.

Question 10

The nurse is initiating an IV infusion of lactated Ringer’s (LR) for the client in shock- What is the purpose of LR for this client?

Accepted Answer

Answer reason: Lactated Ringer’s is an isotonic crystalloid, so it primarily expands the extracellular/intravascular compartment without creating a significant osmotic shift across cell membranes. As circulating volume improves, renal perfusion increases, which commonly increases urine output and provides a practical marker of resuscitation response. A hypertonic solution would be used to pull water into the vasculature, and LR is not intended to provide calories (dextrose) or targeted electrolyte repletion for arrhythmia stabilization.

Question 11

A child is receiving 8 g of I.V. gamma globulin for treatment of Kawasaki disease. The child weighs 20 kg. The order is for 8 g of gamma globulin over 12 hours. The concentration is 8 g in 300 ml of normal saline. How many milliliters per hour will this child receive?

Accepted Answer

Answer reason: The prepared solution contains the full ordered dose (8 g) in a total volume of 300 mL, so the entire 300 mL must run over 12 hours. Dividing 300 mL by 12 hours yields 25 mL/hr. Options that are higher or lower reflect common arithmetic errors (e.g., dividing by the wrong time or misreading the total volume).

Question 12

A client with an intravenous line complains of pain at the insertion site. The area appears reddened and the vein feels slightly hard to the touch for approximately 2 inches of the length of the vein. Which is an appropriate action for the nurse to take?

Accepted Answer

Answer reason: The findings of localized pain, erythema, and a palpable cordlike hardness along the vein are most consistent with IV phlebitis. Initial nursing management is to reduce inflammation and promote venous blood flow to relieve discomfort and help the vein recover. Warm, moist compresses are recommended for phlebitis because they increase local circulation and facilitate reabsorption of the inflammatory process. Cold therapy is more appropriate for acute infiltration/extravasation to limit spread, and topical antibiotic ointment is not indicated unless there is evidence of infection (e.g., purulent drainage, systemic signs).

Question 13

A client is diagnosed with hypovolemia following surgery evidenced by low blood pressure and tachycardia. The physician orders albumin 5% 500 milliliters intravenously. The nurse knows the administration of this medication causes a change in?

Accepted Answer

Answer reason: Albumin is a plasma protein that acts as a colloid and increases intravascular oncotic (colloid osmotic) pressure. Raising oncotic pressure pulls water from the interstitial space into the intravascular compartment, expanding circulating volume and improving hypotension in hypovolemia. Hydrostatic and peripheral capillary pressures are not the primary direct effect being tested; any rise in them is secondary to volume expansion. This is why albumin is classified as a colloid volume expander and its key physiologic impact is on oncotic pressure.

Question 14

The client diagnosed with septic meningitis is admitted to the medical floor at 1200. Which HCP’s order would the nurse implement first?

Accepted Answer

Answer reason: In septic meningitis, rapid delivery of time-sensitive IV antibiotics is a priority to reduce mortality and neurologic injury. Establishing IV access is the immediate prerequisite for administering ordered IV antimicrobials and any needed fluids or adjunct medications. Seizure precautions and environmental control are important supportive measures, but they do not address the urgent need for prompt antimicrobial therapy. Starting the line first enables immediate execution of the critical treatment without delay.

Question 15

An 86-year-old client with heart failure is receiving furosemide (Lasix), 40 mg I.V. The physician orders 40 mEq of potassium chloride in 100 ml of dextrose 5% in water, to infuse over 4 hours. The client's most recent serum potassium level is 3.0 mEq/L. At which infusion rate should the nurse set the I.V. pump?

Accepted Answer

Answer reason: The order is to infuse 100 mL over 4 hours, so the pump rate is 100 ÷ 4 = 25 mL/hour. This also aligns with cautious potassium replacement in an older client with heart failure, where excessive fluid or rapid electrolyte infusion increases risk of dysrhythmias and fluid overload. A higher rate such as 50 or 100 mL/hour would complete the infusion earlier than prescribed and could increase adverse risk. The potassium level of 3.0 mEq/L supports replacement, but it does not change the ordered time-based rate calculation.

Question 16

An infant is in need of intravenous access. The nurse makes an observation about scalp veins. Which statement indicates the nurse is knowledgeable about this type of venous access?

