15

Chapter 15: Infusion Therapy
Test Bank
MULTIPLE CHOICE
1. Before the administration of intravenous fluid, it is most important for the nurse to obtain
which information from the health care providers orders?

Intravenous catheter size
Osmolarity of the solution
Vein to be used for therapy
Specific type of IV fluid
a.
b.
c.
d.
ANS: D
An order for infusion therapy must contain the following to be complete: specific type of
fluid, rate of administration, and drugs added to the solution. Osmolarity of the solution is not
necessary because it is incorporated into the specific type of fluid. It is the nurses independent
decision about the most appropriate vein to cannulate and the catheter size to use.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 212
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Error Prevention)
MSC:
Integrated Process: Nursing Process (Assessment)
2. Which IV order does the nurse question?
a. Flush Groshong catheter with 10 mL normal saline every 8 hours.
b. Infuse 20 mEq potassium chloride in 1000 mL D5W at 50 mL/hr.
c. Infuse 500 mL normal saline over 1 hour.
d. Infuse 0.9% normal saline at keep vein open (KVO) rate.
ANS: D
To be complete, IV orders for infusion fluids should specify the rate of infusion. This order
does not specify the rate of infusion and is not considered complete.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
Error Prevention)
MSC:
Integrated Process: Nursing Process (Analysis)
3. Which infusion device does the nurse select for the older adult client with a medical diagnosis
of dehydration?
Cassette pump
Elastomeric balloons
Volumetric controller
Syringe pump
a.
b.
c.
d.
ANS: A
An older adult client who has dehydration will require a large fluid volume that is accurately
measured by using a cassette pump during the infusion. Volumetric controllers count drops for
administered volume and are inherently inaccurate because of variation in drop size. A syringe
pump is accurate but not appropriate for a large volume. Elastomeric balloons are used to
deliver intermittent medications.
REF: N/A
Error Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
4. A nursing administrator is concerned about the incidence of complications related to IV
therapy, including bloodstream infection. Which action by the administrator would have the
biggest impact on decreasing complications?
a. Investigate initiating a dedicated IV team.
b. Require inservice education for all RNs.
c. Limit IV starts to the most experienced nurses.
d. Perform quality control testing on skin preparation products.
ANS: A
The Centers for Disease Control and Prevention (CDC) recommends having a dedicated IV
team to reduce complications, save money, and improve client satisfaction and outcomes. Inservice education would always be helpful, but it would not have the same outcomes as an IV
team. Limiting IV starts to the most experienced nurses does not allow newer nurses to gain
this expertise. The quality of skin preparation products is only one aspect of IV insertion that
could contribute to infection.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications From Diagnostic Tests/Treatments/Procedures)
5. The nurse wants to find written standards for IV therapy. The nursing manager suggests that
the nurse investigate publications from which resource?

a. IV Therapy Nursing Society
b. Infusion Nurses Society
c. Nurses State Board of Nursing
d. Hospitals IV solutions vendor
ANS: B
The Infusion Nurses Society publishes guidelines and standards related to IV therapy and
offers a national certification examination. The State Board of Nursing publishes legal
information related to nursing practice, and the solutions vendor would have written
information pertaining only to specific products. The IV Therapy Nursing Society does not
exist, and the other organizations listed do not provide standards and guidelines related to IV
therapy.
REF: p. 211
Safe Use of Equipment)
6. The RN assigned a new nurse to a client who was receiving chemotherapy through an
intravenous extension set attached to a Huber needle. Which information about disconnecting
the Huber needle is most important for the RN to provide to the new nurse?
a. Apply topical anesthetic cream to the area after discontinuing the system.
b. Be aware of a rebound effect when discontinuing the system.
c. Be sure to flush the system with saline after removing the Huber needle.
d. Place pressure over the site to prevent bleeding.

ANS: B
Huber needles are used to access implanted ports placed under the skin. Because the dense
septum holds tightly to the needle, a rebound can occur when it is pulled from the septum,
often resulting in needle stick injury to the nurse. Topical anesthetic cream can be used when
accessing the system. Flushing is carried out when the system is accessed and once monthly.
Because the implanted port is not being removed, there is no need for a pressure dressing.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Parenteral/Intravenous Therapies)
7. After discontinuing a nontunneled, percutaneous central catheter, it is most important for the
nurse to record which information?

Application of a sterile dressing
Length of the catheter
Occurrence of venospasms
Type of ointment used to seal the tract
a.
b.
c.
d.
ANS: B
After removal of a catheter, measure the catheter length and compare it with the length
documented on insertion. If the entire length has not been removed, the nurse should contact
the physician immediately because some of the catheter may still be in the clients vein.
REF: N/A
8. When assessing the clients peripheral IV site, the nurse observes a streak of red along the
vein path and palpates a 4-cm venous cord. What is the most accurate documentation of this
finding?
a. Grade 3 phlebitis at IV site
b. Infection at IV site
c. Thrombosed area at IV site
d. Infiltration at IV site
ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in
the description indicates that infection, infiltration, or thrombosis is present.
REF: Table 15-6, p. 233
MSC: Integrated Process: Nursing Process (Assessment)
9. What information is most important to teach the client going home with a peripherally
inserted central catheter (PICC) line?

a. Avoid carrying your grandchild with the arm that has the IV.
b. Be sure to place the arm with the IV in a sling during the day.
c. Flush the IV line with normal saline daily.

d. You can use the arm with the IV for most of the activities of daily living.
ANS: A
A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client
considerable freedom of movement. Clients can participate in most activities of daily living;
however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is
important to keep the insertion site and tubing dry, the client can shower. The device is flushed
with heparin.
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
10. A client is to receive 10 days of antibiotic therapy for urosepsis. The nurse plans to insert
which type of intravenous catheter?

Hickman
Midline
Nontunneled central
Short peripheral
a.
b.
c.
d.
ANS: B
Midline catheters are used for therapies lasting from 1 to 4 weeks. Short peripheral catheters
can be inserted by the nurse for use with antibiotic therapy, but they can stay in only for up to
96 hours. If the length of IV therapy is longer than 6 days, a midline catheter should be
chosen. Nontunneled central catheters and Hickman catheters are inserted by a physician.
REF: p. 215
11. A client is admitted to the hospital for excessive nausea and vomiting, and a blood pressure of
90/50 mm Hg. A catheter of which gauge is most appropriate for the nurse to choose for this
clients peripheral IV?
a. 24
b. 22
c. 20
d. 18
ANS: C
The nurse selects the access device most appropriate for the designated purpose. In this case,
because a large amount of fluid will be needed as a result of excessive fluid loss, the
appropriate needle is the 20-gauge catheter IV, because this is the most commonly used size in
adults and it can be used for all fluids. The 22- and 24-gauge catheters will have a slower rate
of flow, which may not be desirable with excessive fluid losses and low blood pressure. The
18-gauge catheter allows rapid flow of IV fluids. However, it requires a large vein and is more
prone to irritation to the vein wall.
REF: N/A

12. To prevent infection when infusing an intermittent piggyback line, which intervention does
the nurse implement?

Backpriming the secondary container from the primary line
Detaching and capping the secondary line after use
Using a new secondary container with each drug infused
Using sterile gloves when administering medication
a.
b.
c.
d.
ANS: A
The backpriming method allows multiple drugs to be infused through the same secondary set.
This method allows the primary and secondary sets to remain connected together as an
infusion system and allows the nurse to adhere to the Infusion Nurses Society (INS) standards
of practice. The client is at increased risk for infection whenever the catheter is disconnected
from the tubing. Sterile gloves are not necessary for IV administration of medication.
REF: N/A
13. The nurse finishes administering an intermittent medication through a Groshong catheter.
What is the nurses next action?

Clamping the catheter
Flushing the line with saline
Flushing with heparin
Removing the access needle
a.
b.
c.
d.
ANS: B
The Groshong catheter is a type of midline catheter. After intermittent use, the catheter is to be
flushed with saline. The manufacturers instructions state that the catheter should not be
clamped to maintain the integrity of the catheter valve. If a heparin flush is ordered, it is given
after the catheter has been flushed with saline. The access needle is used for implanted ports.
REF: N/A
14. The nurse is assessing several clients receiving intravenous therapy. Which client situation
requires immediate intervention?

