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Pharmacological and Parenteral Therapies

NCLEX IV Therapy and Blood Administration Practice Questions

Quick answer

IV therapy and blood administration questions test whether you can spot a site or line problem early and act in the right order. They fall under Pharmacological and Parenteral Therapies, which makes up roughly 13 to 19 percent of the NCLEX-RN, and IV and transfusion items are a steady slice of that.

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Most of these questions are not about drug names. They are about what you do with your hands in the next sixty seconds: stop the pump, clamp the line, change the client's position, call someone. The exam loves a scenario where the client's arm is swollen or a fever shows up ten minutes into a unit of blood, and it wants to know your very first move. The trap students fall into is jumping to the doctor or the rapid response team before doing the one thing a nurse can do alone, like stopping the infusion. Another common slip is mixing up infiltration (cool, swollen, no redness) with phlebitis (warm, red, cord-like vein), because both get the answer "remove the IV" but the follow-up care is different. Read the signs slowly, decide which problem it is, then pick the action.

Practice questions

1

A client receiving a continuous infusion of normal saline through a peripheral IV in the left forearm reports that the site "feels tight." The nurse notes the area is cool, pale and swollen, and the pump is alarming for occlusion. Which action should the nurse take first?

  1. ASlow the infusion rate and reassess in 30 minutes
  2. BApply a warm compress to the site to improve flow
  3. CStop the infusion and remove the catheter
  4. DFlush the catheter with 3 mL of normal saline
Show answer

Answer: C

Cool, pale, swollen tissue with a tight feeling means the fluid is leaking into the surrounding tissue (infiltration), so the first action is to stop the infusion and take the catheter out before more fluid collects. The arm can then be elevated and a new site started on the other arm or above the old site.

Why the others are wrong

Slowing the rate keeps pushing fluid into tissue that is already swollen. A warm compress does nothing while the catheter is still delivering fluid outside the vein, and flushing an infiltrated line forces more fluid into the tissue.

2

The nurse assesses a peripheral IV site that is red, warm to touch and tender along the path of the vein, with a palpable cord. The client has a low grade temperature of 100.2 F. The nurse should recognize these findings as which complication?

  1. AInfiltration
  2. BPhlebitis
  3. CExtravasation
  4. DAir embolism
Show answer

Answer: B

Redness, warmth, tenderness along the vein and a firm cord-like vein are the classic signs of phlebitis, which is inflammation of the vein wall. The IV should be removed, a warm compress applied, and the site documented using a phlebitis scale.

Why the others are wrong

Infiltration produces a cool, pale, swollen site rather than a red warm one. Extravasation involves a vesicant leaking into tissue and causes pain, blistering and tissue damage, not a cord along the vein. Air embolism is a systemic problem with sudden dyspnea and chest pain, not a local site finding.

3

A client receiving IV doxorubicin through a peripheral line reports sudden burning pain at the site. The nurse sees swelling and blanching around the catheter. Which action should the nurse take first?

  1. AStop the infusion and leave the catheter in place to aspirate the drug
  2. BRemove the catheter immediately and apply pressure to the site
  3. CFlush the line with 10 mL of normal saline to dilute the drug
  4. DElevate the arm and call the oncologist
Show answer

Answer: A

Doxorubicin is a vesicant, so this is extravasation. The nurse stops the infusion right away but keeps the catheter in so any remaining drug can be aspirated from the tubing and tissue, then the antidote (if there is one) can be given through the same catheter per protocol. The provider is notified after the infusion is stopped.

Why the others are wrong

Pulling the catheter out first removes the only route for aspirating the drug and giving the antidote. Flushing pushes more vesicant into the tissue. Elevating and calling are reasonable later steps, but they are not the first action while the drug is still infusing.

4

While changing the IV tubing on a client's central venous catheter, the nurse hears a sucking sound and the client suddenly becomes short of breath with chest pain and a drop in blood pressure. The nurse suspects an air embolism. In which position should the nurse place the client?

  1. AHigh Fowler's position
  2. BSupine with legs elevated
  3. CLeft side-lying with the head of the bed lowered (Trendelenburg)
  4. DRight side-lying with the head of the bed raised
Show answer

Answer: C

Clamping the catheter is done at the same time, but the position question asks for left lateral Trendelenburg. Lying on the left side with the head down traps air in the right atrium and apex of the right ventricle, keeping it away from the pulmonary artery while oxygen is started and the provider is called.

