Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to initiate IV therapy for a client.
Which of the following sites should the nurse use to place the peripheral IV catheter?
A. Dominant antecubital basilic vein.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
B. Nondominant dorsal venous arch.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
C. Dominant distal dorsal vein.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
D. Nondominant forearm basilic vein
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
Similar Questions
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?
A. Bradycardia.
Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
B. Red man syndrome.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin. Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
C. Hypotension.
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
D. Hypoglycemia.
Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake. Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
Full Explanation
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
Choice A is wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.
Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
Choice D is wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who has infective endocarditis. Which of the following actions should the nurse take?
A. Discard the medication if it is yellow.
Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
B. Use a gravity flow set.
Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
C. Prime the tubing with 0.9% sodium chloride.
Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
D. Administer the medication over 2 hr.
Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
Full Explanation
The correct answer is d. Administer the medication over 2 hr.
Choice A reason: Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
Choice B reason: Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
Choice C reason: Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
Choice D reason: Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
A nurse is assessing a client who is taking an osmotic laxative.
Which of the following findings should the nurse identify as an indication of fluid volume deficit?
A. Oliguria.
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
B. Nausea.
Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
C. Headaches.
Headaches are wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment. Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
D. Weight gain.
Weight gain is wrong because weight gain is not a sign of fluid volume deficit.
Full Explanation
Osmotic laxatives work by drawing water into the colon to soften the stool and stimulate bowel movements. However, excessive use of osmotic laxatives can cause fluid volume deficit, which is a state of reduced intravascular volume.
One of the signs of fluid volume deficit is oliguria, which means low urine output.
Choice B. Nausea is wrong because nausea is a common side effect of osmotic laxatives, not an indication of fluid volume deficit.
Choice C. Headaches is wrong because headaches are more likely to be caused by dehydration, which is a state of reduced total body water, mostly affecting the intracellular fluid compartment.
Dehydration can result from osmotic laxatives, but it is not the same as fluid volume deficit.
Choice D. Weight gain is wrong because weight gain is not a sign of fluid volume deficit.