Completion of an intermittent medication into a Groshong catheter
Physicians order to discontinue a peripheral intravenous catheter
Nonaccessed implanted port placed 1 month ago without problem
Peripheral IV catheter dated 5 days ago used for once-daily antibiotics
a.
b.
c.
d.
ANS: A
A Groshong catheter is a peripherally inserted catheter that needs to be flushed with saline
after intermittent use. Peripheral IV catheters should be discontinued after 4 days, so this one
should be changed; however, this is not the priority. An order to discontinue the peripheral
catheter requires intervention, but flushing of the Groshong catheter is more of an immediate
intervention to prevent clotting of the catheter. A nonaccessed implanted port site needs to be
assessed, but this is not an immediate intervention.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
15. In examining a peripheral IV site, the nurse observes a red streak along the length of the vein,
and the vein feels hard and cordlike. What action by the nurse takes priority?
a. Applying continuous heat
b. Continuing to monitor site
c. Elevating the extremity
d. Removing the catheter
ANS: D
The clinical manifestations described are those associated with phlebitis. Phlebitis is an
inflammation of the vein. Its presence in a vein being used for IV therapy may be caused by
mechanical forces associated with the IV device, or by chemical factors related to the
composition and osmolarity of the drug solution. The key manifestation is that symptoms are
directly associated with the vein, and the catheter must be removed. Warm compresses can be
applied for 20 minutes four times daily after the catheter is removed. The site needs to be
monitored after the catheter is removed. The arm is not swollen. Therefore, elevation of the
extremity is not a correct option.
REF: N/A
16. When an IV pump alarms because of pressure, what action does the nurse take first?
a. Check for kinking of the catheter.
b. Flush the catheter with a thrombolytic enzyme.
c. Get a new infusion pump.
d. Remove the IV catheter.
ANS: A
Fluid flow through the infusion system requires that pressure on the external side be greater
than pressure at the catheter tip. Fluid flow can be slowed for many reasons. A common
reason, and one that is easy to correct, is a kinked catheter. If this is not the cause of the
pressure alarm, the nurse may have to ascertain whether a clot has formed inside the catheter
lumen, or if the pump is no longer functional.
REF: N/A
17. The nurse is caring for four clients receiving IV therapy. Which client does the nurse assess
first?
a. Client with a newly inserted peripherally inserted central catheter (PICC) line
waiting for x-ray

b. Client with a peripheral catheter for intermittent infusions
c. Older adult client with a nonaccessed implanted port
d. Older adult client with normal saline infusion
ANS: D
Older adults are more prone to fluid overload and resulting congestive heart failure. Because
this client is receiving continuous IV fluid, he or she is at risk for fluid overload and needs to
be assessed. All other clients would need to be assessed for complications of IV catheters.
However, they do not need immediate assessment.
REF: N/A
Establishing Priorities)
MSC:
Integrated Process: Nursing Process (Analysis)
18. A client who is having a tunneled central venous catheter inserted begins to report chest pain
and difficulty breathing. What action does the nurse take first?
Administer the PRN pain medication.
Prepare to assist with chest tube insertion.
Place a sterile dressing over the IV site.
Place the client in the Trendelenburg position.
a.
b.
c.
d.
ANS: B
An insertion-related complication of central venous catheters is a pneumothorax. Signs and

