The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

every 5 hours

once per shift

hourly

once a day

Answer and Explanation

The Correct Answer is C

C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.

A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.

B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.

D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.

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Correct Answer is B

Explanation

B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.

A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.

C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.

D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.

A. Administer the medication using a filter needle. B. Break the ampule by bending the top to the side. C. Flick the bottom of the ampule several times. D. Withdraw medication from the center of the ampule. E. None F. None

Correct Answer is D

Explanation

A. A filter needle is used when withdrawing medication from an ampule, but it is not used to administer the injection. After withdrawal, the filter needle should be replaced with a regular IM needle for administration.
B. The ampule should be broken by snapping the neck away from the body, not by bending it to the side, to prevent injury.
C. The nurse should gently tap the top of the ampule, not the bottom, to move the solution downward before opening.
D. The correct technique is to insert the needle into the center of the ampule to withdraw medication, ensuring that the bevel remains below the fluid line to avoid drawing up air.

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The IV site of a patient receiving a continuous IV infusion should be monitored by the nurse:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to:

Correct Answer is B

Explanation

A nurse is preparing to administer an IM injection to a client using a medication from an ampule. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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