Accepted Answer

Answer reason: Scalp veins in infants are fragile and close to the head/neck vasculature, so constricting venous return with a tourniquet is generally avoided to reduce the risk of excessive congestion, hematoma, and infiltration in a highly vascular area. Instead, gentle manual occlusion or positioning/crying/comfort measures and local warming can help engorge the vein without circumferential constriction. Cannulation direction “toward the neck” is not a requirement and may increase risk by tracking along the vein. The statements about not being able to infuse fast and advancing the catheter 1/8 inch are not specific knowledge points unique to scalp-vein access and are less accurate as general rules.

Question 17

A client receives a nitroglycerin drip. Which is a true statement regarding the use of this medication in intravenous therapy?

Accepted Answer

Answer reason: Nitroglycerin is significantly adsorbed to PVC plastic, which can reduce the delivered dose if standard plastic IV bags and tubing are used. Using a glass container and appropriate administration set helps minimize medication loss and supports more reliable, titratable dosing during continuous infusion. Vented tubing is associated with rigid containers (like glass bottles) to allow air entry so the fluid can flow; venting alone without the correct container does not address the adsorption issue. The other options describe requirements that are not specific or universally required for nitroglycerin infusions (e.g., routine admixture under a hood or an absolute restriction on small-gauge catheters in older adults).

Question 18

The infant of a diabetic mother is receiving D10/0.2 NS IV through a peripheral vein to manage blood glucose levels. After examining the infant, the HCP tells the nurse to change the solution to D12.5/0.2 NS. Which action by the nurse is most important?

Accepted Answer

Answer reason: IV dextrose concentrations above 10% are typically hypertonic and increase the risk of phlebitis and tissue injury if infused through a peripheral IV, especially in a neonate. Moving from D10 to D12.5 raises osmolarity and may require a central line or explicit confirmation that peripheral administration is intended per institutional policy. The nurse’s priority is to clarify the order and the appropriate vascular access before administering a potentially harmful infusion. Obtaining the solution or increasing the rate could lead to inappropriate therapy, and a glucose check is useful but does not address the immediate safety issue of route/concentration compatibility.

Question 19

The median vein is often used in the placement of intravenous access. Which is a true statement regarding the use of this vein?

Accepted Answer

Answer reason: Veins used for peripheral IVs are preferred when they are well supported and less affected by joint motion, which decreases catheter movement, irritation, and infiltration risk. The median (median cubital region) is relatively stable and supported by surrounding structures, effectively “splinting” the site and helping maintain patency. In contrast, sites that cross or are near frequent flexion points are more prone to dislodgement and phlebitis, making that a key drawback of some other common locations. Statements about older clients’ collagen/fat changes are not specific determinants of this vein’s usability compared with overall vein fragility and skin integrity considerations. Lower-extremity circulation concerns relate to avoiding foot/leg IVs in some adults, not to the median vein used for upper-extremity access.

Question 20

Standard orders on the nurse’s unit include an intravenous infusion of 1000 mL normal saline with 20 mEq potassium chloride to run at 100 mL per hour. In which client should this order be questioned?

Accepted Answer

Answer reason: Addison’s disease (primary adrenal insufficiency) causes low aldosterone, which reduces renal potassium excretion and predisposes the client to hyperkalemia. Adding potassium chloride to IV fluids can worsen hyperkalemia and trigger dangerous dysrhythmias, so the nurse should question the order and verify current potassium level/renal function. Normal saline alone may be appropriate for volume support, but routine potassium supplementation is not safe without an indication and labs. By contrast, the other listed conditions do not inherently create the same high baseline risk for potassium retention that Addison’s does.

Question 21

The experienced nurse is supervising the new nurse caring for a hospitalized child. Which action indicates that the new nurse needs additional orientation regarding IV therapy for children?

Accepted Answer

Answer reason: Using a 1000-mL bag is generally inappropriate for children since it provides an excessive volume reservoir and increases the risk of large-volume free flow if the pump malfunctions or the line is mismanaged. Safer pediatric practice commonly uses smaller-volume containers (e.g., buretrol/volutrol or smaller bags) to limit the maximum volume that can infuse. The other actions describe appropriate aseptic setup and routine solution/tubing management rather than a pediatric-specific safety hazard.

Question 22

The nurse selects which of the following isotonic intravenous solutions for the primary purpose of promoting rehydration and elimination, while providing a good vehicle for potassium replacement?