symptoms of a pneumothorax include chest pain and dyspnea. Treatment includes removing
the catheter, administering oxygen, and placing a chest tube. Pain is caused by the
pneumothorax, which must be taken care of with a chest tube insertion. Use of a sterile
dressing and placement of the client in a Trendelenburg position are not indicated for the
primary problem of a pneumothorax.
REF: N/A
19. A client who has just had an IV started in the right cephalic vein tells the nurse that the wrist
and the hand below the IV site feel like pins and needles. Which action by the nurse is best?
a. Document the finding and continue to monitor the IV site.
b. Check for the presence of a strong blood return.
c. Discontinue the IV and restart it at another site.
d. Elevate the extremity above the level of the heart.
ANS: C
The sensation that the client has described is related to the IV needle touching the nerve or
possibly transecting the nerve. This problem can lead to loss of function and the potential for
permanent disability in the distal extremity. It is considered an emergency and the IV must be
discontinued. Continuing just to monitor the IV site may lead to loss of function. The presence
of blood return does not indicate absence of nerve damage. Elevation of the affected extremity
does not ensure that the IV catheter has moved away from the nerve.
REF: N/A
20. The home care nurse is about to administer intravenous medication to the client and reads in
the chart that the peripherally inserted central catheter (PICC) line in the clients left arm has
been in place for 4 weeks. The IV is patent, with a good blood return. The site is clean and
free from manifestations of infiltration, irritation, and infection. Which action by the nurse is
most appropriate?
a. Notify the physician.
b. Administer the prescribed medication.
c. Discontinue the PICC line.
d. Switch the medication to the oral route.
ANS: B
A PICC line that is functioning well without inflammation or infection may remain in place
for months or even years. Because the line shows no signs of complications, it is permissible
to administer the IV antibiotic. The physician does not have to be called to have the IV route
changed to an oral route.
REF: N/A
21. Which assessment finding for a client with a peripherally inserted central catheter (PICC) line
requires immediate attention?

a. Initial dressing over site is 3 days old.
b. Line has been in for 4 weeks.
c. A securement device is absent.
d. Upper extremity swelling is noted.
ANS: D
Upper extremity swelling could indicate infiltration, and the PICC line will need to be
removed. The initial dressing over the PICC site should be changed within 24 hours. This does
not require immediate attention, but the swelling does. The dwell time for PICC lines can be
months or even years. Securement devices are being used more often now to secure the
catheter in place and prevent complications such as phlebitis and infiltration. The IV should
have one, but this does not take priority over the client whose arm is swollen.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationUnexpected
Response to Therapies)

22. A nurse is changing the administration set on a clients central venous catheter. Which
intervention is most important for the nurse to complete?

Have the client hold his breath during the set change.
Keep the slide clamp on the catheter extension open.
Position the client in a high Fowlers position.
Position in the client in a semi-Fowlers position.
a.
b.
c.
d.
ANS: A
An air embolus is less likely to form if the exit site is lower than the level of the heart, and if
pressure in the thoracic cavity is greater when the disconnection occurs. Having the client
perform the Valsalva maneuver and maintain it during disconnection and reconnection helps
maintain higher intrathoracic pressure. The slide clamp on the catheter extension should be
kept clamped. The client should be placed in the flat position when administration sets are
changed.
REF: N/A
23. When assessing a clients peripheral IV site, the nurse notices edema and tenderness above the
site. What action does the nurse take first?

Apply cold compresses to the IV site.
Elevate the extremity on a pillow.
Flush the catheter.
Stop the infusion of IV fluids.
a.
b.
c.
d.
ANS: D
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse should stop the infusion
and remove the catheter. Cold compresses and elevation of the extremity can be done after the
catheter is discontinued to increase client comfort. Alternatively, warm compresses may be
prescribed by institutional policy and may help speed circulation to the area.
REF: N/A
24. What action does the nurse take to prevent infection in the older adult receiving IV therapy?
a. Applying skin protectant before applying the dressing
b. Avoiding the use of alcohol pads when removing tape
c. Shaving the skin before attempting the venipuncture
d. Using maximum friction to cleanse the skin
ANS: A
The skin of an older adult may be more delicate and compromised. Avoidance of a disruption
in skin integrity lessens the chance of an infection occurring with an IV catheter. A barrier
applied to the skin before the IV dressing is placed helps maintain skin integrity. Using
alcohol pads makes it easier to remove tape and avoid skin tears. The skin should never be
shaved before venipuncture because micro-abrasions may occur, and these can lead to
infection. Excessive friction may damage fragile skin and compromise skin integrity.
REF: N/A
25. The nurse is caring for a client who is receiving an epidural infusion for pain management.
Which action has the highest priority?

