IV Patient Assessment & Monitoring 2 — Questions and Answers
Question 1: A patient receiving IV fluids develops sudden onset of chills, fever of 103°F, and hypotension. Which condition should you suspect first?
- Phlebitis
- Septicemia from contaminated IV solution (Correct answer)
- Fluid volume overload
- Air embolism
Correct answer: Septicemia from contaminated IV solution
Sudden fever, chills, and hypotension during IV therapy are classic signs of septicemia, often caused by contaminated IV solution or tubing.
Question 2: When assessing an IV site, you note the skin is taut, cool, and pale with no blood return. The most likely cause is:
- Phlebitis
- Thrombosis
- Infiltration (Correct answer)
- Hematoma
Correct answer: Infiltration
Taut, cool, pale skin with absent blood return indicates infiltration — IV fluid leaking into surrounding tissue.
Question 3: How often should IV insertion sites be assessed in a standard acute care setting?
- Once per shift
- Every 4 hours
- Every 1-2 hours (Correct answer)
- Only when the patient complains
Correct answer: Every 1-2 hours
INS standards recommend IV site assessment every 1-2 hours to detect complications such as infiltration or phlebitis early.
Question 4: A patient's urine output drops below 30 mL/hour during IV fluid therapy. This finding primarily suggests:
- Adequate hydration
- Renal insufficiency or inadequate fluid replacement (Correct answer)
- Overhydration
- Normal variation
Correct answer: Renal insufficiency or inadequate fluid replacement
Urine output below 30 mL/hour indicates inadequate perfusion, possible hypovolemia, or renal compromise requiring immediate evaluation.
Question 5: Which assessment finding is most consistent with speed shock during rapid IV infusion?
- Peripheral edema and crackles
- Flushing, headache, and loss of consciousness (Correct answer)
- Pallor, cool extremities, and slow capillary refill
- Erythema and warmth at the IV site
Correct answer: Flushing, headache, and loss of consciousness
Speed shock presents with flushing, tight chest, headache, and potential loss of consciousness due to too-rapid introduction of medication or fluid.
Question 6: To assess for early fluid overload in a patient receiving IV therapy, the nurse should prioritize:
- Checking skin turgor
- Auscultating lung sounds and monitoring weight (Correct answer)
- Assessing mucous membrane moisture
- Observing urine color
Correct answer: Auscultating lung sounds and monitoring weight
Crackles on auscultation and rapid weight gain are early indicators of fluid overload before overt pulmonary edema develops.
Question 7: A patient on a continuous heparin infusion has an aPTT result of 180 seconds (therapeutic range 60-100 seconds). What is the priority action?
- Increase the infusion rate
- Continue the infusion and reassess in 6 hours
- Stop the infusion and notify the provider (Correct answer)
- Flush the IV line with saline
Correct answer: Stop the infusion and notify the provider
An aPTT of 180 seconds indicates supratherapeutic anticoagulation with bleeding risk; the infusion must be stopped and the provider notified immediately.
IV Patient Assessment & Monitoring 2
A patient receiving IV fluids develops sudden onset of chills, fever of 103°F, and hypotension.
Which condition should you suspect first?