Choice A reason: A drop factor of 10 gtts/mL is typical for macrodrip tubing, used for rapid fluid administration in adults. It delivers larger drops, requiring fewer drops per milliliter, unsuitable for microdrop tubing, which is designed for precise, smaller-volume infusions, such as in pediatrics or critical care settings.
Choice B reason: A drop factor of 15 gtts/mL is also associated with macrodrip tubing, used for standard IV infusions in adults. It delivers larger drops than microdrop tubing, making it inappropriate for situations requiring precise control of small fluid volumes, such as in neonatal or critical care scenarios.
Choice C reason: Microdrop tubing has a drop factor of 60 gtts/mL, delivering smaller drops for precise fluid administration. This is critical in pediatrics or when administering small volumes of medication, ensuring accurate dosing and minimizing fluid overload risks in sensitive populations.
Choice D reason: A drop factor of 20 gtts/mL is used in some macrodrip sets, not microdrop tubing. It is designed for general adult infusions, delivering larger drops than microdrop tubing, which is unsuitable for precise, low-volume fluid administration required in specialized settings like pediatrics.

Choice A reason: Marking the time strip on the IV bag helps track infusion duration but is not the priority before administration. Ensuring bag integrity prevents contamination or leakage, which could introduce pathogens or cause fluid loss, compromising patient safety and treatment efficacy.
Choice B reason: Checking the IV bag’s integrity ensures it is free from leaks, cracks, or contamination. A compromised bag can introduce bacteria or air into the bloodstream, leading to infections or embolisms. This step is critical for patient safety before initiating infusion.
Choice C reason: Selecting a vented administration set depends on the fluid type and container. While important, it is secondary to ensuring the bag’s integrity, as a damaged bag could lead to contamination or improper fluid delivery, posing immediate risks to the patient.
Choice D reason: Calculating tonicity is unnecessary, as IV fluids are pre-formulated with known tonicity (e.g., isotonic, hypotonic). The nurse’s priority is ensuring the bag is intact to prevent contamination or fluid loss, which directly impacts patient safety and treatment effectiveness.

Choice A reason: Replacing the IV catheter may be necessary if the site is compromised, but stopping the infusion first prevents further fluid extravasation, which can cause tissue damage or compartment syndrome due to fluid accumulation in the surrounding tissues.
Choice B reason: Adding tape does not address the leakage, which may indicate infiltration or dislodgement. Continuing the infusion risks extravasation, leading to tissue damage or infection. Stopping the infusion is the priority to prevent further complications.
Choice C reason: Stopping the infusion prevents further fluid leakage into tissues, which can cause infiltration, tissue necrosis, or compartment syndrome. This immediate action minimizes harm, allowing the nurse to assess the site and determine if the catheter is dislodged or infiltrated.
Choice D reason: Elevating the limb may reduce swelling in infiltration but does not address active leakage. Stopping the infusion is critical to prevent further fluid extravasation, which could lead to tissue damage or infection if not addressed promptly.

Choice A reason: Positioning the needle bevel up during IV insertion aligns the sharp edge upward, facilitating smooth vein entry and reducing vessel trauma. This orientation ensures better visualization of the needle tip and minimizes the risk of piercing the vein’s back wall.
Choice B reason: Bevel down or up is not a standard practice, as it lacks specificity. Bevel up is preferred to ensure controlled entry and minimize vein damage. Inconsistent bevel positioning can increase the risk of failed cannulation or hematoma formation.
Choice C reason: Bevel center is not a recognized term in IV insertion. The bevel must be up to optimize vein entry and reduce trauma. Incorrect positioning can lead to vessel perforation or difficulty advancing the catheter, compromising the procedure.
Choice D reason: Bevel down increases the risk of piercing the vein’s back wall, causing hematoma or failed cannulation. Bevel up is the standard to ensure smooth entry, reduce tissue trauma, and facilitate catheter advancement into the vein.

Choice A reason: Placing the catheter in the left hand may be unsafe if the mastectomy was on the left side, as lymph node removal can cause lymphedema, increasing infection or swelling risks. Physician guidance ensures site safety.
Choice B reason: The right foot is an alternative site but not ideal for adults due to higher infection risks and mobility issues. Post-mastectomy, the physician must confirm the safest site to avoid complications like lymphedema or poor venous access.
Choice C reason: The right hand may be contraindicated if the mastectomy was on the right side, as lymph node dissection increases lymphedema risk. Physician consultation is necessary to determine the appropriate site based on surgical history.
Choice D reason: Consulting the physician ensures the IV site avoids the mastectomy side, where lymph node removal increases lymphedema and infection risks. This step confirms safe venous access, preventing complications in patients with altered lymphatic drainage.