a. Assessing the respiratory rate
b. Changing the dressing over the site
c. Using various pain management therapies
d. Weaning the pain medication
ANS: A
Complications from an epidural infusion can be caused by the type of medication being
infused, or they can be related to the catheter. When used for pain management, the client
needs to be assessed for level of alertness, respiratory status, and itching. Dressings are not
routinely changed because the catheter is used for only short periods. Using other pain
management therapies and weaning the pain medication are important, but monitoring
respiratory status has the highest priority in the nursing care of this client.
REF: N/A
26. The nurse is caring for a client with a radial arterial catheter. Which assessment takes priority?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Checking for heparin in infusion container
d. Presence of an ulnar pulse
ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased
perfusion to the extremity. Assessment of ulnar pulse is one way to assess circulation to the
arm in which the catheter is located. The nurse would note that there is enough pressure in the
fluid container to keep the system flushed, and would check to see whether the catheter tubing
needs to be changed. However, these are not assessments of greatest concern. Because of
heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial
catheter.
REF: N/A
27. Five days after the start of intraperitoneal therapy, the client reports abdominal pain and
feeling warm. The nurse prepares to assess the client further for evidence of which
condition?
a. Allergic reaction
b. Bowel obstruction
c. Catheter lumen occlusion
d. Infection
ANS: D
Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the
client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using
strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction
would occur earlier in the course of treatment. Bowel obstruction and catheter lumen
occlusion can occur but would present clinically in different ways.
REF: N/A
MSC: Integrated Process: Nursing Process (Analysis)
28. Which client is the best candidate to receive hypodermoclysis for IV therapy?
a. Client requiring 4000 mL normal saline in 24 hours
b. Client with an extensive burn injury
c. Client with allergy to hyaluronidase
d. Client receiving pain management
ANS: D
Subcutaneous therapy (hypodermoclysis) involves the slow infusion of isotonic fluids into the
clients subcutaneous tissue. Most often, it is used in hospices for pain management. It should
not be used if fluid replacement needs exceed 3000 mL/day. To be used, the client must have
sufficient areas of intact skin. Hyaluronidase is frequently used to help absorb the fluid during
therapy.
REF: p. 234
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy
29. The nurse is caring for a client with an intraosseous catheter placed in the leg 20 hours ago.
Which assessment is of greatest concern?

Length of time catheter is in place
Poor vascular access in upper extremities
Affected leg cool to touch
Site of intraosseous catheter placement
a.
b.
c.
d.
ANS: C
Compartment syndrome is a condition in which increased tissue perfusion in a confined

anatomic space causes decreased blood flow to the area. A cool extremity can signal the
possibility of this syndrome. All other distractors are important. However, the possible
development of a compartment syndrome requires immediate intervention because the client
could require amputation of the limb if the nurse does not pick up this perfusion problem.
REF: p. 235
30. A client is receiving an infusion of amiodarone (Cordarone), and the nurse notes that the
clients arm has begun to blister around the IV site. This manifestation is consistent with
which condition?
a. Extravasation
b. Infiltration
c. Infection
d. Phlebitis
ANS: A
Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous

irritants that can cause tissue sloughing and necrosis if the IV infiltrates. The other three
complications are possible with any infusion and are not specific to amiodarone.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 211
Adverse Effects/Contraindications/Interactions/Side Effects)
31. A client is to receive a blood transfusion. Before the transfusion, what action by the nurse
takes priority?
Verifying the clients identity
Ensuring that the blood bank has enough blood
Establishing a peripheral IV site
Feeding the client before starting the blood
a.
b.
c.
d.
ANS: A
Blood transfusion reactions can be devastating and can be prevented in large measure by
positive client identification. This is accomplished by two professionals using two different
client identifiers. Ensuring that the blood bank has enough blood would not be a normal
nursing action, and transfusions can be given without regard to food and drink.
REF: N/A
Error Prevention)
32. The nurse has just performed an IV start on a client. After the catheter has been threaded its
full length in the clients vein, which action does the nurse perform next?
a. Secure the IV with a securement device or tape.
b. Dispose of the IV needle in the sharps container.
c. Engage the safety mechanism of the IV catheter
d. Note the date and time of the dressing application over the insertion site.
ANS: C
A federal law enacted in 2000 requires health care facilities to use IV catheters with an
engineered safety mechanism to prevent needle sticks, which can be a source of contamination
by bloodborne pathogens. This priority action would help keep the nurse safe. Securing the IV
and dating/timing the dressing are also important actions, but engaging the safety mechanism
comes first. After engaging the safety mechanism, safely dispose of the needle in the sharps
container.

REF: N/A
33. A new nurse is preparing to start an IV on a client who is dehydrated and needs significant
fluid volume. The new nurse selects a butterfly needle for the infusion. What action by the
supervising nurse is best?
a. Help the new nurse with the procedure as needed.
b. Make sure the new nurse has the correct dressing.
c. Stop the new nurse and review the procedure in private.
d. Get the ultrasonic vein finder to help illuminate veins.
ANS: C
Winged (butterfly) needles generally are used for single doses of medications or for blood
sampling. They would not be used for large volumes of fluid or kept in for any length of time.
The other options do not acknowledge that the new nurses actions are incorrect and should be
stopped.
34. A nursing student asks why midline catheters need strict sterile dressing changes when short
peripheral IVs do not. Which answer by the experienced nurse is most accurate?
Because of the length of time they stay inserted.
They really dont need strict sterile technique.
Because the tip is in the right atrium of the heart.
The tonicity of the fluids used promotes infection.
a.
b.
c.
d.
ANS: A
Midline catheters can stay in place for as long as 4 weeks, so dressing changes must be done
with strict sterile technique to reduce the incidence of infection. The tip does not lie in the
right atrium; it resides no farther than the axillary vein. These catheters are used for a wide
range of fluids and medications, so tonicity would not be a factor in infection risk.
REF: p. 216
35. A nurse is preparing to administer two drugs at the same time to a client via a double-lumen
midline catheter. Which action by the nurse is most important?

a. Check the two drugs for compatibility.
b. Compare the recommended infusion times.
c. Schedule any post-infusion lab draws.
d. Flush both lumens with saline before starting the infusion.
ANS: A
Because midline catheters dwell in the peripheral, not central, circulation, incompatible drugs
should not be given together via a double-lumen midline catheter because the flow rate of the
blood is not high enough to dilute the drugs before they mix. The other options are valid
interventions before starting the infusion, but they do not take precedence over determining
whether the drugs may be infused at the same time.
REF: N/A
36. A client has just had a central venous access line inserted. What is the nurses next action?
a. Beginning the prescribed infusion as soon as possible
b. Confirming placement of the catheter by x-ray
c. Having the infusion team start the IV therapy
d. Confirming that solutions are appropriate for the central line
ANS: B
A central venous access device, once placed, needs an x-ray confirmation of proper placement
before it is used. The bedside nurse would be responsible for beginning the infusion once
placement has been verified. Any IV solution can be given through a central line.
REF: N/A
37. A new nurse is securing the connections on a new IV administration set connected to a
peripherally inserted central catheter (PICC) line with tape. Which action by the precepting
nurse is most appropriate?
a. Make sure the tape being used is from a sterile IV start kit.
b. Stop the nurse and confirm that the Luer-Lok connections are tight.
c. Help the new nurse document the set change appropriately.
d. Show the new nurse how to turn back the corner of the tape for easy removal.
ANS: B
PICC line administration sets must be secured using the Luer-Lok to help prevent air emboli.
Using tape is not sufficient. When starting peripheral IVs, nurses must use the tape from the
sterile IV start kit when possible, instead of using tape that might be dirty. Documentation is a
critical function, but it does not take priority over doing a procedure correctly, nor does
showing the new nurse time- and work-saving tips.
REF: N/A
38. The nurse is preparing to administer an infusion of dopamine (Intropin) using a smart pump.
After programming the pump and attaching the IV to the client, what action by the nurse is
most important?
a. Start the infusion as ordered.
b. Hand-calculate the infusion rate.
c. Ensure that the pump is plugged in.

d. Place a time tape on the IV bag.
ANS: B
Using a smart pump does not relieve the nurse of the responsibility of ensuring that the rate is
correct. Pumps can malfunction or can be programmed incorrectly, and concentrations of
solution can change and differ from the pumps drug library. The nurse must hand-calculate
the rate before starting the infusion, then must ensure that the pump is plugged into an
electrical source. Time tapes on the sides of IV bags are no longer used to show
approximate volume infused.
REF: N/A
39. A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV
line in the left arm. What instruction by the faculty member is most important?
a. Use the arm that doesnt have the IV site in it.
b. Dont inflate the cuff too high if you use the left arm.
c. Make sure the IV line is secure before taking the BP.
d. While the BP is taken, a little backflow of the IV is okay.
ANS: A
Nurses should not take blood pressure on arms that have IVs because increased pressure can
cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm
should not be used for BP, none of the other options can be correct.
REF: p. 224
40. The nurse preparing to insert an IV on an older adult client notices that the clients skin is
extremely fragile. Which action by the nurse is best?

a. Use a blood pressure cuff to cause the vein to distend.
b. Slap the skin vigorously to cause the vein to rise.
c. Place a gauze pad under the tourniquet before tightening.
d. Avoid the use of a tourniquet if the vein is already hard.
ANS: A
The skin of older adults is often fragile, and a tourniquet may leave an ecchymotic area after
the IV insertion. One option for fragile skin is to inflate a blood pressure cuff to a reading just
slightly less than the clients diastolic pressure. Tapping the skin lightly may help distend a
vein, but avoid slapping vigorously. Gauze padding would not prevent bruising. Veins that are
already distended may be cannulated without using a tourniquet, but they must be assessed
first, and hard or cordlike veins need to be avoided.
REF: N/A
41. The nurse is caring for a client admitted yesterday with an intraosseous (IO) infusion after a
car crash. Which action by the nurse takes priority?

