Chapter 36: Administering Intravenous Solutions and Medications

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MULTIPLE CHOICE

1. A patient is receiving an intravenous (IV) infusion of 5% dextrose in 0.45% saline. This

solution is
1. isotonic.
2. hypotonic.
3. hypertonic.
4. low molecular.
ANS: 3
This solution is a hypertonic or high molecular solution, as are 5% dextrose in 0.9% saline,
5% dextrose in Ringer’s lactate, and 10% dextrose in water.

DIF: Cognitive Level: Knowledge REF: Page 715; Table 36-1

OBJ: Theory #3 TOP: Types of Intravenous Solutions
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

2. A patient will be receiving a blood transfusion. The nurse will need to use a
1. piggyback set.
2. primary infusion set.
3. controlled-volume set.
4. Y administration set.
ANS: 4
A Y administration set is used to place the blood on one side and normal saline on the other.

DIF: Cognitive Level: Analysis REF: Page 716 OBJ: Theory #3

TOP: Administration Sets KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

3. The nurse is gathering equipment needed for a pediatric patient who will begin IV therapy.
The tubing size appropriate for this patient is
1. 60 gtt/mL.
2. 20 gtt/mL.
3. 15 gtt/mL.
4. 10 gtt/mL.
ANS: 1
A microdrip infusion set, which delivers 60 gtt/mL, is used for infants and children.

DIF: Cognitive Level: Analysis REF: Page 716 OBJ: Theory #3

TOP: Tubing Size KEY: Nursing Process Step: Planning MSC: NCLEX: N/A

4. A patient is receiving a medication via IV piggyback. What indicates the setup is incorrect?
1. Secondary bag is hung higher than the primary bag.
2. Primary line clamp is closed.
 3. Slide clamp near the insertion site is open.
4. Secondary line clamp is open.
ANS: 2
When a medication is given via piggyback setup, the secondary bag is hung slightly higher
than the primary line and, when the secondary infusion finishes, the primary one takes over
again; so all clamps (roller and slide) must be open for the setup to work properly.

DIF: Cognitive Level: Application REF: Page 716

OBJ: Clinical Practice #5 TOP: Secondary or Piggyback Intravenous Set
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

5. The nurse is assisting in the care of a patient who will receive a unit of blood. The
appropriate solution to infuse through a parallel infusion set before and after the infusion is
1. 5% dextrose in water.
2. 10% dextrose in water.
3. lactated Ringer’s solution.
4. normal saline.
ANS: 4
Normal saline is the only solution used in conjunction with infusion of a blood product.

DIF: Cognitive Level: Application REF: Page 716

OBJ: Clinical Practice #7 TOP: Blood Infusion
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

6. A patient who is able to eat a normal diet has an order to receive an IV infusion of an
antibiotic every 6 hours. This patient is likely to have a(n)
1. primary IV line.
2. secondary IV line.
3. intermittent infusion device.
4. central venous line.
ANS: 3
Patients who do not require large amounts of fluid but receive intermittent IV medications
benefit from an intermittent infusion device.

DIF: Cognitive Level: Application REF: Page 717 OBJ: Theory #3

TOP: Saline or PRN Lock KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A

7. A patient is receiving IV fluids through an infusion pump. How often should the nurse
check the functioning of the pump?
1. Every 15 to 30 minutes
2. Every 1 to 2 hours
3. Every 2 to 4 hours
4. Once during the shift
ANS: 2
An IV infusion pump should be checked every 1 to 2 hours to ensure that it is functioning
properly.
 DIF: Cognitive Level: Comprehension REF: Page 719; Box 36-1
OBJ: Theory #3 TOP: Infusion Pumps
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment

8. A patient has an IV line dressing that is dated 7/17. Today is July 18. The catheter should be
changed
1. tomorrow or the next day.
2. in 3 or 4 more days.
3. in 5 more days.
4. in 7 days.
ANS: 1
IV catheters are generally replaced every 48 to 72 hours (every 2 to 3 days) according to
agency policy.

DIF: Cognitive Level: Analysis REF: Page 719 OBJ: Theory #3

TOP: Intravenous Catheters KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A

9. A patient is admitted with a peripherally inserted central catheter (PICC). As part of

standard care for this patient, the nurse should
1. obtain the patient’s temperature every 2 hours.
2. prepare to infuse fluids at high volumes.
3. avoid taking blood pressures on the arm with the PICC line.
4. have the catheter withdrawn while the patient is hospitalized.
ANS: 3
PICC lines are inserted by physicians or specially trained nurses, and they are used for long-
term therapy; blood pressures are not taken in the arm that has the PICC line to avoid
interfering with the function or the life of the catheter.