Accepted Answer

Answer reason: Lactated Ringer’s is isotonic and commonly used for volume replacement; it also has an electrolyte composition that makes it an appropriate maintenance/rehydration base fluid when potassium is ordered as an additive. In contrast, 0.45% sodium chloride is hypotonic and is not the preferred primary fluid for rapid rehydration, and D5W becomes effectively hypotonic after dextrose metabolism. D5 in 0.45% saline is not purely isotonic and is generally less appropriate when the main goal is straightforward isotonic volume repletion with a compatible electrolyte vehicle.

Question 23

The nurse is preparing to administer IV potassium to a client with hypokalemia. Which action is appropriate?

Accepted Answer

Answer reason: IV potassium must be diluted and delivered via an infusion pump to control the rate and reduce the risk of sudden hyperkalemia and cardiac arrest. IV push administration is unsafe and contraindicated regardless of whether the access is peripheral or central. Cardiac monitoring may be indicated for higher infusion rates, but monitoring does not make undiluted or rapid administration acceptable.

Question 24

The nurse is documenting client care after initiating continuous IV fluids through a client's existing venous access device (VAD). Which of the following is the best example of documentation for this procedure?

Accepted Answer

Answer reason: Confirming brisk blood return and that a saline flush was tolerated documents catheter patency and supports that the line is safe to use for continuous infusion. Site appearance alone is important but does not confirm intraluminal patency or rule out infiltration/occlusion. Technique notes like “started slowly” are vague and do not capture the essential safety check that justifies initiating fluids through the device.

Question 25

A client receiving vesicant chemotherapy through a peripheral IV reports a burning sensation at the IV site. What should be the nurse's immediate action?

Accepted Answer

Answer reason: Vesicant chemotherapy can cause severe tissue necrosis if extravasation occurs, so the priority is to immediately prevent further drug infiltration into surrounding tissue. Burning, stinging, or pain at the IV site is an early warning sign of possible extravasation, making prompt cessation of the infusion the safest first step. After stopping the infusion, the nurse typically leaves the catheter in place to attempt aspiration and to administer any ordered antidote through the existing access. Removing the IV first is unsafe because it can eliminate the ability to aspirate residual drug and may worsen local tissue exposure.

Question 26

A newly hired nurse is caring for a client who is receiving prescribed total parenteral nutrition (TPN) therapy. The nurse preceptor should intervene if the newly hired nurse?

Accepted Answer

Answer reason: TPN is a high-risk parenteral therapy that requires strict measures to prevent particulate infusion and microbial contamination because it is administered through central venous access. An in-line filter is used to reduce the risk of infusion-related complications by trapping particulates and, depending on the formulation, helping limit certain contaminants. Omitting the filter represents an unsafe IV-therapy technique that can directly increase patient harm risk and therefore warrants immediate preceptor intervention. By contrast, mask use during central line dressing changes and frequent glucose checks are appropriate infection-control and monitoring practices for TPN patients.

Question 27

During the infusion of a medication through an implanted port, a client reports pain at the insertion site. Which of these complications should the nurse suspect to be the most likely cause of the pain?

Accepted Answer

Answer reason: This can occur if the noncoring needle is malpositioned or the catheter/port integrity is compromised, causing local tissue irritation and pressure. Infection is more often associated with erythema, warmth, drainage, and systemic signs rather than acute infusion-related pain as the primary finding. Chylothorax and catheter migration are less likely to present primarily as localized insertion-site pain during infusion.

Question 28

The nurse selects which of the following isotonic intravenous solutions for the primary purpose of promoting rehydration and elimination, while providing a good vehicle for potassium replacement?

Accepted Answer

Answer reason: This solution is considered isotonic on initiation and is commonly used as a maintenance fluid that supports hydration and urine output, making it a practical carrier for potassium supplementation. In contrast, 0.45% sodium chloride is hypotonic and is more likely to shift water into cells rather than primarily expand intravascular volume for rehydration and elimination goals. Ringer’s lactate is isotonic but contains electrolytes (including calcium) that can limit compatibility with certain additives and is not the classic carrier emphasized for potassium replacement in basic nursing test items. D5 in 0.45% saline is not purely isotonic and is less directly aligned with the question’s stated primary purpose.

Question 29

The client is to receive 1L of I/V Dextrose & 2L of I/V N/S for 24 hour. But I/V set delivers 20 drop/min. The drip rate should be set at?

Accepted Answer

Answer reason: Total volume is 1 L + 2 L = 3 L = 3000 mL to run over 24 hours (1440 minutes), so the flow in mL/min is 3000/1440 ≈ 2.08 mL/min. With a 20 gtt/mL set, drip rate = 2.08 × 20 ≈ 41.7 gtt/min, which is rounded to 42 gtt/min. Therefore, the closest accurate setting is 42 drop/min, and 32 drop/min would under-infuse the prescribed fluids.

Question 30

Which solution is used for burn patients?

Accepted Answer

Answer reason: Ringer’s lactate is the preferred fluid for burn resuscitation (e.g., Parkland formula) because it closely resembles plasma and helps correct fluid and electrolyte losses.

Question 31

A nurse is caring for a client with a peripherally inserted central catheter (PICC). Which intervention is appropriate when administering medications through the line?

Accepted Answer

Answer reason: The key principle is maintaining central line patency and preventing medication incompatibilities and occlusions. A 10 mL normal-saline flush is standard for PICC medication administration to clear the catheter and ensure full drug delivery; flushing before, between, and after meds reduces precipitation when drugs are incompatible. Using smaller syringes increases pressure within the catheter and can damage the line or dislodge a clot. Scrubbing the hub should use an appropriate antiseptic with adequate contact time (typically alcohol/chlorhexidine for longer than 5 seconds), making the betadine/5-second step an unsafe/incomplete technique.

Question 32

While assessing a client’s intravenous (IV) line, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. What complication should the nurse document?

Accepted Answer

Answer reason: Infiltration is characterized by coolness, pallor, swelling, and discomfort due to fluid leaking into surrounding tissue. Phlebitis would present with warmth and redness, not coolness.

Question 33

A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first?

Accepted Answer

Answer reason: This fluid most closely matches extracellular fluid composition and helps restore perfusion while avoiding rapid free-water shifts. Colloids such as albumin are generally not first-line in the immediate phase because increased capillary permeability can allow them to extravasate, limiting benefit early on. Dextrose solutions do not provide effective volume expansion for shock resuscitation. Potassium-containing fluids are avoided initially until urine output and renal function are confirmed because early hyperkalemia can occur after tissue injury.

Question 34

When giving intravenous (I.V.) phenytoin, which of the following methods should you use?

Accepted Answer

Answer reason: IV phenytoin has formulation characteristics that make it prone to precipitation, so administration techniques must minimize particulate delivery and line occlusion. Using an in-line filter helps trap crystals/particulates that can form during infusion, improving safety of IV delivery. Dextrose-containing solutions are incompatible and can precipitate the medication, so flushing with dextrose is unsafe. Normal saline compatibility is important, but the question asks for the method to use during administration, and filtration best addresses the key IV safety issue being tested.

Question 35

A nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse obtains which most essential piece of equipment before hanging the solution?

Accepted Answer

Answer reason: An infusion pump is essential to ensure accurate, continuous administration and to prevent dangerous under- or over-infusion due to gravity flow variability. While bedside glucose monitoring is important because PN can cause hyperglycemia, it is not the most essential equipment needed to safely initiate the infusion itself. A blood pressure monitor and urine test strips are not required to administer PN and do not control the delivery rate.

Question 36

A client is prescribed to receive a continuous infusion of IV nitroglycerin. What consideration should the nurse make in preparing to administer this medication?

Accepted Answer

Answer reason: IV nitroglycerin is significantly adsorbed onto polyvinyl chloride (PVC) plastic IV containers and tubing, which can reduce the delivered dose and lead to inadequate therapeutic effect. Using glass (or other non-PVC, compatible containers and tubing) minimizes drug loss and helps ensure accurate infusion delivery during continuous administration. Light protection may be needed depending on institutional policy, but simply covering the bag does not address PVC adsorption as directly as selecting appropriate container materials. Routine replacement every 2 hours is not a standard stability requirement for nitroglycerin infusions, and laminar flow hoods are for sterile compounding needs rather than a primary administration consideration at the bedside.

Question 37

The healthcare provider is going to prescribe a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered?

Accepted Answer

Answer reason: dehydration reflects an intracellular fluid deficit, often from hypertonic extracellular conditions, so a hypotonic IV fluid helps shift water from the intravascular/extracellular space into cells via osmosis. This option is a classic hypotonic crystalloid used to provide free water relative to plasma and support intracellular rehydration when appropriate. In contrast, 0.9% normal saline and lactated Ringer’s are isotonic and primarily expand the extracellular compartment without promoting intracellular water movement. 5% dextrose in normal saline is hypertonic initially and would not be the expected choice when the explicit order is for a hypotonic solution.