Why the others are wrong

High Fowler's lets air travel toward the pulmonary circulation. Supine with legs up does not trap the air in the right heart. Right side-lying with the head raised is the opposite of what is needed and lets air move into the pulmonary outflow tract.

5

The nurse is preparing to change the dressing on a client's internal jugular central line. Which action by the nurse is correct?

  1. AWear clean gloves and a mask, and clean the site with chlorhexidine using a back and forth scrub
  2. BWear sterile gloves only and clean the site with alcohol in a circular motion from the outside inward
  3. CRemove the old dressing with sterile gloves and apply the new dressing with clean gloves
  4. DSkip the mask because the client is awake and able to turn the head away
Show answer

Answer: A

A central line dressing change is a sterile procedure. The nurse and client wear masks, the old dressing comes off with clean gloves, then sterile gloves go on and the site is scrubbed with chlorhexidine using friction (a back and forth motion) and allowed to dry fully before the new transparent dressing is applied.

Why the others are wrong

Alcohol cleaned from outside to inside is backward and not the preferred antiseptic for central lines. Sterile gloves are needed for the new dressing, not clean gloves. A mask is required regardless of whether the client can turn the head, since the nurse is the main source of droplets over the site.

6

A client has been receiving total parenteral nutrition (TPN) at 100 mL/hr through a central line for three days. The new bag has not arrived from the pharmacy and the current bag is nearly empty. Which action should the nurse take?

  1. AStop the infusion and wait for the new TPN bag
  2. BHang 10 percent dextrose in water at the same rate until the TPN arrives
  3. CRun 0.9 percent sodium chloride at 100 mL/hr through the TPN line
  4. DSlow the remaining TPN to 20 mL/hr to make it last
Show answer

Answer: B

TPN is high in dextrose and the client's pancreas is producing matching insulin, so a sudden stop can cause rebound hypoglycemia. If the next bag is delayed, the nurse hangs D10W at the same rate until it arrives, and checks a fingerstick glucose per protocol (usually every 4 to 6 hours while on TPN).

Why the others are wrong

Stopping TPN abruptly risks hypoglycemia. Normal saline has no dextrose and will not prevent the glucose drop. Slowing the rate to stretch the bag under-delivers calories and still lets the bag run dry, and TPN that has been hanging longer than 24 hours should not be used.

7

The nurse is caring for a client receiving TPN through a triple-lumen central catheter. The client has an IV antibiotic due and the nurse notes the other two lumens are in use. Which action should the nurse take?

  1. APiggyback the antibiotic into the TPN line using the Y-port closest to the client
  2. BHold the TPN for 30 minutes, give the antibiotic through that lumen, then restart
  3. CContact the provider to discuss a peripheral IV or an alternative lumen for the antibiotic
  4. DMix the antibiotic into the TPN bag so both infuse together
Show answer

Answer: C

TPN runs through a dedicated lumen or line and nothing else is piggybacked, pushed or mixed into it, because of the infection risk and the chance of precipitation or incompatibility. When no lumen is free, the nurse asks the provider about another access option rather than interrupting the TPN.

Why the others are wrong

Piggybacking into the TPN line breaks the dedicated-line rule. Holding TPN even for 30 minutes risks a glucose drop and still uses the TPN lumen for a drug. Adding anything to the TPN bag after pharmacy preparation is never done.

8

The nurse is about to hang a unit of packed red blood cells. Which step is most important before spiking the unit?

  1. APrime the tubing with dextrose 5 percent in water
  2. BVerify the client's identity and the blood product with a second licensed nurse at the bedside
  3. CWarm the unit in the medication room microwave for 30 seconds
  4. DObtain a set of vital signs after the first 100 mL has infused
Show answer

Answer: B

Two licensed nurses check the client's identification band, the blood bank number, blood type and Rh, expiration date and the order at the bedside before the unit is started. This step prevents the most dangerous error, giving the wrong blood to the wrong client. After starting, the nurse runs it slowly (about 2 mL/min) for the first 15 minutes and stays with the client.

Why the others are wrong

Blood is primed and run only with 0.9 percent sodium chloride, since dextrose causes red cells to clump and hemolyze. Blood is never warmed in a microwave; only an approved blood warmer is used when ordered. Vital signs are taken before starting and again at 15 minutes, not after an arbitrary volume.

