IV IV Complications & Adverse Events 2 — Questions and Answers
Question 1: Which position should the nurse place a patient in if air embolism is suspected during central line care?
- High Fowler's position
- Left lateral Trendelenburg (Durant's maneuver) (Correct answer)
- Right lateral decubitus
- Prone position
Correct answer: Left lateral Trendelenburg (Durant's maneuver)
Left lateral Trendelenburg (Durant's maneuver) positions the air bubble away from the pulmonary outflow tract, reducing obstruction and cardiac effects.
Question 2: Speed shock is best prevented by which of the following nursing actions?
- Using large-bore peripheral catheters
- Programming infusion pumps with appropriate rate limits and using bolus checks (Correct answer)
- Warming IV fluids before administration
- Using only central lines for rapid infusions
Correct answer: Programming infusion pumps with appropriate rate limits and using bolus checks
Speed shock — a systemic reaction to rapid IV drug delivery — is best prevented by programming infusion pumps with correct rate settings and utilizing secondary line checks.
Question 3: A patient develops chills, fever, hypotension, and tachycardia shortly after a blood transfusion begins. What is the priority nursing action?
- Slow the transfusion rate and reassess
- Stop the transfusion and keep the IV line open with normal saline (Correct answer)
- Administer diphenhydramine and continue the transfusion
- Increase the infusion rate to flush the reaction
Correct answer: Stop the transfusion and keep the IV line open with normal saline
A suspected acute hemolytic transfusion reaction requires immediately stopping the transfusion and maintaining IV access with normal saline to support perfusion.
Question 4: Which clinical finding most strongly indicates fluid overload from IV therapy?
- Decreased blood pressure
- Crackles in the lung bases and jugular venous distension (Correct answer)
- Dry mucous membranes
- Decreased central venous pressure
Correct answer: Crackles in the lung bases and jugular venous distension
Pulmonary crackles and jugular venous distension are hallmark findings of hypervolemia resulting from excessive IV fluid administration.
Question 5: Which of the following describes a Grade 3 infiltration according to the INS Infiltration Scale?
- Skin blanched with no pain
- Skin blanched, translucent, with gross edema and mild pain
- Skin tight, leaking, bruised, and swollen with pitting edema >1 inch (Correct answer)
- Any amount of swelling with or without pain
Correct answer: Skin tight, leaking, bruised, and swollen with pitting edema >1 inch
INS Grade 3 infiltration is characterized by skin that is tight, translucent, gross edema >1 inch, cool to touch, and associated with mild to moderate pain.
Question 6: Thrombophlebitis differs from simple phlebitis in that it also involves which additional finding?
- Presence of fever
- Palpable cord along the vein (Correct answer)
- Purulent drainage at the site
- Positive blood cultures
Correct answer: Palpable cord along the vein
Thrombophlebitis involves both inflammation and thrombus formation, making the vein palpable as a hard, cord-like structure along its course.
IV IV Complications & Adverse Events 2
Which position should the nurse place a patient in if air embolism is suspected during central line care?