IV Therapy Troubleshooting
A nurse is caring for a client receiving IV fluids by gravity. Which factor would most likely decrease the flow rate?
A. The IV bag is positioned below the insertion site.
B. The IV tubing is coiled on the bed.
C. The client is lying flat.
D. The IV bag is full.
A: The IV bag is positioned below the insertion site.
Which nursing action is appropriate when administering medications through a nasogastric tube?
A. Flush the tube with water before and after each medication
B. Avoid flushing if patient is fluid-restricted
C. Mix medications with formula
D. Crush all medications together
A. Flush the tube with water before and after each medication
Which finding indicates a Stage III pressure injury?
A. Partial-thickness skin loss
B. Exposed bone or muscle
C. Full-thickness skin loss with visible fat
D. Intact skin with non-blanchable redness
C. Full-thickness skin loss with visible fat
What is the priority nursing action after removing an indwelling urinary catheter?
A. Monitor the clients first voiding
B. Measure urine output for 24 hours
C. Encourage fluid intake
D. Document the time of removal
A. Monitor the clients first voiding
During an abdominal assessment, which technique should the nurse perform first?
A. Auscultation
B. Palpation
C. Inspection
D. Percussion
C. Inspection
A provider orders 1,000 mL of IV fluid to infuse over 8 hours. What is the hourly rate in mL/hr?
125 mL/hr
A client has swelling and coolness at the IV site. Which complication should the nurse suspect?
A. Infection
B. Phlebitis
C. Extravasation
D. Infiltration
D. Infiltration
What should the nurse do first before administering a bolus enteral feeding?
A. Warm the formula
B. Auscultate bowel sounds
C. Check for gastric residual volume
D. Elevate the head of bed
B. Auscultate bowel sounds
Which type of wound healing occurs when a wound is left open to heal from the inside out?
A. Secondary intention
B. Tertiary intention
C. Open drainage
D. Primary intention
A. Secondary intention
A nurse is preparing to insert a urinary catheter in a male client with BPH. Which catheter type is most appropriate?
A. Standard Foley
B. Coude catheter
C. Three-way catheter
D. Straight catheter
B. Coude catheter
A patient has a new ileostomy. Which output would the nurse expect?
A. Formed stool
B. Blood-tinged stool
C. Liquid stool with digestive enzymes
D. Mucus-like drainage
C. Liquid stool with digestive enzymes
The order is for 500 mg of a medication. The vial is labeled 250 mg/mL. How many mL will you administer?
2 mL
Which action should the nurse take first when signs of extravasation are noted?
A. Apply warm compresses
B. Flush the IV site
C. Elevate the limb
D. Stop the infusion immediately
D. Stop the infusion immediately
A patient receiving a continuous tube feeding develops diarrhea. What is the nurses best action?
A. Decrease the feeding rate
B. Administer antidiarrheal medication
C. Notify the provider and review the feeding formula
D. Stop the feeding for 24 hours
C. Notify the provider and review the feeding formula
The nurse notes purulent drainage and increased warmth around a surgical wound. What is the priority action?
A. Notify the healthcare provider
B. Document the finding
C. Change the dressing
D. Apply a warm compress
A. Notify the healthcare provider
Which finding during a bladder scan suggests urinary retention?
A. Bladder scan of 100 mL before voiding
B. Voided volume of 300 mL
C. Post-void residual of 250 mL
D. Post-void residual of 30 mL
C. Post-void residual of 250 mL
What is the nurses best response when a client asks why their abdomen will be auscultated before palpated?
A. Auscultation takes less time
B. Palpation may alter bowel sounds
C. It is less invasive
D. To assess for organ enlargement
B. Palpation may alter bowel sounds
How many mL are in 2.5 teaspoons of medication?
12.5 mL
Which systemic complication is most associated with sudden shortness of breath during IV therapy?
A. Air embolism
B. Fluid overload
C. Infiltration
D. Phlebitis
A. Air embolism
Which assessment finding would most likely indicate aspiration during a tube feeding?
A. Abdominal cramping
B. High blood pressure
C. Coughing and shortness of breath
D. Increased gastric residual
C. Coughing and shortness of breath
What is the most important initial step in performing a sterile dressing change?
A. Documenting the wound
B. Applying clean gloves
C. Opening the sterile field
D. Hand hygiene and gathering supplies
D. Hand hygiene and gathering supplies
Which finding suggests a need for catheter irrigation?
A. Fever and chills
B. Pain during urination
C. Cloudy urine with odor
D. Decreased urine output with suspected blockage
D. Decreased urine output with suspected blockage
Which stoma finding should be reported to the provider?
