IV Patient Assessment & Monitoring 3 — Questions and Answers
Question 1: Which parameter is MOST important to monitor in a patient receiving hypertonic saline (3% NaCl)?
- Blood glucose every 2 hours
- Serum sodium levels and neurological status (Correct answer)
- INR and PT values
- Platelet count
Correct answer: Serum sodium levels and neurological status
Hypertonic saline corrects severe hyponatremia; monitoring serum sodium and neuro status prevents osmotic demyelination syndrome from overcorrection.
Question 2: When performing a pre-infusion assessment, the nurse notes the patient has a documented penicillin allergy. The ordered IV antibiotic is cephalexin. The nurse should:
- Administer and monitor for reaction
- Administer a test dose first
- Withhold the drug and clarify with the prescriber (Correct answer)
- Give diphenhydramine prophylactically and proceed
Correct answer: Withhold the drug and clarify with the prescriber
Cross-reactivity between penicillins and cephalosporins exists; the nurse must clarify with the prescriber before administering due to potential allergic reaction.
Question 3: A patient's IV site shows a Phlebitis Scale score of 3 (erythema, streak formation, and palpable cord). The correct action is:
- Apply warm compresses and continue the infusion
- Discontinue the IV and restart at a new site (Correct answer)
- Slow the infusion rate and document
- Flush the line with heparin solution
Correct answer: Discontinue the IV and restart at a new site
A phlebitis score of 3 or above requires discontinuation of the IV catheter and insertion at a new site to prevent further vascular damage.
Question 4: During a peripheral IV assessment, the nurse notices blood backing up into the tubing when the bag is lowered below the insertion site. This indicates:
- Arterial placement
- Patent IV with adequate venous pressure (Correct answer)
- Infiltration
- Occluded catheter
Correct answer: Patent IV with adequate venous pressure
Blood return when the IV bag is lowered below the site confirms catheter patency and proper venous placement.
Question 5: A patient receiving potassium chloride IV develops peaked T waves on telemetry. This finding indicates:
- Hypokalemia
- Hyperkalemia (Correct answer)
- Hyponatremia
- Hypocalcemia
Correct answer: Hyperkalemia
Peaked T waves are an early ECG sign of hyperkalemia, which may result from excessive IV potassium administration.
Question 6: Which assessment is essential before administering IV calcium gluconate?
- Checking the patient's BUN and creatinine
- Verifying cardiac rhythm and heart rate (Correct answer)
- Assessing blood glucose level
- Measuring urinary specific gravity
Correct answer: Verifying cardiac rhythm and heart rate
Rapid IV calcium can cause bradycardia and cardiac arrest; cardiac rhythm monitoring is essential before and during administration.
Question 7: A patient receiving IV vancomycin develops flushing, erythema of the neck and face, and pruritus without hypotension. This presentation is consistent with:
- Anaphylaxis
- Red Man Syndrome (Correct answer)
- Phlebitis
- Septicemia
Correct answer: Red Man Syndrome
Red Man Syndrome is a rate-related infusion reaction to vancomycin causing flushing and erythema that resolves by slowing the infusion rate.
IV Patient Assessment & Monitoring 3
Which parameter is MOST important to monitor in a patient receiving hypertonic saline (3% NaCl)?