Choice A reason: Hanging IV fluids for 72 hours increases bacterial contamination risk, as fluids provide a medium for microbial growth. Most protocols recommend changing bags every 24 hours to maintain sterility and prevent bloodstream infections.
Choice B reason: A 48-hour duration exceeds standard guidelines for IV fluid bags, risking microbial growth and contamination. Changing bags every 24 hours minimizes infection risk, ensuring patient safety during intravenous therapy.
Choice C reason: A 36-hour duration still poses a contamination risk, as IV fluids can harbor bacteria over time. Standard practice requires changing bags every 24 hours to prevent catheter-related bloodstream infections and ensure sterile delivery.
Choice D reason: IV fluids should hang no longer than 24 hours to minimize bacterial growth and contamination risks. This standard ensures sterility, reduces catheter-related infections, and maintains safe fluid administration for patient safety.

Choice A reason: An 18-gauge catheter (green hub) is larger, used for rapid infusions or blood transfusions. A pink hub indicates a 20-gauge catheter, suitable for standard IV therapy, balancing flow rate and vein preservation.
Choice B reason: A pink hub corresponds to a 20-gauge catheter, ideal for most adult IV therapies. It provides adequate flow for fluids and medications while minimizing vein trauma, suitable for stable patients requiring routine infusions.
Choice C reason: A 22-gauge catheter (blue hub) is smaller than a pink 20-gauge. It is used for smaller veins or pediatrics but may restrict flow for certain therapies, making it less suitable for general adult use.
Choice D reason: A 24-gauge catheter (yellow hub) is smaller, used for neonates or fragile veins. A pink 20-gauge catheter offers better flow for adult IV therapy, reducing the risk of occlusion while preserving vein integrity.

Choice A reason: Transparent dressings are designed to secure IV catheters, not cause dislodgement. They adhere firmly, reducing movement and maintaining catheter stability, which prevents complications like infiltration or accidental removal during therapy.
Choice B reason: Permeability to air does not prevent air embolus, which occurs from air entering the bloodstream via the catheter. Transparent dressings are semi-occlusive, allowing some air exchange but primarily preventing moisture and bacterial entry.
Choice C reason: Not all transparent dressings are hypoallergenic; some patients may have adhesive sensitivities. While many are designed to minimize reactions, their primary function is to protect the site and allow visualization, not guarantee hypoallergenicity.
Choice D reason: Transparent dressings are impermeable to moisture, preventing bacterial entry and infection while allowing visualization of the IV site. This enables nurses to monitor for signs of infiltration, infection, or dislodgement without removing the dressing.

Choice A reason: Vein distension under the needle may indicate improper placement or infiltration, not successful cannulation. Advancing the catheter without blood return risks extravasation, causing tissue damage or therapy failure.
Choice B reason: Lack of discomfort is not a reliable indicator of proper catheter placement. Patients may not feel pain despite incorrect positioning. Blood return confirms venous access, ensuring safe advancement of the catheter.
Choice C reason: Easy catheter advancement may occur but does not confirm venous placement. Without blood return, the catheter may be in tissue, risking infiltration. Blood return is the definitive sign for safe advancement.
Choice D reason: Blood return in the backflash chamber indicates the catheter is in the vein, confirming successful cannulation. This allows safe advancement, ensuring proper IV therapy delivery without risking extravasation or tissue damage.

Choice A reason: Scrubbing the spike with alcohol may not fully sterilize it after contact with a non-sterile surface. Contaminated tubing risks introducing bacteria into the bloodstream, leading to catheter-related infections or sepsis.
Choice B reason: Replacing the IV bag is unnecessary, as the bag was not contaminated. The spike, which contacts the bag’s sterile port, is the compromised component, requiring new tubing to ensure sterility.
Choice C reason: New IV tubing ensures sterility after the spike contacts a non-sterile surface. Contaminated tubing could introduce pathogens into the IV system, causing bloodstream infections. Replacing it maintains the sterile field for safe infusion.
Choice D reason: Wiping with Betadine may not adequately sterilize the spike after contamination. Betadine requires contact time and may leave residue. New tubing is the safest option to prevent infection during IV administration.