DIF: Cognitive Level: Application REF: Page 720 OBJ: Theory #3

TOP: PICC KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

10. A patient has just undergone placement of a central venous catheter through the subclavian
vein. Fluid infusions through the catheter cannot begin until placement is verified by
1. length of catheter that was inserted.
2. quality of breath sounds.
3. absence of heart murmurs.
4. results of chest x-ray.
ANS: 4
Correct placement of subclavian catheters must be verified by radiographic studies before
any fluid is infused through them.

DIF: Cognitive Level: Comprehension REF: Page 721 OBJ: Theory #3

TOP: Central Venous Catheter Placement
 KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment

11. The nurse observes that the insertion site of an IV catheter looks pale and puffy. When
palpated, the area feels cool to the touch. The best action for the nurse to take is to
1. discontinue the infusion and start a new IV site.
2. apply warm compresses to the site.
3. monitor the patient’s temperature every 4 hours.
4. call the physician and report these findings.
ANS: 1
Infiltration is the most common complication of IV therapy, and it occurs when fluid or
medication leaks out of the vein and into the tissue. Signs are pale, cool skin that is
edematous (puffy).

DIF: Cognitive Level: Application REF: Page 721

OBJ: Clinical Practice #2 TOP: Infiltration of Intravenous Fluids
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

12. A patient rings the call bell and states that the IV insertion site is painful. The site is
reddened, warm, and swollen. The patient is most likely experiencing
1. blood stream infection.
2. catheter embolus.
3. infiltration of the line.
4. phlebitis.
ANS: 4
Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or
additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness.

DIF: Cognitive Level: Comprehension REF: Page 721 OBJ: Theory #2

TOP: Phlebitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

13. A patient who has been receiving IV fluid therapy experiences an air embolus in the line.
The nurse should immediately turn the patient onto the
1. right side and raise the head of the bed.
2. right side and lower the head of the bed.
3. left side and raise the head of the bed.
4. left side and lower the head of the bed.
ANS: 4
To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should
turn the patient onto the left side and lower the head of the bed. The physician is notified
immediately.

DIF: Cognitive Level: Application REF: Page 722; Table 36-2

OBJ: Theory #2 TOP: Catheter Bolus
KEY: Nursing Process Step: Implementation
 MSC: NCLEX: Physiological Integrity

14. Regardless of the state or setting in which an LPN/LVN practices, he can expect to have
which responsibility with regard to IV therapy?
1. Add medications to IV solutions.
2. Hang IV piggyback medications.
3. Monitor IV therapy.
4. Start IV lines.
ANS: 3
All nurses monitor IV therapy and add IV solutions without medication to existing IV
setups. The other responsibilities may vary from state to state.

DIF: Cognitive Level: Knowledge REF: Page 722 OBJ: Theory #3

TOP: Role of Nurse KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

15. A nurse is monitoring the status of an elderly patient who is receiving IV therapy. Which
clinical sign is more indicative that this patient is experiencing fluid overload?
1. Crackles in the lung fields
2. Pulse rate of 64 beats/min, irregular
3. Respirations of 16 breaths/min, regular
4. Slight edema to the feet
ANS: 1
Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness
of breath.

DIF: Cognitive Level: Analysis REF: Page 723; Elder Care Points
OBJ: Theory #4 TOP: Elder Care: IV Therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. A patient has an order for an infusion of 5% dextrose in 0.45% sodium chloride at a rate of
100 mL/hr IV. The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute
should the nurse regulate the infusion?
1. 15
2. 17
3. 25
4. 33
ANS: 3
The formula for calculating IV flow rates is as follows:

DIF: Cognitive Level: Application REF: Page 724; Box 36-2

 OBJ: Clinical Practice #2 TOP: IV Calculations
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

17. A nurse is caring for a patient with an IV piggyback whose infusion is behind schedule. The
best nursing action is to
1. restart the infusion with a new IV solution bag.
2. open the clamp and infuse a large amount of fluid at one time.
3. hang the solution that is to run in first at the lowest height.
4. track accurate intake and output every shift.
ANS: 4
The nurse must maintain an accurate record of intake and output to monitor fluid overload
or dehydration.

DIF: Cognitive Level: Analysis REF: Page 725; Box 36-3

OBJ: Theory #2 TOP: IV Guidelines
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

18. A patient is to have an IV insertion site changed. The current line is in the lower right
forearm. Which location is contraindicated for the new site?
1. Right upper forearm
2. Right hand
3. Left upper forearm
4. Left hand
ANS: 2
A new IV site should not be placed distal to an old site; the right hand is distal to the right
forearm, so it should not be used.

