CRNI Patient Assessment and Monitoring Practice Test 2 — Questions and Answers
Question 1: What is the recommended frequency for peripheral IV site assessment in an adult patient?
- Once per shift only
- Every 1-2 hours for continuous infusions, and before, during, and after each intermittent infusion (Correct answer)
- Every 24 hours
- Only when the patient reports pain
Correct answer: Every 1-2 hours for continuous infusions, and before, during, and after each intermittent infusion
Current INS standards recommend peripheral IV site assessment every 1-2 hours for patients receiving continuous infusions. For intermittent infusions, the site should be assessed before, during, and after each infusion. More frequent assessment is needed for vesicant medications, patients with altered sensation, and pediatric patients.
Question 2: A patient receiving IV vancomycin develops flushing of the face, neck, and trunk. What assessment should the nurse perform first?
- Check the drug's expiration date
- Assess the infusion rate, as this reaction is typically rate-related (Red Man Syndrome) rather than a true allergy (Correct answer)
- Obtain blood cultures
- Check the patient's white blood cell count
Correct answer: Assess the infusion rate, as this reaction is typically rate-related (Red Man Syndrome) rather than a true allergy
Red Man Syndrome (vancomycin flushing reaction) is a histamine-mediated response typically caused by rapid infusion. The nurse should first assess the current infusion rate because slowing the rate usually resolves symptoms. This is not a true allergy but a rate-dependent reaction. The minimum infusion time for vancomycin is usually 60 minutes per gram.
Question 3: Which assessment tool is used to evaluate the degree of phlebitis at a peripheral IV site?
- Braden Scale
- Visual Infusion Phlebitis (VIP) Scale (Correct answer)
- Norton Scale
- Morse Fall Scale
Correct answer: Visual Infusion Phlebitis (VIP) Scale
The Visual Infusion Phlebitis (VIP) Scale is the standardized assessment tool for evaluating phlebitis severity at peripheral IV sites. It grades phlebitis from 0 (no symptoms) to 5 (advanced thrombophlebitis with purulent drainage), based on objective observable signs including erythema, pain, palpable cord, streak formation, and purulence.
Question 4: A patient receiving a blood transfusion develops dyspnea, bilateral crackles on auscultation, and distended neck veins. Which complication is most likely?
- Febrile non-hemolytic reaction
- Transfusion-associated circulatory overload (TACO) (Correct answer)
- Allergic transfusion reaction
- Transfusion-related acute lung injury (TRALI)
Correct answer: Transfusion-associated circulatory overload (TACO)
The triad of dyspnea, bilateral pulmonary crackles, and jugular vein distention indicates fluid overload consistent with TACO. This occurs when the transfusion rate or volume exceeds the patient's cardiac capacity. Unlike TRALI (which presents with non-cardiogenic pulmonary edema and hypotension), TACO presents with hypertension and signs of volume overload.
Question 5: What is the primary assessment parameter for monitoring a patient receiving continuous IV heparin therapy?
- Platelet count only
- Activated partial thromboplastin time (aPTT) or anti-Xa level (Correct answer)
- Prothrombin time (PT/INR)
- Bleeding time
Correct answer: Activated partial thromboplastin time (aPTT) or anti-Xa level
The aPTT (or anti-Xa level) is the primary laboratory parameter for monitoring continuous IV unfractionated heparin therapy. aPTT is checked 6 hours after initiation and after each dose change to verify therapeutic anticoagulation. The target aPTT range (typically 1.5-2.5 times normal) varies by institution and clinical indication.
Question 6: A nurse is assessing a central venous catheter insertion site during a dressing change. Which finding requires immediate notification of the provider?
- Slight tenderness during dressing removal
- Purulent drainage from the insertion site (Correct answer)
- Small amount of dried blood on the dressing
- Mild erythema within 1 cm of the insertion site on day 1 post-insertion
Correct answer: Purulent drainage from the insertion site
Purulent drainage from a CVC insertion site indicates a possible exit site infection or tunnel tract infection and requires immediate provider notification. This finding warrants wound culture, blood cultures, assessment for systemic infection signs, and initiation of empiric antibiotic therapy pending culture results. The catheter may need to be removed.
CRNI Patient Assessment and Monitoring Practice Test 2
What is the recommended frequency for peripheral IV site assessment in an adult patient?