Ensure that the IV flow rate has been recalculated for an IO infusion.
Plan to insert another kind of IV line during the shift.
Determine which IV medications can be given safely via the IO.
Monitor the site and dressings routinely for hemorrhage.
a.
b.
c.
d.
ANS: B
IO infusions, although valuable in an emergency, should be left in place for only 24 hours.
The nurse should plan to insert a peripheral IV sometime during the shift. IV solutions, flow
rates, and medications are given the same way that they are given IV. Hemorrhage is not a
complication of IO infusion.
REF: N/A
MULTIPLE RESPONSE
1. The RN is working with an experienced LPN (licensed practical nurse) who has been assigned
several clients receiving IV therapy. What actions guide the RN in delegating aspects of IV
therapy to the LPN? (Select all that apply.)
a. Look up and read the State Nurse Practice Act.
b. Check facility policy regarding LPNs and IV therapy.
c. Ask the LPN what he or she is comfortable performing.
d. Supervise the LPN when performing IV therapy.
e. Divide the clients up between the two of them.
ANS: A, B
The State Nurse Practice Act will have the information the RN needs, and in some states,
LPNs are able to perform specific aspects of IV therapy. However, in a client care situation, it
may be difficult and time-consuming to find it and read what LPNs are permitted to do, so
another good solution would be for the nurse to check facility policy and follow it.
REF: N/A
Delegation)
2. The nurse is preparing to administer a medication IV push. What information does the nurse
need to know before beginning the infusion? (Select all that apply.)
Any dilution required
Rate of administration
Compatibility with infusions
Other routes of administration
Specific monitoring needed
a.
b.
c.
d.
e.
ANS: A, B, C, E
Giving IV push medications requires specific knowledge about each drug, including dilution,
rate of administration, compatibility, and monitoring. pH and osmolarity and specific infusion
sites appropriate for giving the specific drug are also important to know. When giving an IV
push medication, it is not necessary to know whether other routes of administration are
possible.
REF: p. 212
3. A client has a peripherally inserted central catheter (PICC) line and the primary nurse is
updating the care plan. For which common complications does the nurse assess? (Select all
that apply.)
a. Phlebitis
b. Pneumothorax
c. Thrombophlebitis
d. Excessive bleeding
e. Extravasation
ANS: A, C
Although the complication rate with PICC lines is fairly low, the most common complications
are phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Pneumothorax,
excessive bleeding, and extravasation are not common complications.
REF: N/A
4. The nurse is preparing to give a client an IV push medication through an intermittent IV set
(saline lock) using a needleless system. Which actions by the nurse are most appropriate?
(Select all that apply.)
a. Cleanse the access port vigorously for at least 30 seconds.
b. Use an antimicrobial agent when cleansing the port.
c. Clean the ridges in the Luer-Lok connection well.
d. Rinse the antimicrobial agent off with saline.
e. Allow the antimicrobial agent to dry before using IV.
ANS: A, B, C
Needleless systems need careful cleansing before use. Guidelines include scrubbing the
connection vigorously with an antimicrobial agent for 30 seconds, and paying special
attention to the ridges in the Luer-Lok device. Rinsing and drying are not necessary.
REF: N/A
SHORT ANSWER
1. A client is scheduled to receive 1000 mL of normal saline in 24 hours. The nurse should set
the infusion pump to deliver how many milliliters per hour? _____________ mL/hr
ANS:
42
1000 mL divided by 24 hours = 41.6 mL/hr
REF: N/A
2. If a client is to receive an entire 250-mL bag of saline over the next 4 hours and the drop rate
of the IV tubing chamber is 15 drops/mL, at what drop rate per minute will the nurse set this
IV? ____________ drops/min
ANS:
16
Drops per minute = volume drop factor total minutes
250 15
= 15.625
4 (hours) 60 (minutes/hour)
REF: N/A
OTHER
1. The nurse is caring for an older adult client who has been admitted for dehydration and needs
IV fluids. Which location does the nurse choose to place a peripheral IV on this client?
ANS:
B [basilic vein]
The most appropriate veins for peripheral IV therapy include the dorsal venous network and
the basilic, cephalic, and median veins. However, an older client has poor skin turgor on the
back of the hand, making this a poor selection. The palmar side of the wrist should be avoided
because the median nerve is located there, causing increased pain and difficulty with
stabilization. The cephalic vein, although large and prominent in most people, is not the best
choice because the sensory branch of the median nerve intersects with it up to three times. The
best choice is the basilic vein.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesParenteral/Intravenous Therapies)
2. The nurse is preparing to flush a PICC line. The protocol specifies using 50 units of heparin.
Available is a multidose vial containing heparin, 10 units/mL. Which syringe does the nurse
use to draw up and administer the heparin?
ANS:
D [the 10-mL syringe]
Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates
higher pressure, which could rupture the lumen of the PICC line.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

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Chapter 15: Infusion Therapy

which information from the health care providers orders?

the nurse investigate publications from which resource?

d. Place pressure over the site to prevent bleeding.

nurse to record which information?

inserted central catheter (PICC) line?

c. Flush the IV line with normal saline daily.

which type of intravenous catheter?

MSC: Integrated Process: Nursing Process (Implementation)

the nurse implement?

What is the nurses next action?

requires immediate intervention?

waiting for x-ray

An insertion-related complication of central venous catheters is a pneumothorax. Signs and

requires immediate attention?

MSC: Integrated Process: Nursing Process (Implementation)

intervention is most important for the nurse to complete?

site. What action does the nurse take first?

Which action has the highest priority?

Which assessment is of greatest concern?

Compartment syndrome is a condition in which increased tissue perfusion in a confined

Certain medications, including amiodarone, vancomycin, and ciprofloxacin, are venous

DIF: Cognitive Level: Application/Applying or higher

midline catheter. Which action by the nurse is most important?

c. Ensure that the pump is plugged in.

extremely fragile. Which action by the nurse is best?

car crash. Which action by the nurse takes priority?

D [the 10-mL syringe]

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