9

Ten minutes into a transfusion of packed red blood cells, a client reports chills, low back pain and feeling anxious. Temperature has risen from 98.4 F to 100.8 F. Which action should the nurse take first?

  1. ASlow the transfusion and notify the provider
  2. BStop the transfusion and keep the IV open with normal saline using new tubing
  3. CAdminister the ordered PRN acetaminophen and continue monitoring
  4. DDraw a blood sample and send it with the blood bag to the lab
Show answer

Answer: B

Chills, back pain, anxiety and a temperature rise within the first 15 minutes point to a transfusion reaction. The nurse stops the blood immediately, disconnects the blood tubing and keeps the vein open with 0.9 percent sodium chloride through a new administration set so no more blood from the old tubing reaches the client. The provider and blood bank are notified next.

Why the others are wrong

Slowing the rate still delivers more of the reacting blood. Giving acetaminophen and continuing ignores a possible hemolytic reaction. Sending blood and urine samples is part of the follow-up, but it comes after the transfusion is stopped and the line is secured.

10

A client with a history of heart failure is receiving a unit of packed red blood cells. Which statement by the client's family member shows they understand what to watch for during the transfusion?

  1. A"If she gets short of breath or starts coughing, I will press the call light right away."
  2. B"She will probably feel very thirsty, so I will give her extra water during the blood."
  3. C"A little swelling in her feet is normal while the blood goes in."
  4. D"If she gets a headache I should give her the aspirin she takes at home."
Show answer

Answer: A

A client with heart failure is at high risk for circulatory overload during a transfusion. Dyspnea, cough, crackles, jugular vein distention, hypertension and a bounding pulse are the signs, and the family member calling the nurse right away allows the rate to be slowed or the transfusion stopped and the client sat upright.

Why the others are wrong

Extra oral fluid adds volume to a client already at risk for overload. New edema during a transfusion is a warning sign, not an expected finding. Aspirin should not be given by family during a transfusion and a headache may be an early sign of a reaction that needs the nurse.

Quick tips

  • Infiltration is cool, pale and swollen. Phlebitis is red, warm and cord-like. Both start with "stop and remove the IV," but phlebitis gets a warm compress and a phlebitis scale score, and infiltration gets elevation of the limb.
  • For a vesicant extravasation, stop the pump but do not pull the catheter until any aspiration and antidote are done. Pulling first is a common wrong answer.
  • Air embolism: clamp the line, left side, head down, oxygen, call the provider. Picture the air bubble getting trapped in the right heart.
  • TPN never stops suddenly. If the bag is late, hang D10W at the same rate. Check glucose every 4 to 6 hours and keep the TPN lumen dedicated.
  • Blood: two-nurse bedside check, normal saline only, start at about 2 mL/min, stay with the client for the first 15 minutes, and finish the unit within 4 hours of leaving the blood bank. Any reaction means stop the blood first, then saline through new tubing.
  • Fluid choice: isotonic (0.9 percent NaCl, lactated Ringer's) for volume loss such as blood loss or dehydration, hypotonic (0.45 percent NaCl) to rehydrate cells but never for increased intracranial pressure, hypertonic (3 percent NaCl, D10W) for severe hyponatremia or as a calorie source, given through a central line or with close monitoring.
  • Tubing timing: continuous primary tubing every 96 hours (per facility, often with the site change), intermittent tubing every 24 hours, blood tubing after every 1 to 2 units or 4 hours, TPN and lipid tubing every 24 hours.

Related topics

FAQ

What is the first thing you do if a blood transfusion reaction starts?

Stop the blood. Then keep the IV open with normal saline through a new tubing set, stay with the client, check vital signs and notify the provider and blood bank. On the NCLEX, any option that keeps the blood running, even slowly, is wrong.

How do I tell infiltration from phlebitis on the NCLEX?

Look at temperature and color. Infiltration is cool, pale and puffy because fluid is sitting in the tissue. Phlebitis is warm, red and tender along the vein, sometimes with a cord you can feel. If the drug is a vesicant like a chemo agent or vasopressor, the question is really about extravasation.

Why can't you stop TPN suddenly?

TPN delivers a steady load of dextrose, so the client's insulin level rises to match it. Cutting that off without a dextrose replacement causes rebound hypoglycemia. Hang D10W at the same rate until the new bag arrives and check a fingerstick glucose.

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