DIF: Cognitive Level: Analysis REF: Page 731

OBJ: Clinical Practice #3 TOP: IV Site
KEY: Nursing Process Step: Planning MSC: NCLEX: N/A

19. A patient who needs to have an IV line started has poor-quality veins. Her nurse would plan
to get another nurse to try to obtain a line if he was not successful in
1. five attempts.
2. three attempts.
3. two attempts.
4. one attempt.
ANS: 3
If the nurse cannot initiate a patent IV in two attempts, it is good judgment to ask another
nurse to perform the task.

DIF: Cognitive Level: Application REF: Page 731; Elder Care Points
OBJ: Clinical Practice #3 TOP: Starting an IV
KEY: Nursing Process Step: Planning MSC: NCLEX: N/A
20. A nurse is assigned to care for a patient with a continuous IV infusion running. The IV bag
should be changed when how many milliliters of solution remain in the old one?
1. 10
2. 25
3. 50
4. 100
ANS: 3
When the container has only 50 mL of solution left, the next ordered solution is added to the
setup and the flow begun to prevent air from entering the line.

DIF: Cognitive Level: Comprehension REF: Page 732

OBJ: Clinical Practice #4 TOP: Maintaining an IV
KEY: Nursing Process Step: Planning MSC: NCLEX: N/A

21. A patient who requires an immediate transfusion of blood has previously signed a consent
form to receive it. The consent must be signed within the last
1. 8 hours.
2. 12 hours.
3. 24 hours.
4. 48 to 72 hours.
ANS: 4
A consent to receive blood must be signed by the patient, usually no more than 48 to 72
hours before receiving the blood product.

DIF: Cognitive Level: Knowledge REF: Page 742

OBJ: Clinical Practice #7 TOP: Blood Transfusion
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

22. A patient complains of chills, back pain, and shortness of breath a few minutes after the
blood infusion is started. The first thing the nurse should do is
1. slow the blood infusion down.
2. stop the blood infusion and start the saline.
3. monitor vital signs and call the physician.
4. start low-flow oxygen as per facility protocol.
ANS: 2
If a transfusion reaction occurs, such as chills, back pain, and shortness of breath or itching,
the nurse should stop the infusion and start the saline to keep the line open.

DIF: Cognitive Level: Analysis REF: Page 745; Skill 36-6

OBJ: Theory #5 TOP: Blood Transfusion Reaction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

23. The LVN/LPN is told by the RN to discontinue an IV line to the patient. The best nursing
action is to
1. check the physician’s order.
2. stop the IV flow by clamping tubing securely.
 3. wash hands and don gloves.
4. quickly withdraw the cannula and apply pressure.
ANS: 1
Checking the physician’s order will prevent inadvertently discontinuing the IV and having
to restart it.

DIF: Cognitive Level: Analysis REF: Page 742; Steps 36-3

OBJ: Clinical Practice #6 TOP: Discontinuing an IV
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

24. A patient has an intermittent IV device, or a saline lock. An important nursing consideration
is to
1. monitor continuous fluid infusion to the device.
2. infuse saline or heparin solution to maintain patency.
3. discontinue when the IV medication is finished.
4. keep the patient in bed to prevent dislodgement.
ANS: 2
The intermittent IV device should be flushed periodically to maintain patency, which allows
more freedom of movement for the patient.

DIF: Cognitive Level: Application REF: Page 718

OBJ: Clinical Practice #5
TOP: Medication to Intermittent Intravenous Device
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment

COMPLETION

25. A patient has an IV of 1000 mL 5% dextrose in ½-normal saline (0.45% sodium chloride)
infusing via microdrip for 12 hours. The IV is infusing ________ gtt/min.

ANS:
83

DIF: Cognitive Level: Analysis REF: Page 724; Box 36-2

OBJ: Clinical Practice #2 TOP: Intravenous Medication Administration
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment

MULTIPLE RESPONSE
26. The physician orders an IV of 5% dextrose in normal saline (0.45% sodium chloride) to
infuse over a 10-hour period. Which of the following actions should the nurse take? (Select
all that apply.)
1. Monitor intake and output (I&O) every shift.
2. Monitor weight daily.
3. Flush with heparin solution intermittently.
4. Monitor lung sounds every 4 hours.
5. Monitor IV site for infiltration.
6. Monitor blood sugar levels.
ANS: 1, 4, 5
To monitor fluid overload, it is important to assess lung sounds and I&O. Monitoring the IV
site for infiltration or phlebitis is also critical.

DIF: Cognitive Level: Application REF: Page 725; Box 36-3

OBJ: Theory #3 TOP: IV Nursing Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity