Chapter 28: Intravenous Therapy

Multiple Choice

1. After inserting a peripheral IV line into the patient, the nurse provides patient teaching about the IV insertion site. What information does the nurse give to the patient?

a. Expect minor pain at the insertion site.

b. Report redness at the insertion site.

c. Remain on bed rest with the IV infusion.

d. Disconnect IV tubing to change a gown.

ANS: B

The nurse instructs the patient to report redness at the insertion site for early detection of IV complications, including infection and phlebitis. The IV site should cause very little discomfort if the infusion is proceeding without problems. Pain associated with an IV infusion indicates vein irritation from infusing fluid, irritating medication, infiltration, extravasation, infection, or phlebitis. Patients with IV infusions are not confined to bed. The nurse instructs the patient to call for help when changing the gown because, if the gown has no snaps at the shoulder, the nurse must feed the IV tubing and bag through the opening of the gown when the gown is changed.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Avoid using soft, bouncy veins. b. Choose the patient’s best proximal vein. c. Choose a site large enough for adequate blood flow. d. Always use the smallest-gauge IV catheter available.

2. The nurse is trying to access the best insertion site on a patient for IV therapy. Which principle would the nurse use to achieve this goal?

ANS: C

The site must be large enough to prevent interruption of venous flow while allowing adequate blood flow around the catheter. The nurse chooses a site for venipuncture with soft, bouncy veins because these veins are more easily punctured and stabilized during the insertion. The most distal vein is the best for insertion to maintain the maximum number of potential sites for future use. The smallest-gauge IV catheter suitable for both the therapy and the patient’s vein should be selected, which may not be the smallest available.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Infuse a bolus of D5NS to the patient now. b. Regulate an IV infusion pump at 125 mL/hr. c. Call the health care provider to clarify the order. d. Perform venipuncture with a butterfly needle.

3. The health care provider’s order reads, “Administer 5% dextrose solution with normal saline (D5NS) intravenously now.” What action does the nurse perform first?

ANS: C

The only recourse for the nurse is to clarify the order because it is incomplete. It is missing an infusion rate. You would not start an IV or give the IV until you have the infusion rate information. Butterfly needles would not be used for a continuous infusion.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Compare weight to baseline data. b. Replace the infusion pump batteries. c. Assess the patient for respiratory distress. d. Reduce the infusion rate below 75 mL/hr.

4. The prescription for the patient’s IV infusion reads, “100 mL/hr.” The nurse observes that the patient’s IV line infused 125 mL in addition to the ordered volume after 2 hours. Which is the most important intervention for the nurse to implement?

ANS: C

The nurse assesses the patient for respiratory distress after an excessive infusion of 125 mL of IV fluid because excess total body fluid often leaks into the pulmonary vascular bed to decrease gas exchange. This may lead to hypoxemia and dyspnea because the patient has difficulty with oxygenation, and there can be enough fluid overload to precipitate heart failure in a patient with heart disease or respiratory failure in a patient with pulmonary disease. Weighing the patient is a reasonable nursing intervention to differentiate patient weight gain from fluid or caloric intake but would be done later. Verifying patient safety and well-being is a better choice and is more important than differentiating the weight because the extra fluid can cause dyspnea, desaturation, and heart failure. Checking the infusion pump batteries is a reasonable intervention if the pump operates on battery power. The nurse can reduce the infusion rate to 75 mL/hr after collaborating with the health care provider. The nurse cannot change the infusion rate independently because doing so is out of the nurse’s scope of practice.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Instruct the patient how to protect the IV site. b. Apply a new sterile dressing every day. c. Change the IV tubing at least daily. d. Flush the IV catheter every morning.

5. The patient has an intermittent infusion device inserted in the hand. Which strategy does the nurse use to prevent the IV catheter from being dislodged?

ANS: A

The most important prevention strategy for the nurse to implement is to instruct the patient to protect the IV site by reducing trauma, keeping the IV line in sight, and getting out of bed properly. Less manipulation or trauma to the IV site reduces IV irritation and maintains a better seal at the skin to prevent the entry of microorganisms. IV dressings for primary and secondary infusions are changed at least every 5–7 days, or when needed due to soiling or disruption. Daily flushing of the IV access is not related to preventing the catheter from being dislodged. The nurse changes the IV tubing according to agency policy to prevent infection, depending on the type of solution being infused. Intermittent infusion devices are flushed more often than once a day.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Tell the patient that this is a common occurrence. b. Stop the infusion and notify the health care provider. c. Flush the tubing with normal saline solution. d. Attach a 0.22-micrometer inline IV filter.

6. The nurse observes fine white crystals in the IV tubing that is infusing an antibiotic. Which action by the nurse is most appropriate?

ANS: B

White crystals in IV tubing indicate precipitation of a substance in the infusion, most likely the medication because it is the solute with the highest concentration. If the crystals enter the patient, they can behave like emboli, occluding tiny vessels, and cause regional irritation. At a minimum, the crystals usually occlude the IV line. The nurse stops the infusion, discards the IV tubing, checks to ensure compatibility of all agents in the infusion, and notifies the health care provider. The IV access potentially needs to be changed. The nurse avoids telling the patient that this is a common occurrence because it is a complication of an IV infusion. He or she avoids flushing the tubing because injecting a fluid bolus increases the risk of infusing a crystal into the patient. He or she uses an IV filter when indicated for effective therapy.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Instruct the patient to elevate his or her arm on two pillows. b. Discontinue the IV infusion and start one in the right arm. c. Apply a warm, moist compress to the IV site. d. Reassess the IV site in 2 hours for any change.

7. The nurse observes that the patient’s left cephalic IV site is cool, swollen, and mildly tender, although the IV line is infusing at the prescribed rate. Which action does the nurse take first?

ANS: B

The patient’s IV site is infiltrated; thus, the nurse should discontinue the infusion immediately and start another IV infusion, preferably in the other arm. If the right arm is contraindicated, the nurse chooses a subsequent site that is proximal to the original site to avoid additional irritation of the vein. An infiltrated IV site increases the risk of regional phlebitis. The nurse can apply a warm, moist compress to facilitate healing and provide comfort once the IV line has been removed. After the nurse discontinues the IV infusion, he or she instructs the patient to elevate the arm to reduce edema because this technique facilitates venous return.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Adjusting the infusion rate b. Changing the IV dressing c. Reporting patient complaints d. Administering IV antibiotics

8. The nurse is explaining to nursing assistive personnel (NAP) how to help maintain the patient’s IV therapy. What action regarding IV therapy can be delegated to the NAP?

ANS: C

The nurse delegates very little to the NAP related to IV therapy. The NAP is expected to report patient complaints to the nurse because he or she receives training to perform this task; however, the nurse must determine the meaning of the complaint and how to resolve it. The nurse retains responsibility for adjusting the infusion rate, changing the dressing, and administering IV antibiotics because these nursing tasks require critical thinking and nursing judgment.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Use a 3-mL syringe to flush. b. Aspirate the IV line for a blood return. c. Check for causes of resistance. d. Inject the IV medication slowly.

9. The nurse feels resistance while trying to flush the IV line with a 5-mL syringe of normal saline solution before administering a medication by IV bolus. Which action does the nurse implement next?

ANS: C

The nurse checks for causes of resistance, such as clamped or kinked tubing. If the IV site is occluded, the nurse discontinues the IV infusion and inserts another IV line in another site. Using a 3-mL syringe increases the potential pressure delivered by the flush. The smaller the syringe, the higher the pressure exerted on the vein. Blood return is only one indicator of IV patency; thus, the nurse avoids basing follow-up nursing care on the blood return alone. He or she avoids injecting the medication to prevent complications.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Check the IV access for patency. b. Increase the infusion rate of the blood. c. Discontinue the blood infusion. d. Assess the patient for an ABO mismatch.

10. The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete. Which action is most appropriate?

ANS: C

The nurse infuses whole blood or packed red blood cells within a 4-hour time limit; thus, if the infusion is incomplete at the end of 4 hours, the nurse must discontinue it to decrease the risk of adverse transfusion effects because the blood has warmed sufficiently to promote microorganism growth. Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations that impede infusion rates. However, the nurse must discontinue the blood infusion first because after 4 hours, the blood is not safe to infuse. He or she avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload. Although delayed transfusion reactions occur, if a mismatch exists between the blood and the patient, the patient is more likely to manifest reaction within the first few minutes of the transfusion.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Determining patient history of autologous blood donations b. Assessing patient baseline vital signs before the transfusion c. Confirming the rate of the blood infusion with the health care provider d. Identifying patient blood type, cross-match, and blood product

11. The nurse prepares to administer blood to the patient. Which is the nurse’s priority action?

ANS: D

The most critical intervention to administer blood products safely is to accurately identify patient, blood type, cross-match, and blood product because an identification error potentially leads to devastating adverse effects, including hypersensitivity reactions, renal damage, and death. The nurse follows agency policy throughout the process of blood administration to prevent complications from the administration of blood products. Assessing patient vital signs for baseline data is very important for comparison during the transfusion because the data provide the nurse with a basis of comparison to evaluate patient changes. The patient’s history of blood donations is irrelevant information unless the donations left the patient grossly anemic. The nurse clarifies any orders when a question develops. If the order for blood is properly written, or if agency policy dictates the rate of infusion, there is no need to routinely consult the provider about the rate.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use a site distal to the original site.

12. The nurse prepares to relocate an IV catheter because of signs of infiltration. The IV was located in the patient’s nondominant hand. Which criterion would be best for the nurse to use when deciding on the location of the new IV site?

N b. Place it wherever a vein is suitable. c. Place the new site in a smaller vein. d. Continue to use the nondominant extremity.

ANS: B

Since an IV site has infiltrated, it is no longer appropriate to use, even though it is on the nondominant extremity. The nurse must now find a site where the vein is of adequate size, location, and pliability and place the IV catheter there. The most distal site is suitable for an original IV site, but it should not be used if an IV line is being reinserted in the same extremity because of possible infusion difficulty, especially when infiltration is present. The new site should not be limited to only a smaller vein, which also may not be possible. Although it is ideal to use the patient’s nondominant hand, it may not be possible if the prior IV infusion has infiltrated. Injury and pain to the patient could occur.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Flush with a low concentration of heparin. b. Always change the end cap with each medication dose. c. Change the IV insertion site every day. d. Flush with 0.9% saline solution.

13. The nurse is caring for a patient with a peripheral IV access that is used intermittently for medications but is not a continuous infusion. Which technique does the nurse use for routine care of this peripheral line?

ANS: D

Guidelines for the nursing care and maintenance of IV access devices include regular flushes with normal saline solution to assess for and maintain patency since the line is not used constantly. Heparin flushes are not considered routine but are specifically ordered for use in certain patients. The end cap does not need to be changed with every medication dose unless this is agency policy, but it does need to be swabbed with an antiseptic. Routine nursing care of an IV site should prevent phlebitis and infiltration. Changing the IV insertion site daily causes patient discomfort, increases costs, and is contraindicated.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Slow the infusion rate. b. Discontinue the IV infusion. c. Apply cool compresses. d. Apply warm compresses.

14. The nurse assesses the patient’s IV insertion site and notes that it is warm, red, and tender. Which intervention does the nurse implement first?

ANS: B

The nurse must discontinue the IV infusion with a warm, red, and tender appearance because these clinical indicators are consistent with an infection. The nurse also discontinues the IV infusion to decrease the risk of sepsis, tissue loss, and a thromboembolic event. If the site is infected, slowing the infusion rate is unlikely to help. Cool compress application is an improper therapy for the problem. The nurse applies a warm compress after discontinuing the IV line from the inflamed tissue.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 0.45 normal saline b. 0.9 normal saline c. D5 0.45 normal saline d. Dextrose 5% in water

15. The nurse is preparing to administer blood. What solution is most appropriate for the nurse to use when priming the blood administration set?

ANS: B

The only compatible solution for blood administration is normal saline because it is an isotonic solution (0.9 normal saline). The remaining solutions, especially the dextrose solution, can cause problems with blood administration and are contraindicated.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Prepare a normal saline solution. b. Obtain a Y-tubing for administration. c. Provide the patient with information. d. Identify the blood product and patient.

16. The nurse is setting up to administer a unit of blood. Which is the most important nursing intervention during preparation for this procedure?

ANS: D

Before administering blood, the nurse checks the identification of the patient and the blood product according to agency policy, which includes several patient identifiers. Accurate identification decreases the risk of patient injury, infection, or death from patient-blood mismatch. The nurse prepares the Y-tubing with normal saline before the blood transfusion is started. He or she takes time to teach the patient before beginning the transfusion.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Use clean technique for dressing changes. b. Palpate the insertion site through the dressing. c. Change the IV tubing at 12-hour intervals. d. Routinely apply an antimicrobial to the IV site.

17. The patient has a peripheral infusion for the administration of antibiotics. Which action is most effective for the nurse to use to detect an IV therapy–related infection?

ANS: B

The nurse palpates the insertion site gently through the dressing to detect any infection by checking for tenderness, edema, or swelling. Removing the dressing exposes the insertion site to contamination from the nurse’s contact and environment and risk to the tissues. The nurse uses aseptic technique for IV dressing changes. IV tubing changes every 12 hours are excessive and costly. The nurse applies antimicrobial agents to the insertion site according to agency policy, however; applying an antimicrobial to the site per agency policy does not serve the purpose of detecting an IV therapy-related infection.

N

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Poor skin turgor b. Bilateral crackles c. Mild hypotension d. High serum sodium

18. The nurse assesses several patients who are receiving IV therapy. Which clinical indicator cues the nurse to take special precautions while infusing IV fluids on one of the patients?

