IV Start
A nurse is preparing to start an IV on a patient. Which vein is commonly used for initial IV access in adults?
Answer: D. Median cubital vein
Rationale: The median cubital vein is commonly used for IV access due to its size and accessibility, especially in the antecubital fossa. The femoral vein is used in emergency cases, and the radial artery is not used for IV access.
A patient has a peripheral IV that is red and swollen. What is the first nursing action?
Answer: C. Discontinue the IV and apply a warm compress
Rationale: Redness and swelling indicate potential phlebitis or infiltration, so the IV should be discontinued. A warm compress helps reduce inflammation.
The nurse must administer IV furosemide to a patient. Which of the following should be monitored after administration?
Answer: B. Urine output
Rationale: Furosemide is a diuretic, so urine output is crucial to monitor for effectiveness and to prevent dehydration.
Which interventions can help prevent IV-related infections? (Select all that apply.)
Answer: A, C, E
Rationale: Aseptic technique, disinfecting the port, and securing the site help prevent infection. IV sites typically change every 72 hours, and saline flush timing depends on policy.
A nurse is to administer 50 mg of a medication through IV push over 5 minutes. The medication comes as 100 mg in 10 mL. How many mL should be administered?
Answer: B. 5 mL
Rationale: 50 mg is half of the 100 mg available, so half of 10 mL (5 mL) should be administered.
What is the maximum time a nurse should leave an IV catheter in place before considering changing the site, per current best practices?
Answer: C. 72 hours
Rationale: Current guidelines suggest changing an IV site every 72 hours to reduce infection risk, although this can vary based on institution protocols and patient condition.
Which of the following is a sign of an air embolism?
Answer: A. Shortness of breath and chest pain
Rationale: Air embolism presents with symptoms such as chest pain, shortness of breath, and in severe cases, decreased blood pressure and confusion.
A nurse is caring for a patient who has been ordered 0.9% sodium chloride (normal saline) IV. Which statement best explains why this fluid is considered isotonic?
Answer: C. It has the same concentration of solutes as blood plasma.
Rationale: Isotonic fluids, like 0.9% sodium chloride, have a similar solute concentration as blood plasma, making them ideal for fluid replacement without altering cell volume.
A patient with dehydration has been prescribed Lactated Ringer's solution. Which of the following components are present in Lactated Ringer's? (Select all that apply.)
Answer: A, B, C, E
Rationale: Lactated Ringer’s contains sodium chloride, potassium, calcium, and lactate, which help restore electrolyte balance. It does not contain glucose.
The physician orders a medication to be infused at 100 mL/hr. If the IV tubing delivers 15 drops per mL, what is the drip rate per minute?
Answer: C. 25 drops
Rationale: (100 mL/hr) x (15 drops/mL) ÷ 60 min/hr = 25 drops/min.
When selecting a vein for a patient needing a continuous IV infusion, which site is preferable?
Answer: B. Antecubital fossa veins
Rationale: The antecubital fossa veins are commonly used for long-term access. Hand veins are avoided for continuous infusions as they are more prone to movement.
When assessing a patient with an IV, what signs and symptoms of phlebitis should the nurse observe? (Select all that apply.)
Answer: A, B, D, E
Rationale: Phlebitis presents with redness, pain, swelling, and sometimes fever. Coolness is typically a sign of infiltration, not phlebitis.
Which type of IV fluid is appropriate for a patient with hypovolemic shock who requires rapid volume expansion?
Answer: C. 0.9% sodium chloride
Rationale: 0.9% sodium chloride is an isotonic solution that can help expand extracellular volume quickly in patients with hypovolemic shock.
Which safety checks must a nurse complete before administering a medication via IV push? (Select all that apply.)
Answer: A, B, D, E
Rationale: Patient identification, compatibility, pre-flush, and checking for blood return are necessary steps. IV push meds are given manually, not with a pump rate.
The physician orders 1 gram of an antibiotic to be infused over 30 minutes. The available vial is labeled 2 grams in 100 mL. How many mL should be administered?
Answer: B. 50 mL
Which statement should the nurse include when educating a patient on IV fluid therapy?
Answer: C. "IV fluids are used to help maintain or restore your fluid balance."
Rationale: IV fluids help restore or maintain fluid balance, not necessarily energy levels or nutrients.
A patient receiving IV antibiotics reports discomfort at the IV site. Which actions should the nurse perform first? (Select all that apply.)
Answer: A, D
Rationale: Inspection is the first step to assess for infiltration, phlebitis, or infection. If there is discomfort, the infusion should be stopped until further assessment confirms the IV is safe to use. Increasing the rate could worsen the issue.
The nurse is preparing to administer a medication via IV push. Which action should be performed first?
Answer: B. Verify the patient’s allergies
Rationale: Verifying allergies is the first step to ensure patient safety and prevent an adverse reaction. The line is flushed after confirming that the medication is safe to administer.
The nurse is caring for a patient who has been prescribed a hypertonic IV solution. Which signs and symptoms should the nurse monitor for that could indicate fluid overload? (Select all that apply.)
Answer: A, B, D
Rationale: Hypertonic solutions can cause fluid shifts, potentially leading to fluid overload, presenting as hypertension, edema, and crackles in the lungs. Bradycardia and increased urinary output are not typical signs of fluid overload.
A provider orders 1,000 mL of 0.9% NaCl to be infused over 8 hours. The IV tubing has a drop factor of 15 gtt/mL. What is the flow rate in drops per minute (gtt/min)?
Answer: C. 31 gtt/min
gtts/min = 15gtts/ml x 1000ml/8hr x 1hr/60min
When preparing to administer IV metoprolol, the nurse should monitor which of the following before administration?
Answer: B. Blood pressure and heart rate
Rationale: Metoprolol is a beta-blocker that lowers blood pressure and heart rate. Monitoring these vitals helps assess if it’s safe to administer the drug.
A nurse is educating a patient on signs of IV infiltration. Which symptoms should the patient be instructed to report? (Select all that apply.)
Answer: A, B, C
Rationale: Infiltration often presents with swelling, cool skin, and pain. Warmth and red streaks are more indicative of phlebitis or infection.
A patient with cerebral edema is being monitored closely for fluid balance. Which IV fluid should be avoided due to the risk of increasing intracranial pressure?
Answer: C. Dextrose 5% in water (D5W)
Rationale: D5W acts as a hypotonic solution once dextrose is metabolized, potentially worsening cerebral edema by causing fluid to shift into cells.
Which of the following steps should the nurse take when administering a medication via IV piggyback (IVPB)? (Select all that apply.)
Answer: A, B, D
Rationale: The secondary bag should be hung higher to ensure it infuses first. The secondary tubing is attached above the pump, and the rate is set accordingly. IVPB does not require clamping the primary line if connected above the pump.
The order is for 250 mL of D5W to infuse over 4 hours. What is the flow rate in mL per hour?
Answer: C. 63 mL/hr
ml/hr = 250ml/4hr = 62.5 rounded to nearest tenth = 63ml/hr