Question 38

When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to?

Accepted Answer

Answer reason: Swelling at the IV site is an early sign of infiltration/extravasation, so the immediate priority is to stop the infusion to limit further injury. Continuing the infusion or trying to “push it through” by running it quickly increases the volume of vesicant in the tissues and worsens damage. A central line may be preferred for many vesicants, but peripheral administration can be permitted by protocol; it is not an automatic reason to withhold therapy if a safe, patent line is present and monitoring is ongoing.

Question 39

The client is to receive the intravenous medication vancomycin. To prevent adverse reactions from rapid infusion, by what method should the nurse plan to administer this drug?

Accepted Answer

Answer reason: An electronic pump provides the most accurate, consistent control of the infusion rate over the required time frame, minimizing accidental rapid delivery. Gravity or a manual regulator is more prone to rate drift with changes in bag height, venous access resistance, or patient movement, increasing risk of a too-rapid infusion. Controlling the rate precisely is the key safety action to prevent these predictable adverse reactions.

Question 40

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?

Accepted Answer

Answer reason: IV lipid emulsions must remain uniformly emulsified; visible fat globules or “creaming” indicates instability/separation that can signal an unsafe product. Infusing a separated lipid emulsion increases risk of embolic/particulate infusion and related complications. The safest nursing action is to discard the suspect container and replace it with a new one that appears properly mixed per policy. Shaking vigorously or warming is not an approved corrective step and can further destabilize the emulsion rather than assure product integrity.

Question 41

A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which should the nurse implement before administering the antibiotic?

Accepted Answer

Answer reason: TPN requires a dedicated line/tubing because it is hypertonic and has high dextrose content, making it a high-risk infusate for contamination and precipitation with other medications. Administering an antibiotic through the same lumen as TPN can cause incompatibility, occlude the catheter, and compromise delivery of nutrition. The safest action before giving the antibiotic is to use a separate IV site or a separate lumen on a multi-lumen CVC reserved for medications. Simply flushing or pausing TPN does not reliably prevent incompatibility and increases risk for interruption of therapy and glucose instability.

Question 42

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time?

Accepted Answer

Answer reason: With vasodilation and rapid BP reduction risk, urine output is a key indicator of renal perfusion and overall organ blood flow during aggressive BP management. The prepared concentration (0.1 mg/mL) infused at 50 mL/hr delivers 5 mg/hr, so there is no dosing-rate error requiring pump adjustment. QT prolongation monitoring is not a primary concern for this medication compared with BP/HR effects, and maintaining SBP above a specific number like 170 mm Hg is not a universal target and is provider-directed based on stroke type and treatment eligibility.

Question 43

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome. The client's vital signs, including blood pressure (BP), heart rate (HR), and pain level, are being monitored frequently. Which assessment findings indicate that the current rate of administration should be maintained?

Accepted Answer

Answer reason: This set of findings shows effective symptom control with stable, normotensive blood pressure and a normal heart rate, indicating the therapeutic goal is met without unsafe hemodynamic effects. A markedly low pressure (e.g., 80/50) would suggest excessive vasodilation and would typically require decreasing or holding the infusion despite pain relief. Persistent moderate-to-severe pain with acceptable vitals suggests underdosing and would generally prompt further titration upward rather than maintaining the current rate.

Question 44

The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?

Accepted Answer

Answer reason: The key principle is that catheter advancement should occur only after confirming venous entry to prevent infiltration and tissue injury. A flashback of blood in the catheter chamber indicates the needle tip is in the vein lumen and the catheter can be threaded forward while stabilizing the needle. Easy advancement and lack of discomfort are nonspecific and can still occur with subcutaneous placement, especially early in an infiltration. Vein distension under the needle suggests swelling or infiltration rather than correct intravascular placement, so it is not a cue to advance.

Question 45

A client is in ventricular tachycardia and the primary health care provider prescribes intravenous (IV) lidocaine. The nurse should dilute the concentrated solution of lidocaine with which solution?

Accepted Answer

Answer reason: Lidocaine concentrated solution is commonly diluted in dextrose-containing solutions for continuous IV infusion to ensure compatibility and consistent delivery. Using an incompatible diluent can change pH/ion content and increase the risk of instability or particulate formation, creating a safety hazard during IV administration. Isotonic saline and LR are common diluents for many medications, but lidocaine infusions are typically prepared in dextrose solutions per standard compatibility guidance.

