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NURS 431- Lab Knowledge Exam Questions with Correct Answers
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NURS 431- Lab Knowledge Exam Questions with Correct Answers
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NURS 431- Lab Knowledge ExamQuestions with Correct Answers
A nurse administers a medication to a client using an I.V. route. Which is an advantage
of I.V. administration of medications?
Select one:
a. Provides a route for irritating substances, instant drug action, and better control of
drug administration
b. Causes speed shock, rapid onset of drug action, and allows for the absorption of
drugs in gastric juices
c. Prevents errors in compounding of medication, low risk for infiltration and phlebitis
d. Allows for uninterrupted control of the medication rate, low risk for adverse effects
and adsorption - Answer-a. Provides a route for irritating substances, instant drug
action, and better control of drug administration
IV admin does not prevent errors, and drug loss via absorption of IV containers and
administration can still occur.
A client complains to a nurse that his or her I.V. site is "sore." The nurse notes that the
site is red and edematous, but there is no palpable cord or streak. Using the criteria for
infusion phlebitis, what should the nurse document as the severity of this phlebitis?
Select one:
a. 1+
b. 2+
c. 3+
d. 4+ - Answer-b. 2+
1+ Erythema, with or without pain
2+ pain at site, erythema, or edema
3+ pain, erythema and/or edema, streak formation, and palpable cord
4+ Pain, erythema and/or edema, streak formation, palpable venous cord greater than 1
inch, and purulent drainage
Which systemic complication of I.V. therapy should a nurse suspect if a client has a
fever, chills, malaise, tachycardia, tachypnea, hypotension, and altered mental status?
Select one:
a. Septicemia
b. Local infection
c. Thrombophlebitis
d. Inflammatory response - Answer-a. Septicemia
, Local infection is not a systemic response
Thrombophelbitis and inflammatory response are both local complications.
A nurse is caring for multiple clients with I.V. access devices. The nurse carefully
assesses each client for signs of local complications. For which systemic complication
should the nurse observe?
Select one:
a. Phlebitis
b. Hematoma
c. Speed shock
d. Extravasation - Answer-c. Speed shock
Phlebitis is a local complication. Hematoma is swelling due to blood forming a mass
confined by subcutaneous tissue, not due to IV introduction. Extravasation is
inadvertent admin of medication to the surrounding tissue rather than the circulation.
A nurse assesses a client who is receiving an intermittent I.V. infusion of vancomycin
hydrochloride. The nurse notes that the I.V. site is warm, edematous, and taut. The
nurse also observes pinkish blood return and fluid leaking from the insertion site. Based
on this information, which condition should the nurse suspect?
Select one:
a. Occlusion
b. Septicemia
c. Extravasation
d. Thrombophlebitis - Answer-c. Extravasation
Occlusion is a restriction of blood flow that causes the fluid to back up and cause
infiltration and dependent edema.
Septicemia is a systemic infection.
Thrombophlebitis is a venous inflammation with clot formation.
Upon inspection of a client's peripheral I.V. site, a nurse notes 3+ phlebitis of the client's
vein. Which action by the nurse is most appropriate?
Select all that apply:
a. Watch the site and document observations
b. Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes. - Answer-b.
Discontinue the cannula
c. Elevate extremity slightly
d. Apply warm compresses after 30 to 45 minutes
e. Apply cold to the site initially for approximately 30 to 45 minutes.
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