IV therapeutics Testbank Exam Questions &
Answers. A+ Rated
A labor and delivery nurse is caring for a client who has just received epidural
anesthesia prior to cesarean section. For which potential adverse effects of epidural
pain medication should the nurse observe?
a. Urinary retention, pruritus, and hypotension
b. Pruritus, nausea, and urinary incontinence
c. Polyuria, hypertension, and respiratory depression
d. Respiratory depression, hypertension, and hemiparesis - a. Urinary retention,
pruritus, and hypotension
The primary problem associated with receiving epidural anesthesia is hypotension
due to the blocking of sympathetic fibers in the epidural space. The decreased
peripheral resistance that results in the circulatory system causes dilation of
peripheral blood vessels. A simple measure that prevents most hypotension is the
infusion of 500 to 1000 mL fluid intravenously into the client before the procedure.
Urinary retention is a common side effect that may last 10 to 20 hours after the
first injection. Pruritus is caused by the opiate's interaction with the dorsal horn,
not by a histamine release, and is best treated with an antagonist rather than with
diphenhydramine hydrochloride. Respiratory depression can occur when too much
narcotic is being administered.
A nurse, who is making rounds, notes that a client's lipid emulsion infusion is 1
hour behind schedule. Which action by the nurse is most appropriate?
a. Adjust the line to run wide open until the solution is back on time.
b. Leave the lipid emulsion at the present rate.
c. Adjust the rate to catch up over the next 2 hours.
d. Adjust the rate to catch up over the next hour. - b. Leave the lipid emulsion at
the present rate.
,The nurse should not increase the rate of a fat emulsion to make up the difference
if the infusion falls behind, doing so could place the client at risk for fat overload.
The same principle applies to increasing the rate of the PN, which could suddenly
cause hyperglycemia and fluid overload.
A nurse specialist is performing placement of a midline catheter. Midline
placement refers to a:
a. peripherally inserted catheter with the tip location in the superior vena cava.
b. peripheral catheter less than or equal to 3 inches in length.
c. peripheral catheter that is between 3 and 8 inches in length with the distal tip
dwelling in the basilic, cephalic, or brachial vein at or below the level of the axilla.
d. catheter surgically placed into a vessel, body cavity, or organ and attached to a
reservoir that is placed under the skin. - c. peripheral catheter that is between 3 and
8 inches in length with the distal tip dwelling in the basilic, cephalic, or brachial
vein at or below the level of the axilla.
Midline placement of a peripheral catheter is designed for intermediate-term
therapies from 1 to 4 weeks.
During a nurse's initial assessment of a client, the nurse observes that the client's
IV solution is not infusing. Which intervention should the nurse implement first?
a. Notify the physician.
b. Inspect the tubing for kinks.
c. Discontinue the IV infusion.
d. Lower the height of the IV solution container. - b. Inspect the tubing for kinks.
One of the most frequent causes of slowed or stopped infusion is kinked tubing,
especially when infusion is by gravity control. The nurse's first action should be to
straighten the tubing. The nurse should then check the flow and recalculate the
infusion.
,A nurse is caring for a client who has a newly implanted port. For which
complication, specifically associated with implanted ports, should the nurse
observe?
a. Air embolus
b. Occlusion
c. External catheter breakage
d. Displacement of the septum - d. Displacement of the septum
Implanted ports have a septum, which is also called port migration. The port is
sutured but can move out of position if the sutures become loose or if the client's
hand manipulates the port. Air embolus and occlusion can occur with a central
venous device. External catheter breakage is specifically related to peripherally
inserted central or tunneled catheters.
Current Infusion Nursing Standards of Practice (2011) recommend which of the
following for routine site care and dressing changed on short-peripheral catheters.
a. Change dressings every 72 hours.
b. Change gauze and tape dressings every 7 days.
c. Routine dressing changes are not performed on PIV unless the dressing is soiled
or no longer intact.
d. Change dressings daily. - c. Routine dressing changes are not performed on PIV
unless the dressing is soiled or no longer intact.
Peripheral catheter care should be performed after an IV catheter with catheter-site
rotation or when the dressing is soiled or no longer intact. Current practice dictates
that if the dressing is removed on a functioning intact catheter, the integrity of the
catheter could be compromised.
A nurse is preparing an IV administration set for a client's IV infusion. Which
administration set must be used with a closed-glass system?
a. A Y-set
b. A vented set
, c. A nonvented set
d. A volume control set - b. A vented set
The closed-glass system, which has a sealed rubber bung, must use a vented
administration set to allow air to enter the container.
A nurse is evaluating a client who began receiving IV therapy 3 hours earlier. The
nurse observes that the client's face is flushed and that the client has an irregular
pulse rate. The client reports having a headache and has a tight feeling in the chest.
The nurse suspects speed shock, which is:
a. a systemic disease caused by the presence of pathogenic microorganisms in the
body.
b. a systemic reaction that occurs when a foreign substance is rapidly introduced
into the circulation.
c. an undesirable effect occurring within a client, as a result of two or more drugs
being given concurrently.
d. a sudden obstruction of a blood vessel by a clot or foreign material that is
formed or introduced into the circulatory system. - b. a systemic reaction that
occurs when a foreign substance is rapidly introduced into the circulation.
Speed shock occurs when a foreign substance, usually a medication, is rapidly
introduced into the circulation. Rapid injection permits the medicinal concentration
in the plasma to reach toxic proportions, flooding the organs rich in blood (e.g.,
heart and brain). Syncope, shock, and cardiac arrest may result.
A nurse notes that a client is scheduled to receive an intrathecal medication. The
nurse should interpret this to mean that the drug will be administered:
a. into the marrow of a long bone.
b. within the spinal canal.
c. into the peritoneal cavity.
d. into the intraosseous space. - b. within the spinal canal.