Question 46

A client has a deep vein thrombosis and is receiving a heparin drip. The client's activated partial thromboplastin time (aPTT) has been in the therapeutic range for the past 24 hours. The most recent laboratory value shows that the current aPTT equals the control value. What explanation should the nurse consider?

Accepted Answer

Answer reason: An infiltrated IV catheter can cause the heparin to infuse into subcutaneous tissue rather than the bloodstream, producing a “normal” aPTT despite the ordered drip. True heparin “tolerance” is not an expected acute explanation for an abrupt normalization after stability. Spinach intake affects vitamin K–dependent anticoagulation (warfarin/INR), not heparin/aPTT, and thrombocytopenia is monitored for HIT risk but does not directly normalize aPTT in this way.

Question 47

A child is admitted to the hospital with dehydration. The physician orders potassium to be added to the child’s IV. What must be assessed prior to the administration of potassium?

Accepted Answer

Answer reason: Before adding potassium to IV fluids, the nurse must verify adequate kidney function by assessing urine output (e.g., voiding and appropriate mL/kg/hr) and related genitourinary findings. In dehydration, oliguria may already be present, making this a critical safety check prior to administration. Findings like mucous membranes help gauge dehydration severity but do not determine whether potassium can be safely cleared.

Question 48

A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?

Accepted Answer

Answer reason: TPN is a high-alert, hypertonic solution that should run on its own dedicated line to prevent incompatibility, precipitation, and interruption of continuous nutrient delivery. Administering an IV antibiotic through the same lumen increases risk of physical/chemical incompatibility and can compromise line patency or deliver an unsafe mixture. Using a separate IV access (another lumen or peripheral line) is the safest standard approach before giving intermittent medications. Turning off TPN or simply flushing the catheter does not address incompatibility risk and unnecessarily interrupts TPN, which can also destabilize glucose control.

Question 49

The nurse is inserting an intravenous (IV) line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation?

Accepted Answer

Answer reason: The key principle is that catheter advancement should occur only after confirming intravascular placement to reduce infiltration/extravasation risk. Visible blood return (flashback) indicates the needle/catheter tip has entered the vein lumen, signaling it is appropriate to advance the catheter off the needle. Ease of advancement, vein distention, or absence of discomfort are not reliable indicators of correct venous placement and can still occur with subcutaneous placement or partial wall puncture. Using flashback as the cue supports safe IV insertion and decreases complications.

Question 50

What is the smallest gauge intravenous catheter that can be used to administer blood?

Accepted Answer

Answer reason: A 22-gauge catheter is commonly accepted as the smallest size suitable for packed RBC administration in stable, routine situations (with slower infusion rates as needed). Smaller catheters like 24- or 26-gauge are more prone to inadequate flow, clotting, and pump/pressure alarms, making transfusion unreliable and potentially unsafe. Larger catheters (e.g., 20-gauge) are preferred when rapid transfusion or higher viscosity products are anticipated, but they are not the smallest acceptable size.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Intravenous Therapy NCLEX Practice Test

Continue Learning

Which medication is added to the client’s central line infusion/flush setup to maintain the patency of the hemodynamic monitoring system?

A 12-year-old child with burns over 40% of his body is ordered to receive 1,500 ml of I.V. fluid over 6 hours. At what rate should the nurse set the infusion pump?

A client diagnosed with a contusion to the brain has an intravenous line. Which solution should be contraindicated for this client?

The client with cellular dehydration is to receive an IV solution that will rehydrate cells. Which solution, if prescribed by the HCP, should the nurse proceed to administer?

A client is to receive an intravenous line and has requested that lidocaine hydrochloride 1% (Lidocaine) be used to locally anesthetize the area. Which is a potential complication that can occur with the use of this technique?

Which nursing action helps to prevent the occurrence of phlebitis due to intravenous line insertion?

A client who takes warfarin sodium (Coumadin) requires blood testing to guide treatment. The client requests the implanted venous access device be utilized. Which test should not be drawn from the device?

The nurse is assessing the veins of the client’s hand and arm prior to inserting an IV catheter for a transfusion of RBCs. Which vein would be best for the nurse to select?

An elderly client who receives intravenous therapy has a history of a fractured femur, acute myocardial infarction, glaucoma, and hypothyroidism. Which of these conditions most likely influences the rate at which fluids should be infused for this client?