ANS: B

The nurse scrutinizes IV therapy for patients with crackles in the lungs because it is consistent with clinical indicators of fluid overload and pulmonary edema. As a result, the nurse administers IV fluids to the patient with heightened scrutiny to avoid administering excess IV fluids. Poor skin turgor, hypernatremia, and hypotension indicate a potential need for additional fluid volume.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Slap the selected vein gently several times. b. Select a proximal site on the extremity. c. Shave the hair in the area of the insertion site. d. Tie a tourniquet above the selected insertion site.

19. The nurse is preparing to insert a peripheral IV line. Which technique does the nurse implement to prepare for the IV insertion?

ANS: D

The nurse applies a tourniquet to the patient’s arm to engorge the vein selected for IV insertion. This facilitates catheter insertion because a larger vein is easier to enter without transecting the vein than a small vessel. The nurse avoids tapping and massaging the vein before IV insertion because these actions increase the risks of hematoma formation and vasoconstriction. The most distal site on the extremity suitable for IV therapy is selected, and hair around the potential IV insertion site is clipped if needed, not shaved, because shaving increases the risks of impaired skin integrity and infection through microabrasions.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Elevating the patient’s arm to maintain the ordered flow b. Padding the IV site for skin protection c. Inspecting the insertion site on a regular schedule d. Changing the site every day at the same time

20. The nurse is caring for several patients who have IV lines. What responsibility does the nurse have related to the assessment and maintenance of a peripheral IV site?

ANS: C

The nurse inspects the insertion site regularly for early detection of inflammation, infection, phlebitis, and leakage to fulfill the duty the nurse owes to the patient for preventing complications. Elevating the patient’s arm is unnecessary. Changing the site daily increases patient risk for infection and trauma. Padding the site obstructs direct observation of the site and prevents early detection of complications; the best method of protecting the IV site is patient education and continuously observing site.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. An elevated heart rate b. Decreased skin temperature c. Erythema along the vein line d. Edema around the insertion site

21. The nurse assesses the patient’s IV site. Which clinical indicator does the nurse recognize as being most consistent with phlebitis?

ANS: C

The nurse scrutinizes the IV insertion site for redness along the outline of the vein through the skin. The erythema indicates inflammation of the vein. Tachycardia is consistent as a clinical indicator for infection. Cool skin is consistent with clinical indicators for infiltration. Regional edema is consistent with clinical indicators for inflammation and infection.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Hold pressure on the site. b. Replace the dressing. c. Apply a warm compress. d. Lower the site below the level of the heart.

22. The nurse observes bleeding on the dressing of a site where the IV was discontinued. Which action should the nurse take first?

ANS: A

The nurse needs to hold pressure on the site since it is continuing to bleed after the IV was discontinued. Replacing the dressing will not address the cause. A warm compress causes vasodilation to increase localized blood flow. Lowering the site will increase the bleeding.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. A+ b. O+ c. O d. AB

23. A patient in the emergency department needs a blood transfusion of A blood, and none is available. Nursing care would be correct if the nurse administered blood of which type?

ANS: C

The nurse can administer O because it doesn’t contain any proteins or substances that the patient doesn’t already have. O+ and A+ nor AB cannot be administered because the presence of the Rh factor would cause a reaction in the patient. The patient has antibodies to the B antigens found in the AB blood.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

N a. The patient gains 2 1/2 pounds in 2 days. b. The patient’s insertion site is warm and dry. c. The patient has subcutaneous emphysema. d. The patient’s neck veins are less distended today than yesterday.

24. The nurse is administering an IV infusion via a central venous access device. Which outcome would best substantiate the nurse’s assessment that the patient has not experienced a complication?

ANS: B

The insertion site should be warm and appear dry. Increased temperature locally would indicate infection. The rapid weight gain indicates fluid overload. Subcutaneous emphysema would indicate pneumothorax, hemothorax, hydrothorax, or an air embolus. Distended neck veins would indicate incorrect placement or catheter migration.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Hang another bag of the identical IV solution. b. Change the tubing when preparing a new IV bag. c. Allow IV fluid to empty into the upper part of the tubing. d. Change the bag when approximately 50 mL is left in the old bag.

25. The nurse is preparing to change the IV solution after the current one infuses. What action is most appropriate for the nurse to take?

ANS: D

When the old bag has about 50 mL left (when the fluid remains only in the neck of the bag), the nurse changes the bag. Hanging the identical IV solution can contradict the prescription so the nurse needs to ensure the orders have not changed. Changing the tubing with each new bag is unnecessary and wasteful. The nurse stops the infusion before air reaches the IV tubing.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Stabilize the IV catheter until the tape is in place. b. Place folded gauze under the IV catheter hub. c. Wear clean gloves to remove the old dressing. d. Clean in a circular motion away from the site.