A. Dark purple stoma
B. Occasional gas passage
C. Small amount of mucus
D. Pink and moist stoma
A. Dark purple stoma
Convert 154 pounds to kilograms (round to the nearest tenth).
70 kg
What is the nurses priority when an IV site becomes red, swollen, and painful?
A. Apply heat and elevate the arm
B. Stop the infusion and remove the IV
C. Flush the IV line
D. Administer antibiotics
B. Stop the infusion and remove the IV
What is the best nursing action if a gastrostomy tube becomes clogged?
A. Wait 1 hour and try feeding again
B. Remove and replace the tube
C. Push air into the tube
D. Attempt to flush the tube with warm water
D. Attempt to flush the tube with warm water
A nurse documents a wound with yellow slough and foul odor. What is the next best step?
A. Notify the provider and obtain a wound culture
B. Increase protein in the diet
C. Apply a hydrogel dressing
D. Irrigate the wound with saline
A. Notify the provider and obtain a wound culture
What instruction should the nurse give a client when collecting a midstream clean-catch urine specimen?
A. Hold urine for 12 hours before collection
B. Use any container available
C. Begin urinating, then collect urine midstream in sterile container
D. Collect urine at the start of urination
C. Begin urinating, then collect urine midstream in sterile container
What is the best position for a client receiving an enema?
A. Supine with legs straight
B. Right lateral
C. Fowlers position
D. Left lateral (Sims position)
D. Left lateral (Sims position)
A client is to receive 1 L of fluid over 10 hours. What is the IV rate in mL/hr?
100 mL/hr
Which of the following best describes the difference between gravity and pump IV infusions? (Select all that apply.)
A. Pump allows precise control of rate
B. Gravity relies on height and flow clamp
C. Pump requires larger gauge IVs
D. Gravity is used only for blood products
A. Pump allows precise control of rate
B. Gravity relies on height and flow clamp
What is the appropriate nursing action after checking gastric residual volume of 50 mL for a bolus feeding?
A. Double the feeding rate
B. Proceed with the feeding as ordered
C. Stop the feeding and notify the provider
D. Give antiemetic before feeding
B. Proceed with the feeding as ordered
What is the correct technique to measure a wound?
A. Use a paper ruler only
B. Measure only width and length
C. Estimate visually
D. Measure length, width, and depth using a sterile swab and ruler
D. Measure length, width, and depth using a sterile swab and ruler
Remember 12 o'clock is the head and 6 o'clock is the feet
What should the nurse do first if urine stops draining from an indwelling catheter?
A. Flush the catheter
B. Reposition the client
C. Irrigate with sterile saline
D. Check for kinks in the tubing
D. Check for kinks in the tubing
A postoperative client calls the nurse and reports, “My incision feels like it popped open.” Upon assessment, the nurse observes protruding bowel loops from the abdominal wound. What is the nurse’s priority action?
A. Notify the healthcare provider and obtain vital signs
B. Apply sterile gauze soaked in normal saline over the wound
C. Reinsert the bowel using sterile gloves
D. Place the client in a high Fowler’s position and administer oxygen
B. Apply sterile gauze soaked in normal saline over the wound
How many mg are in 0.25 grams of a medication?
250 mg
Which intervention is most important when preparing to prime secondary IV tubing?
A. Label tubing with date
B. Ensure air is removed from tubing before connecting to patient
C. Keep tubing clamped
D. Use gloves for entire procedure
B. Ensure air is removed from tubing before connecting to patient
A nurse is reviewing the plan of care for a client on continuous enteral feeding. Which intervention best prevents aspiration?
A. Suction the airway every 2 hours
B. Pause feedings during sleep
C. Administer all water flushes at once
D. Keep the head of the bed elevated 30–45 degrees
D. Keep the head of the bed elevated 30–45 degrees
Which drainage type is most concerning for infection?
A. Serous drainage
B. Sanguineous drainage
C. Serosanguineous drainage
D. Purulent drainage with foul odor
D. Purulent drainage with foul odor
The nurse is preparing to insert an indwelling urinary catheter in a female client. What is the most appropriate position for this procedure?
A. Semi-Fowler’s with legs extended
B. Side-lying with knees together
C. Supine with legs flat
D. Dorsal recumbent with knees flexed and hips externally rotated
D. Dorsal recumbent with knees flexed and hips externally rotated
The nurse is assessing a client for jaundice. Which area should the nurse examine to detect early signs of jaundice in a client with dark skin?
A. Cheeks and chest wall
B. Nail beds and palms
C. Sclera and hard palate of the mouth
D. Dorsum of the hands and feet
C. Sclera and hard palate of the mouth
You are to administer 60 mL over 30 minutes using an IV pump. What is the infusion rate?
120 mL/hr