The nurse is initiating an IV infusion of lactated Ringer’s (LR) for the client in shock- What is the purpose of LR for this client?

A child is receiving 8 g of I.V. gamma globulin for treatment of Kawasaki disease. The child weighs 20 kg. The order is for 8 g of gamma globulin over 12 hours. The concentration is 8 g in 300 ml of normal saline. How many milliliters per hour will this child receive?

A client with an intravenous line complains of pain at the insertion site. The area appears reddened and the vein feels slightly hard to the touch for approximately 2 inches of the length of the vein. Which is an appropriate action for the nurse to take?

A client is diagnosed with hypovolemia following surgery evidenced by low blood pressure and tachycardia. The physician orders albumin 5% 500 milliliters intravenously. The nurse knows the administration of this medication causes a change in?

The client diagnosed with septic meningitis is admitted to the medical floor at 1200. Which HCP’s order would the nurse implement first?

An infant is in need of intravenous access. The nurse makes an observation about scalp veins. Which statement indicates the nurse is knowledgeable about this type of venous access?

A client receives a nitroglycerin drip. Which is a true statement regarding the use of this medication in intravenous therapy?

The infant of a diabetic mother is receiving D10/0.2 NS IV through a peripheral vein to manage blood glucose levels. After examining the infant, the HCP tells the nurse to change the solution to D12.5/0.2 NS. Which action by the nurse is most important?

The median vein is often used in the placement of intravenous access. Which is a true statement regarding the use of this vein?

Standard orders on the nurse’s unit include an intravenous infusion of 1000 mL normal saline with 20 mEq potassium chloride to run at 100 mL per hour. In which client should this order be questioned?

The experienced nurse is supervising the new nurse caring for a hospitalized child. Which action indicates that the new nurse needs additional orientation regarding IV therapy for children?

The nurse selects which of the following isotonic intravenous solutions for the primary purpose of promoting rehydration and elimination, while providing a good vehicle for potassium replacement?

The nurse is preparing to administer IV potassium to a client with hypokalemia. Which action is appropriate?

The nurse is documenting client care after initiating continuous IV fluids through a client's existing venous access device (VAD). Which of the following is the best example of documentation for this procedure?

A client receiving vesicant chemotherapy through a peripheral IV reports a burning sensation at the IV site. What should be the nurse's immediate action?

A newly hired nurse is caring for a client who is receiving prescribed total parenteral nutrition (TPN) therapy. The nurse preceptor should intervene if the newly hired nurse?

During the infusion of a medication through an implanted port, a client reports pain at the insertion site. Which of these complications should the nurse suspect to be the most likely cause of the pain?

The nurse selects which of the following isotonic intravenous solutions for the primary purpose of promoting rehydration and elimination, while providing a good vehicle for potassium replacement?

The client is to receive 1L of I/V Dextrose & 2L of I/V N/S for 24 hour. But I/V set delivers 20 drop/min. The drip rate should be set at?

Which solution is used for burn patients?

A nurse is caring for a client with a peripherally inserted central catheter (PICC). Which intervention is appropriate when administering medications through the line?

While assessing a client’s intravenous (IV) line, the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. What complication should the nurse document?

A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first?

When giving intravenous (I.V.) phenytoin, which of the following methods should you use?

A nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse obtains which most essential piece of equipment before hanging the solution?

A client is prescribed to receive a continuous infusion of IV nitroglycerin. What consideration should the nurse make in preparing to administer this medication?

The healthcare provider is going to prescribe a hypotonic intravenous solution for a client with cellular dehydration. The nurse would expect which fluid to be administered?

When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to?

The client is to receive the intravenous medication vancomycin. To prevent adverse reactions from rapid infusion, by what method should the nurse plan to administer this drug?

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?

A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which should the nurse implement before administering the antibiotic?

The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?

A client is in ventricular tachycardia and the primary health care provider prescribes intravenous (IV) lidocaine. The nurse should dilute the concentrated solution of lidocaine with which solution?

A child is admitted to the hospital with dehydration. The physician orders potassium to be added to the child’s IV. What must be assessed prior to the administration of potassium?

A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?

The nurse is inserting an intravenous (IV) line into a client’s vein. After the initial stick, the nurse would continue to advance the catheter in which situation?

What is the smallest gauge intravenous catheter that can be used to administer blood?

Think you’re ready for the NCLEX?

Leave a Reply Cancel reply