26. The nurse is caring for a patient with a peripheral IV line and needs to change the dressing. What action by the nurse prevents accidental dislodgement of the IV catheter?

ANS: A

To prevent accidental catheter dislodgement, the nurse stabilizes the IV catheter with the nondominant hand until the agency-approved covering is in place during the IV dressing change. The nurse places a folded 2  2–inch gauze pad under the hub to prevent excessive skin pressure from the hub. He or she wears clean gloves to remove the old dressing to prevent self-contamination. The insertion site is cleansed using a circular motion from the center to the exterior of the site to prevent recontamination.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Begin the infusion at 2 mL/min. b. Establish a single-line infusion. c. Check vital signs in 30 minutes. d. Shake the blood gently to mix the preservative.

27. The nurse is preparing to initiate a blood transfusion. Which step of the procedure does the nurse implement first?

ANS: A

The nurse initiates infusion of the blood very slowly at 2 mL/min to prevent the infusion of a large-volume bolus of potentially incompatible blood. Most transfusion reactions occur during the first 15 minutes of the infusion; thus, the nurse continues the slow rate for 15 minutes while closely monitoring the patient. The nurse needs to infuse blood products through a Y-tubing administration set. The nurse evaluates the patient’s vital signs within 5–15 minutes of starting the infusion or according to agency policy. The nurse avoids shaking blood products because violent movement damages erythrocytes and increases their hemolysis.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Pull the IV catheter out smoothly but quickly. b. Apply sterile gloves before going to the patient’s bedside. c. Check the most recent clotting studies. d. Apply pressure over the insertion site for 5–10 minutes.

28. A patient on an anticoagulant is going home and needs the peripheral IV line removed. Which action is essential for the nurse to take?

ANS: D

The patient taking an anticoagulant has a longer bleeding time; thus, the nurse applies pressure to the puncture site for 5–10 minutes after catheter removal to minimize blood loss and prevent hematoma formation. The nurse removes the catheter slowly to avoid patient injury or damage to the catheter. He or she applies clean gloves because the dressing and catheter are contaminated. Checking the most recent coagulation is helpful, but, regardless of the results, extra pressure should be applied over the insertion site after removal for 5–10 minutes.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the health care provider. b. Notify the blood bank. c. Complete the vital signs. d. Remove the IV tubing.

29. The nurse administers blood to the patient and observes that the patient has tachycardia, chills, and lower back pain. What action does the nurse take first?

ANS: D

Once the nurse suspects a transfusion reaction, he or she immediately stops the infusion so the patient receives no additional blood from the current bag and quickly primes different IV tubing with saline solution. He or she uses this to replace the blood tubing but retains the blood and the tubing for the blood bank. He or she completes the vital signs and notifies the health care provider and the blood bank. Stopping the infusion is the priority to limit the transfusion reaction as much as possible.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

Completion

1. The health care provider prescribes 500 mL of 0.25% normal saline intravenously over 4 hours for the patient. At which rate does the nurse infuse the IV solution into the patient using IV tubing with a drop factor of 15 gtts/mL? _____ gtts/min.

ANS: 31 gtts/min

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

2. The prescription for the patient’s IV fluid reads, “Infuse 1000 mL over 10 hours.” At which rate does the nurse infuse the IV fluids using IV tubing with a drop factor of 15 gtts/mL? _____gtts/min.

ANS:

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

3. A patient has IV fluids prescribed at 40 mL/hr through microdrip tubing. Which rate does the nurse use to infuse the patient’s IV fluid? _____ gtts/min.

ANS: 40 gtts/min

When the nurse uses microdrip tubing, he or she realizes that the infusion rate in drops per minute equals the hourly rate because the drip factor for this tubing is 60 gtts/mL.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

4. The order calls for the patient to receive 500 mL of IV fluid over 4 hours, and the nurse uses IV tubing with a drop factor at 10 gtts/mL. Which rate should the nurse use on an electronic infusion pump for IV fluids to administer this prescription? ________ mL/hr.

ANS: 125 mL/hr

The electronic infusion pump administers fluid in milliliters per hour; thus, the nurse programs the pump to infuse 125 mL/hr. The nurse obtains the infusion rate by dividing the total volume to be infused by the number of total hours for the infusion: 500 ÷ 4 = 125. If the nurse uses gravity to administer the fluid, he or she should use the roller clamp to limit the drops per minute to 21 gtts/min by using tubing with a drop factor of 10 gtts/mL.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation