LPN IV Therapy and Fluid Management 1 — Questions and Answers

Question 1: A client's IV site is red, warm, painful, and has a palpable cord along the vein. The LPN should document this as:

Infiltration
Phlebitis (Correct answer)
Thrombosis
Cellulitis

Correct answer: Phlebitis

Redness, warmth, pain, and a palpable cord along a vein are classic signs of phlebitis — inflammation of the vein wall, a common IV complication.

Phlebitis is inflammation of the tunica intima (inner vessel wall) and occurs from mechanical irritation (cannula movement), chemical irritation (irritant medications), or bacterial contamination. Signs: pain, erythema, warmth, and swelling along the vein trajectory; a palpable cord indicates thrombus formation (thrombophlebitis). VIP (Visual Infusion Phlebitis) scale grades severity 0–5. Management: discontinue the IV catheter, rotate to a new site in the opposite arm, apply warm compress, elevate the limb, and document. The catheter tip and site are not reused. Report grade 3+ phlebitis to the charge nurse. Prevention: proper site selection, catheter stabilization, appropriate dressing.

Question 2: A client receiving IV vancomycin develops flushing, erythema, and pruritus on the face and neck during the infusion. The LPN recognizes this as:

An anaphylactic allergic reaction requiring epinephrine
Red Man Syndrome — an infusion-rate reaction requiring slowing the infusion (Correct answer)
Vancomycin toxicity requiring the dose to be held
A normal expected side effect requiring no intervention

Correct answer: Red Man Syndrome — an infusion-rate reaction requiring slowing the infusion

Red Man Syndrome is a non-immune, infusion-rate-dependent reaction to vancomycin causing histamine release. It is treated by slowing the infusion, not stopping it, and may be prevented with diphenhydramine.

Red Man Syndrome (RMS) is an infusion-related reaction caused by non-immune-mediated histamine release when vancomycin is infused too rapidly (faster than 10 mg/min or less than 60 minutes per gram). Presentation: sudden flushing, erythema, and pruritus of the face, neck, chest, and upper extremities; may include hypotension and muscle spasm. Management: (1) Slow the infusion rate (infuse over a minimum of 60 minutes per gram); (2) Administer diphenhydramine (Benadryl) if symptoms occur; (3) Resume at a slower rate after symptoms resolve; (4) Premedicate with diphenhydramine for subsequent doses. It is NOT a true allergy or anaphylaxis; anaphylaxis involves urticaria, bronchospasm, and hypotension requiring epinephrine.

Question 3: The LPN is calculating an IV flow rate. An order reads: Infuse 1,000 mL 0.9% NaCl over 8 hours. The drip factor is 20 gtts/mL. What is the correct flow rate in gtts/min?

20 gtts/min
42 gtts/min (Correct answer)
30 gtts/min
50 gtts/min

Correct answer: 42 gtts/min

Formula: Volume (mL) ÷ Time (min) × Drip factor = 1000 ÷ 480 × 20 = 41.7 ≈ 42 gtts/min.

IV flow rate calculation: Flow rate (gtts/min) = [Volume to infuse (mL) ÷ Time in minutes] × Drop factor (gtts/mL). Step by step: (1) Convert 8 hours to minutes: 8 × 60 = 480 minutes; (2) Divide volume by time: 1,000 ÷ 480 = 2.08 mL/min; (3) Multiply by drip factor: 2.08 × 20 = 41.7 gtts/min, rounded to 42 gtts/min. The LPN must verify the IV flow rate against pump settings and gravity drip counts. Macro-drip sets typically deliver 10, 15, or 20 gtts/mL; micro-drip sets deliver 60 gtts/mL. When using an IV pump, the rate would be set to 125 mL/hr (1,000 ÷ 8).

Question 4: A client is receiving a blood transfusion. After 15 minutes, the client develops a temperature of 38.7°C (101.7°F), chills, and back pain. The LPN's first action is:

Slow the transfusion rate and monitor closely
Administer acetaminophen and continue the transfusion
Stop the transfusion immediately, keep the IV line open with normal saline, and notify the charge nurse (Correct answer)
Increase the transfusion rate to complete the unit quickly before the reaction worsens

Correct answer: Stop the transfusion immediately, keep the IV line open with normal saline, and notify the charge nurse

Fever, chills, and back pain during a transfusion suggest an acute hemolytic reaction (ABO incompatibility). The transfusion must be stopped immediately, the line kept open with NS, and the charge nurse notified.

Acute hemolytic transfusion reaction (AHTR) is caused by ABO incompatibility — antibodies in the recipient's plasma react against transfused RBCs, causing intravascular hemolysis. Signs: fever, chills, back/flank pain (hemoglobin deposits in kidneys), hypotension, tachycardia, hematuria, DIC. It can be fatal. Immediate actions: (1) STOP the transfusion; (2) Keep the IV line open with normal saline (new tubing — do not use blood tubing); (3) Notify charge nurse and provider; (4) Return the blood bag and tubing to the blood bank; (5) Send samples to the lab (type and crossmatch, CBC, urinalysis, coagulation studies); (6) Monitor vital signs every 5 minutes; (7) Monitor urine output for hemoglobinuria.

Question 5: A client has a peripheral IV infusing. The nurse notices the infusion site is cool, pale, puffy, and non-painful. The LPN documents this as:

Phlebitis grade 2
Infiltration (Correct answer)
Extravasation of a vesicant
Local infection

Correct answer: Infiltration

Coolness, pallor, swelling, and absence of pain at an IV site indicate infiltration — IV fluid leaking into the subcutaneous tissue from a displaced or perforated catheter.

Infiltration occurs when a non-vesicant IV solution infuses into the subcutaneous tissue rather than the vein, typically from catheter dislodgement. Signs: swelling, blanching, coolness, firmness, and pain or no pain at the site. Extravasation is similar but involves a vesicant (tissue-damaging) medication and causes more severe damage (necrosis). Management of infiltration: (1) Stop the infusion; (2) Remove the catheter; (3) Elevate the extremity; (4) Apply warm or cold compress per facility policy; (5) Document using an infiltration scale (0–4); (6) Restart IV at a new site. If vesicant extravasation is suspected, follow facility protocol (may include antidote injection) and notify the charge nurse immediately.

Question 6: A client is prescribed D5W (5% dextrose in water) 500 mL IV. The LPN understands this solution is classified as:

Isotonic in the bag, but becomes hypotonic once infused as the dextrose is metabolized (Correct answer)
Hypertonic, pulling fluid from tissues into the vascular space
Isotonic that distributes evenly throughout the body without shifting fluid
Hypertonic in the bag but isotonic once dextrose is metabolized

Correct answer: Isotonic in the bag, but becomes hypotonic once infused as the dextrose is metabolized

D5W is technically isotonic in the bag (308 mOsm/L), but once dextrose is metabolized by cells, it effectively becomes free water (hypotonic), distributing into all body compartments.

D5W has an osmolality of approximately 252–308 mOsm/L (near isotonic), so it does not cause significant immediate fluid shifts when infused. However, dextrose is rapidly metabolized by cells within minutes of entering the bloodstream, leaving behind free water. This free water distributes into all body fluid compartments (approximately 66% intracellular, 33% extracellular), behaving like a hypotonic solution. Implications: D5W is not appropriate for fluid resuscitation (ineffective at expanding intravascular volume) or for hyponatremic clients (worsens hyponatremia). D5W is used for medication dilution, free water replacement, and preventing hypoglycemia during NPO periods.

Question 7: The LPN is flushing a client's intermittent IV access device (saline lock) before medication administration. The appropriate flushing technique is:

Flush with heparin 100 units/mL before and after medication
Flush with 3–5 mL normal saline, administer medication, then flush with 3–5 mL normal saline (SASH if heparin ordered) (Correct answer)
Use sterile water to flush the saline lock before medication
Flush with 10 mL D5W before each medication to prevent precipitate

Correct answer: Flush with 3–5 mL normal saline, administer medication, then flush with 3–5 mL normal saline (SASH if heparin ordered)

The SASH technique (Saline-Administer medication-Saline-Heparin) or SAL (without heparin) ensures catheter patency and prevents drug incompatibilities. Normal saline is the standard flush solution.

The standard intermittent flush protocol for peripheral IV catheters: (1) Assess site for patency (no resistance, no swelling); (2) Flush with 3–5 mL normal saline (0.9% NaCl) before medication to confirm patency and clear the catheter; (3) Administer medication as ordered; (4) Flush with 3–5 mL normal saline after medication to clear residual drug and prevent drug interactions; (5) Some facility protocols add heparin flush (10–100 units/mL) for central lines or PICC lines (SASH protocol). Heparin is generally NOT used for peripheral IV saline locks in current practice. Sterile water and D5W are incorrect flush solutions.

Question 8: A client with heart failure is receiving IV fluids ordered at 250 mL/hr. Two hours into the infusion, the client develops worsening dyspnea and oxygen saturation drops from 98% to 91%. The LPN should:

Continue the infusion as ordered and reassess in 1 hour
Slow the IV infusion, sit the client upright, apply oxygen, and immediately notify the charge nurse (Correct answer)
Increase the IV rate to improve cardiac output
Remove the IV line and call the provider for new orders

Correct answer: Slow the IV infusion, sit the client upright, apply oxygen, and immediately notify the charge nurse

Worsening dyspnea and oxygen desaturation during IV fluid therapy in a heart failure client indicate fluid volume overload and developing pulmonary edema — a medical emergency requiring immediate intervention.

Clients with heart failure have reduced cardiac reserve; rapid IV fluid administration can quickly overwhelm the compensatory mechanisms, causing fluid to back up into the pulmonary circulation (pulmonary edema). Signs of fluid overload: worsening dyspnea, crackles, declining SpO2, S3 gallop, increased work of breathing, orthopnea. Immediate interventions: (1) Slow or stop the IV infusion; (2) Place in high Fowler's position; (3) Apply supplemental oxygen; (4) Notify charge nurse and provider immediately; (5) Obtain vital signs; (6) Prepare for IV diuretics. Never increase the rate. The LPN should document the assessment, interventions, and client response.

Question 9: A client requires a central venous catheter (CVC) insertion. Which position and preparation reduces air embolism risk during insertion?

Elevate the head of bed 45 degrees and have the client perform the Valsalva maneuver
Place in Trendelenburg position (head lower than feet) and have the client hold breath during insertion (Correct answer)
Place the client flat and have them breathe deeply during needle insertion
Sit the client at 90 degrees and turn the head toward the insertion site

Correct answer: Place in Trendelenburg position (head lower than feet) and have the client hold breath during insertion

Trendelenburg position increases central venous pressure, distending the vein for easier access and reducing the risk of air entering the catheter during insertion by raising venous pressure above atmospheric.

Air embolism during CVC insertion occurs when negative intrathoracic pressure during inspiration creates a pressure gradient that draws air into the open catheter. Prevention: (1) Trendelenburg position (10–25 degrees head-down) elevates central venous pressure above atmospheric, preventing air entry; (2) Valsalva maneuver during catheter attachment/disconnection raises intrathoracic pressure; (3) Catheter hubs should always be capped; (4) Avoid deep inspiration during needle insertion. Post-insertion chest X-ray confirms placement before infusion. Signs of air embolism: sudden chest pain, dyspnea, hypotension, mill-wheel murmur — place in left lateral Trendelenburg to trap air in right ventricle.

Question 10: A client is receiving potassium chloride (KCl) 40 mEq IV. The LPN knows that this infusion must:

Be given as an IV bolus for rapid correction of severe hypokalemia
Never exceed a rate of 10–20 mEq/hour for peripheral IV infusion (Correct answer)
Be mixed in D5W to prevent vein irritation
Be administered undiluted through a central line

Correct answer: Never exceed a rate of 10–20 mEq/hour for peripheral IV infusion

IV potassium must never be given as a bolus (can cause fatal cardiac arrest) and peripheral infusion must not exceed 10 mEq/hr to prevent venous irritation and cardiac toxicity.

Potassium chloride is a high-alert medication. Key safety rules: (1) NEVER give IV potassium undiluted or as a rapid bolus — can cause fatal ventricular fibrillation or cardiac standstill; (2) Maximum peripheral IV rate: 10 mEq/hr (maximum 20 mEq/hr through a central line with continuous cardiac monitoring); (3) Maximum concentration: 40 mEq/100 mL for peripheral; up to 60–80 mEq/100 mL for central; (4) Must be diluted in normal saline (NOT glucose/D5W, which may worsen hypokalemia by driving K+ into cells via insulin release); (5) Monitor ECG, serum potassium, urine output, and IV site (potassium is irritating to veins). Never mix KCl in standing bags — always check pre-mixed.

Question 11: A client receiving a continuous IV heparin infusion develops petechiae, nosebleed, and oozing from the venipuncture site. The LPN should:

Apply direct pressure to bleeding sites and continue monitoring
Immediately stop the heparin infusion and notify the charge nurse (Correct answer)
Administer vitamin K as the reversal agent for heparin
Document the findings and notify the provider at morning rounds

Correct answer: Immediately stop the heparin infusion and notify the charge nurse

Signs of bleeding complications from heparin therapy require immediate discontinuation of the infusion and urgent notification, not continuation while applying pressure.

Heparin anticoagulation can cause bleeding at any site. Spontaneous bleeding (petechiae, ecchymosis, nosebleed, gum bleeding, oozing from puncture sites, hematuria, GI bleeding, intracranial hemorrhage) requires immediate assessment of aPTT and urgent intervention. The LPN must: (1) Stop the heparin infusion; (2) Apply pressure to accessible bleeding sites; (3) Notify the charge nurse and provider immediately; (4) Prepare to administer protamine sulfate (the antidote for heparin — 1 mg per 100 units heparin received in last 2–3 hours); (5) Monitor vital signs; (6) Draw STAT aPTT, PT, CBC. Vitamin K reverses warfarin, not heparin.

Question 12: A client has a PICC (peripherally inserted central catheter) line. The nurse notes the catheter appears to have pulled out approximately 2 cm since insertion. The LPN should:

Advance the catheter back to the original position using sterile technique
Irrigate the line and continue using it, as displacement is expected with movement
Do not use the line — notify the charge nurse and anticipate repositioning confirmation (Correct answer)
Remove the PICC line and replace it immediately at the bedside

Correct answer: Do not use the line — notify the charge nurse and anticipate repositioning confirmation

A PICC line that has migrated must not be used for infusion until catheter position is confirmed by X-ray. Never advance a catheter that has partially withdrawn — it is now contaminated.

PICC line displacement can occur from arm movement, coughing, or tension on the tubing. The catheter tip must be positioned at the cavoatrial junction or distal SVC for safe use. A withdrawn PICC: (1) Cannot be readvanced (the external portion is contaminated and sterility is broken); (2) Must not be used for infusion until tip position is confirmed by X-ray; (3) External measurement (exposed length) should be documented daily to detect migration; (4) The charge nurse and vascular access team or provider must be notified; (5) An X-ray is ordered to confirm tip position; (6) If mispositioned, the line may need to be replaced. Administering medications through a mispositioned central line risks extravasation into chest cavity or cardiac irritation.

Question 13: A client receiving IV amiodarone through a peripheral IV develops severe pain and a burning sensation at the infusion site. The skin around the site is blistering. The LPN should immediately:

Slow the infusion rate and apply a warm compress
Stop the infusion and notify the charge nurse — amiodarone is a vesicant causing extravasation injury (Correct answer)
Flush the IV with 20 mL saline to dilute the medication
Elevate the arm and continue monitoring

Correct answer: Stop the infusion and notify the charge nurse — amiodarone is a vesicant causing extravasation injury

Amiodarone is a vesicant — it causes tissue necrosis when extravasated. Blistering indicates tissue damage. Stop the infusion immediately and escalate to the charge nurse for vesicant extravasation protocol.

Amiodarone is classified as a vesicant medication that causes tissue necrosis, sloughing, and potential permanent damage if extravasated into subcutaneous tissue. Ideally, amiodarone should be infused through a central line for infusions lasting >1 hour. Signs of extravasation: pain, burning, blistering, blanching, swelling, and skin breakdown. Immediate actions: (1) STOP the infusion; (2) Do NOT remove the catheter — attempt to aspirate any remaining drug; (3) Apply specific antidote if available per protocol; (4) Mark the extravasation area; (5) Notify charge nurse and provider immediately; (6) Photograph and document extensively; (7) Consult wound care or plastic surgery. Further flushing can spread the vesicant.

Question 14: A client with a serum sodium of 120 mEq/L (normal 135–145 mEq/L) is receiving hypertonic saline (3% NaCl). Which complication is most important to monitor for?

Hypokalemia from sodium-potassium exchange
Osmotic demyelination syndrome from correcting sodium too rapidly (Correct answer)
Pulmonary edema from excessive fluid administration
Metabolic acidosis from chloride excess

Correct answer: Osmotic demyelination syndrome from correcting sodium too rapidly

Rapidly correcting severe hyponatremia with hypertonic saline can cause osmotic demyelination syndrome (central pontine myelinolysis), causing permanent neurological damage or death.

Osmotic demyelination syndrome (ODS), also known as central pontine myelinolysis, occurs when severe chronic hyponatremia is corrected too rapidly. Rapid osmotic shifts cause demyelination of brainstem and other neurons. Clinical presentation (appearing 2–6 days after rapid correction): progressive dysarthria, dysphagia, seizures, altered mental status, paraplegia/quadriplegia, 'locked-in' syndrome. Prevention: correct sodium at no more than 6–12 mEq/L per 24 hours (goal 8 mEq/L/day for most; 10–12 mEq/L for severe symptomatic). Monitor sodium levels every 2–4 hours during hypertonic saline infusion. The LPN should report any rate of rise exceeding safe limits to the charge nurse immediately.

Question 15: A nurse is preparing to administer an IV infusion to a child weighing 22 kg. The order reads 0.9% NaCl at maintenance rate. Using the Holliday-Segar method, the maintenance fluid rate is:

44 mL/hr
62 mL/hr (Correct answer)
82 mL/hr
22 mL/hr

Correct answer: 62 mL/hr

Holliday-Segar: 100 mL/kg for first 10 kg (=1000) + 50 mL/kg for next 10 kg (=500) + 20 mL/kg for remaining 2 kg (=40). Total = 1540 mL/24hr ÷ 24 = 64.2 ≈ 62–65 mL/hr.

Holliday-Segar method for pediatric maintenance fluids (hourly rate): 4 mL/kg/hr for first 10 kg + 2 mL/kg/hr for next 10 kg + 1 mL/kg/hr for weight beyond 20 kg. For 22 kg: (4 × 10) + (2 × 10) + (1 × 2) = 40 + 20 + 2 = 62 mL/hr. Alternative using 24-hour formula: 100 mL/kg for first 10 kg (1,000 mL) + 50 mL/kg for next 10 kg (500 mL) + 20 mL/kg for remaining 2 kg (40 mL) = 1,540 mL/24 hr ÷ 24 = 64.2 mL/hr (≈ 62–65 mL/hr depending on rounding). This is a fundamental calculation the LPN must know for pediatric and adult IV therapy management.

Question 16: A client with a peripherally inserted IV catheter has not been infusing for 4 hours. Before resuming the infusion, the LPN should:

Resume the infusion at the ordered rate without assessment
Assess the site, flush with normal saline to verify patency, and check for blood return in peripheral IV before restarting (Correct answer)
Apply pressure over the site for 2 minutes to clear any clot
Remove and replace the catheter before any assessment

Correct answer: Assess the site, flush with normal saline to verify patency, and check for blood return in peripheral IV before restarting

Before resuming any IV infusion, the LPN must assess the site and flush to verify patency. Blood return confirms catheter is in the vein, not in subcutaneous tissue.

Before restarting an IV infusion after any interruption: (1) Inspect the IV site for redness, swelling, warmth, or leaking (phlebitis or infiltration); (2) Flush with 3–5 mL normal saline using a 10 mL syringe (smaller syringes create higher pressure, risking vessel damage); if resistance is felt, do not force — remove and replace catheter; (3) For PIVs: blood return confirms intravascular placement (though absence of flashback doesn't always confirm extravasation); (4) For central lines: always confirm blood return before infusing; (5) Palpate the surrounding tissue for firmness or bogginess indicating extravasation. Document site assessment before and after IV restart.

Question 17: A client is admitted with dehydration. Assessment findings include dry mucous membranes, poor skin turgor, urine output of 20 mL/hr, and serum sodium of 148 mEq/L. The LPN anticipates which IV fluid will be ordered?

Normal saline (0.9% NaCl) — isotonic saline to expand vascular volume
Lactated Ringer's solution to correct acidosis
0.45% NaCl (half-normal saline) — hypotonic fluid to replace free water deficit (Correct answer)
3% NaCl to correct hypernatremia

Correct answer: 0.45% NaCl (half-normal saline) — hypotonic fluid to replace free water deficit

A serum sodium of 148 mEq/L indicates hypernatremia from free water deficit. Hypotonic solution (0.45% NaCl) is used to replace free water and gradually correct hypernatremia.

Hypernatremia (Na+ >145 mEq/L) indicates a water deficit relative to sodium. In dehydration with hypernatremia, the free water deficit is calculated and replaced with hypotonic fluids (0.45% NaCl or D5W for more severe cases) or via the enteral route. Key: correct hypernatremia slowly (no more than 10–12 mEq/L per 24 hours) to avoid cerebral edema — rapid correction can cause brain cells to swell as water rapidly moves back in. Signs of cerebral edema: increasing confusion, seizures, headache, and increased ICP. Isotonic saline (0.9% NaCl) expands volume but does not correct hypernatremia. 3% NaCl is used for severe symptomatic hyponatremia.

Question 18: During a blood transfusion, the client develops urticaria (hives) on the trunk and arms but no respiratory symptoms or hemodynamic changes. The LPN should:

Stop the transfusion permanently and start normal saline
Slow or temporarily stop the transfusion, administer diphenhydramine per order, and resume after symptoms resolve (Correct answer)
Continue the transfusion and administer oral antihistamines
Report to the blood bank immediately for a full hemolytic workup

Correct answer: Slow or temporarily stop the transfusion, administer diphenhydramine per order, and resume after symptoms resolve

Urticaria during a transfusion indicates a mild allergic reaction. The standard management is to slow or temporarily stop the transfusion, administer an antihistamine, and resume at a slower rate after symptoms resolve.

Mild allergic transfusion reactions (urticaria only) are the most common transfusion reaction type, occurring in 1–3% of transfusions, caused by IgE-mediated reaction to plasma proteins. Management: (1) Slow or temporarily stop the transfusion; (2) Administer diphenhydramine IV or IM per protocol; (3) Continue monitoring vital signs; (4) Resume the transfusion at a slower rate after symptoms resolve (mild allergic reactions can be completed unlike hemolytic reactions); (5) Document the reaction. If any systemic symptoms develop (dyspnea, hypotension, stridor, bronchospasm), stop the transfusion permanently and treat as anaphylaxis. Premedication with antihistamines is used for clients with a history of mild transfusion reactions.

Question 19: A client receiving normal saline develops a temperature of 40°C (104°F), severe shaking chills, hypotension, and tachycardia within minutes of starting the IV infusion. The LPN suspects:

Phlebitis from the IV catheter
Febrile nonhemolytic reaction
Septic reaction from a contaminated IV solution (Correct answer)
Speed shock from too-rapid infusion

Correct answer: Septic reaction from a contaminated IV solution

High fever, rigors, and septic shock signs immediately after starting an IV (even with saline) indicate a septic reaction from a contaminated solution — a life-threatening emergency.

Septic transfusion or IV reactions occur when IV solutions, blood products, or IV lines are contaminated with gram-negative bacteria (releasing endotoxins). Presentation: abrupt high fever (often >40°C), rigors, hypotension, tachycardia, and rapid progression to septic shock. It is immediately life-threatening. Actions: (1) STOP the infusion immediately; (2) Do not discard the IV bag — send it to the lab for culture; (3) Notify charge nurse and provider emergently; (4) Obtain blood cultures from a separate site; (5) Establish new IV access; (6) Support blood pressure (IV fluids, vasopressors); (7) Administer antibiotics per order. Febrile nonhemolytic reactions are milder; speed shock causes cardiovascular collapse from volume or drug overload.

Question 20: The LPN is changing a central line dressing. Which technique is most important to prevent catheter-related bloodstream infection (CRBSI)?

Use sterile gloves and maximum barrier precautions with chlorhexidine skin antisepsis (Correct answer)
Change the dressing weekly using clean technique and tape
Flush the line with heparin before dressing change to prevent clotting
Apply petroleum jelly gauze over the insertion site for moisture retention

Correct answer: Use sterile gloves and maximum barrier precautions with chlorhexidine skin antisepsis

CRBSI prevention requires maximum sterile barrier precautions (sterile gloves, mask, cap, gown, large sterile drape) and chlorhexidine-based skin antisepsis — the gold standard per CDC guidelines.

Catheter-related bloodstream infections (CRBSI) are associated with significant morbidity, mortality, and cost. Central Line Bundle (CDC/IHI) for CRBSI prevention: (1) Hand hygiene; (2) Maximal sterile barrier precautions during insertion and dressing changes (sterile gloves, mask, cap, sterile gown, large sterile drape); (3) Chlorhexidine gluconate (>0.5% in alcohol) for skin antisepsis — allow to dry completely; (4) Optimal catheter site selection (subclavian preferred, femoral avoided); (5) Daily assessment of line necessity — remove when no longer needed; (6) Transparent semipermeable dressing changed every 5–7 days or immediately if soiled/loose. These five elements together reduce CRBSI by >65%.

Question 21: A client on TPN (total parenteral nutrition) via a central line has blood glucose of 380 mg/dL. The LPN should:

Stop the TPN infusion immediately to lower blood glucose
Reduce the TPN rate by half and notify the charge nurse
Notify the charge nurse and anticipate an order for insulin per sliding scale (Correct answer)
Document the finding and continue the infusion at the current rate

Correct answer: Notify the charge nurse and anticipate an order for insulin per sliding scale

Hyperglycemia is a common complication of TPN due to high dextrose concentration. The LPN should notify the charge nurse and anticipate orders for insulin supplementation, not alter the TPN rate independently.

TPN contains concentrated dextrose (15–25%), which commonly causes hyperglycemia — a significant complication associated with increased infection risk, delayed wound healing, and osmotic diuresis. Target blood glucose during TPN: 140–180 mg/dL (per ASPEN guidelines). At 380 mg/dL, insulin supplementation is needed. The LPN should: (1) Notify the charge nurse and provider; (2) Do not independently adjust or stop the TPN (changing TPN rates must be ordered — abrupt discontinuation causes rebound hypoglycemia); (3) Anticipate a sliding scale or regular insulin added to the TPN bag; (4) Monitor blood glucose every 4–6 hours; (5) Monitor electrolytes (phosphate, potassium, magnesium for refeeding syndrome). Only the provider can order TPN modifications.

Question 22: A client's IV infusion pump alarms with 'occlusion distal.' The LPN should:

Increase pump pressure to override the obstruction and maintain flow rate
Silence the alarm and continue the infusion manually
Assess the IV line for kinks, check the IV site, and verify clamp is open before troubleshooting (Correct answer)
Remove the entire IV setup and restart from the beginning

Correct answer: Assess the IV line for kinks, check the IV site, and verify clamp is open before troubleshooting

A distal occlusion alarm indicates blockage between the pump and the patient. Systematically assess the tubing for kinks, clamps, and the IV site for infiltration or positional occlusion before escalating.

Infusion pump occlusion alarms indicate resistance to flow. 'Distal occlusion' means the blockage is between the pump and the patient; 'proximal occlusion' means blockage between the fluid bag and the pump. Systematic troubleshooting for distal occlusion: (1) Check tubing for kinks, twisting, or compression; (2) Ensure all clamps are open; (3) Assess the IV site for infiltration (swelling, coolness), positional occlusion (arm position affecting flow), or thrombus; (4) Lower the arm to check for gravity flow; (5) Attempt to aspirate for blood return (central lines); (6) Flush gently if no resistance. If the problem persists and cannot be resolved, notify the charge nurse and restart the IV. Never force fluid against resistance.

Question 23: A client is receiving IV morphine 2 mg every 4 hours via a PCA pump. The nurse notes the client's respiratory rate is 8 breaths/minute and the client is difficult to arouse. The LPN's priority action is:

Decrease the PCA dose setting and monitor for improvement
Stop all IV medications and call a code
Stop the morphine PCA infusion, apply supplemental oxygen, notify the charge nurse, and prepare to administer naloxone (Correct answer)
Stimulate the client and recheck the respiratory rate in 30 minutes

Correct answer: Stop the morphine PCA infusion, apply supplemental oxygen, notify the charge nurse, and prepare to administer naloxone

A respiratory rate of 8/min with decreased arousal in a client on opioids indicates respiratory depression — a medical emergency requiring opioid cessation, oxygenation, and naloxone administration.

Opioid-induced respiratory depression is a life-threatening emergency. Clinical criteria: respiratory rate <10/min, SpO2 <90%, sedation score ≥3 (difficult to arouse). Immediate interventions: (1) Stop the PCA/opioid infusion; (2) Apply supplemental oxygen (nasal cannula or non-rebreather mask); (3) Stimulate the client (sternal rub); (4) Notify the charge nurse and provider immediately; (5) Administer naloxone (Narcan) 0.4–2 mg IV, IM, or intranasal — titrate to restore adequate respirations, not to full reversal (precipitates acute withdrawal and severe pain); (6) Monitor continuously; (7) Keep the IV/pump off until provider reassesses dosing. Respiratory depression from PCA is a never event in most facilities.

Question 24: A client has been on IV antibiotics for 72 hours. The current peripheral IV site (right forearm) has been in place for 96 hours with no signs of complications. The LPN should:

Continue using the current site as long as it remains functional
Change the IV site according to facility policy (typically every 72–96 hours) or if any complications are present (Correct answer)
Immediately report the situation as a medication error
Add heparin to the IV fluid to maintain patency

Correct answer: Change the IV site according to facility policy (typically every 72–96 hours) or if any complications are present

The CDC recommends changing peripheral IV catheters every 72–96 hours to minimize phlebitis and infection risk, or immediately if complications arise, per facility policy.

Current CDC guidelines recommend replacing peripheral IV catheters every 72–96 hours to reduce the risk of phlebitis, infection, and catheter failure. However, recent evidence and clinical practice increasingly support changing peripheral IVs only when clinically indicated (signs of phlebitis, infiltration, or malfunction) rather than on a routine schedule, particularly for difficult venous access patients. The LPN should follow facility-specific policy, which may specify 72–96 hours or 'as indicated.' At 96 hours, the CDC threshold is met, and rotation is appropriate. Document the new site location, insertion date, gauge, and assessment findings. Using an established catheter site reduces overall venipuncture attempts.

Question 25: A client develops a catheter-associated urinary tract infection (CAUTI) while hospitalized with a Foley catheter. The LPN understands that the MOST effective prevention of CAUTI involves:

Routine catheter changes every 7 days to prevent biofilm formation
Daily meatal cleansing with povidone-iodine solution
Daily assessment of catheter necessity and prompt removal when no longer needed (Correct answer)
Prophylactic antibiotics for all catheterized clients

Correct answer: Daily assessment of catheter necessity and prompt removal when no longer needed

The single most effective intervention to prevent CAUTI is daily assessment of the need for the catheter and prompt removal as soon as it is no longer clinically indicated.

CAUTIs are the most common hospital-acquired infection and are associated with increased morbidity, length of stay, and cost. The core prevention strategy is the CAUTI bundle: (1) Avoid unnecessary catheter insertion; (2) Insert using aseptic technique; (3) Maintain a closed drainage system; (4) Maintain unobstructed urine flow (bag below bladder, no kinking); (5) DAILY assessment of catheter necessity and removal as soon as possible. Every day with a catheter increases CAUTI risk by 3–7%. Routine catheter exchanges do not reduce CAUTI. Antiseptic meatal care has not been shown to reduce CAUTI. Prophylactic antibiotics are not recommended (promotes resistance).

Question 26: A client receiving IV fluid therapy has an intake of 2,800 mL and urine output of 800 mL over the past 8 hours. The LPN should:

Increase IV fluid rate to match the high output
Notify the charge nurse of positive fluid balance of 2,000 mL and assess for signs of fluid overload (Correct answer)
Document as normal — 2,800 mL intake is within expected range for an 8-hour shift
Restrict oral fluids only and continue IV therapy as ordered

Correct answer: Notify the charge nurse of positive fluid balance of 2,000 mL and assess for signs of fluid overload

A 2,000 mL positive fluid balance in 8 hours is significant. With adequate urine output of only 800 mL, fluid retention is likely occurring, requiring assessment for fluid overload and provider notification.

Fluid balance monitoring is a key nursing responsibility. Normal urine output is 0.5–1 mL/kg/hr (approximately 30–60 mL/hr for average adult = 240–480 mL per 8 hours). Output of 800 mL in 8 hours is within acceptable range. However, a 2,000 mL positive balance over 8 hours indicates significant fluid retention. The LPN should: assess for signs of fluid overload (crackles, edema, dyspnea, weight gain), notify the charge nurse and provider, document the complete intake/output record, and anticipate possible IV fluid rate adjustment or diuretic order. Fluid balance should be calculated every shift (or more frequently in critical clients) and reported to the oncoming nurse.

Question 27: A client's peripheral IV has been infusing normal saline for the past 8 hours. The nurse notices the IV has been infusing at 250 mL/hr instead of the ordered 125 mL/hr. The LPN's first action is:

Recount the drops and slow the rate to 125 mL/hr without reporting the error
Complete an incident report only and continue monitoring
Assess the client for signs of fluid overload, notify the charge nurse, and document per facility protocol (Correct answer)
Increase oral restrictions to compensate for the excess fluid given

Correct answer: Assess the client for signs of fluid overload, notify the charge nurse, and document per facility protocol

A medication/fluid administration error requires immediate client assessment for harm, notification of the charge nurse and provider, and incident report documentation — not concealment.

When a medication or IV fluid administration error is discovered: (1) FIRST assess the client for any harm (signs of fluid overload: crackles, dyspnea, edema, SpO2 change, blood pressure change); (2) Correct the rate immediately to the ordered rate; (3) Notify the charge nurse and provider immediately with full details; (4) Document the error in the medical record (what happened, client response, interventions); (5) Complete an incident/variance report per facility policy (separate from the medical record); (6) Do NOT alter or omit documentation to hide the error. Incident reports improve system safety and are not punitive for honest errors. Correcting the rate without reporting is a professional and ethical violation.

Question 28: A client with chronic renal failure is prescribed normal saline at 75 mL/hr. Two hours into the infusion, the client develops worsening shortness of breath and peripheral edema has increased from trace to 2+. The LPN should:

Continue the infusion — these symptoms are expected in renal failure
Slow the infusion rate by half and document the findings
Stop the infusion, assess vital signs and respiratory status, and notify the charge nurse immediately (Correct answer)
Reposition the client and increase the infusion rate to improve renal perfusion

Correct answer: Stop the infusion, assess vital signs and respiratory status, and notify the charge nurse immediately

Clients with chronic renal failure have impaired fluid excretion. Worsening dyspnea and edema during IV saline infusion indicate acute fluid overload requiring immediate assessment and intervention.

Clients with chronic kidney disease (CKD) have severely impaired ability to excrete excess fluid and sodium. Even 'routine' IV fluid rates can cause acute fluid overload. Worsening edema and dyspnea indicate accumulation of fluid in interstitial spaces and lungs. The LPN must: (1) Stop or slow the infusion immediately pending provider assessment; (2) Assess respiratory rate, SpO2, lung sounds (crackles), heart rate, blood pressure; (3) Elevate the head of bed; (4) Apply supplemental oxygen; (5) Notify the charge nurse and provider for orders; (6) Anticipate orders for IV furosemide, fluid restriction, and possible dialysis. These clients require meticulous fluid balance monitoring throughout hospitalization.

Question 29: A client has a prescription for 1 L NS with 20 mEq KCl to infuse over 4 hours. The client's most recent potassium level is 3.0 mEq/L. Which assessment is most critical before starting the infusion?

Check the client's last serum sodium level
Verify urine output is at least 30 mL/hr before initiating potassium-containing IV fluids (Correct answer)
Confirm the client has been NPO for the past 8 hours
Assess blood pressure and cardiac history

Correct answer: Verify urine output is at least 30 mL/hr before initiating potassium-containing IV fluids

Potassium must never be administered if the client has inadequate urine output — hyperkalemia and fatal cardiac dysrhythmias can result if potassium cannot be excreted.

IV potassium safety rule: Potassium must NEVER be given if urine output is less than 30 mL/hr (or 0.5 mL/kg/hr). The kidneys are the primary route of potassium excretion; if urine output is absent or inadequate, administered potassium will accumulate in the blood, causing hyperkalemia and potentially fatal cardiac arrhythmias (peaked T-waves, wide QRS, ventricular fibrillation, cardiac arrest). Before initiating any potassium-containing infusion: verify urine output, confirm the IV is patent and site is intact, calculate the administration rate (should not exceed 10 mEq/hr peripherally), ensure cardiac monitoring for high doses, and have the client on continuous monitoring. Urine output is the single most critical pre-infusion check.

Question 30: When preparing to change a client's central line dressing, the LPN opens the sterile field and reaches across it to retrieve a piece of gauze. A colleague asks if the setup is still sterile. The LPN should:

Confirm the field is sterile — reaching across doesn't contaminate it if gloves are sterile
Discard the setup and prepare a new sterile field — reaching across breaks sterility (Correct answer)
Continue the dressing change since gloves were sterile when reaching across
Wipe the gauze with an alcohol swab to re-sterile it

Correct answer: Discard the setup and prepare a new sterile field — reaching across breaks sterility

Sterile technique requires that nothing reaches over or across the sterile field. The arm passing over the field risks dropping contaminated particles onto sterile supplies, breaking sterility.

Sterile technique principles include: (1) Only sterile objects touch sterile objects; (2) Never reach over or across the sterile field — the area below the level of the sterile drape is not considered sterile; (3) Sterile fields are considered contaminated if they are out of sight, face downward, become wet, or are reached over; (4) If contamination is uncertain — it IS contaminated (when in doubt, throw it out); (5) Sterile gloves do not protect the field when the arm passes over it (non-sterile clothing sleeve, particulate from the arm); (6) Discard the contaminated setup, prepare a new sterile field, and begin again. There is no method to re-sterilize supplies at the bedside. CRBSI prevention relies absolutely on maintaining sterility.

Question 31: A client is to receive packed red blood cells (PRBCs) for a hemoglobin of 6.5 g/dL. Before beginning the transfusion, the LPN's PRIORITY safety check is:

Confirming the client has eaten within the past 2 hours
Two-nurse verification of blood product label (client name, blood type, expiration) against the client's armband (Correct answer)
Flushing the IV with D5W to verify IV patency
Confirming written consent only — no other checks are needed

Correct answer: Two-nurse verification of blood product label (client name, blood type, expiration) against the client's armband

Blood administration requires two-nurse verification of the blood product against the client's identification to prevent ABO incompatibility from wrong-patient/wrong-blood errors, the most common fatal transfusion error.

Blood product administration requires a mandatory two-nurse verification process at the bedside: (1) Client name and date of birth verified against the blood bank label; (2) Blood type and Rh compatibility; (3) Unit number matches blood bank label; (4) Expiration date; (5) Appearance of the product (abnormal color, clots, or cloudiness — discard and return to blood bank); (6) Client consent confirmed; (7) Baseline vital signs obtained. PRBCs must be infused using normal saline ONLY (D5W, lactated Ringer's, and other solutions cause hemolysis). The transfusion must begin within 30 minutes of leaving the blood bank and complete within 4 hours of issue. Wrong blood/patient events are a National Patient Safety Goal (NPSG).

Question 32: A client is receiving TPN and the TPN bag is empty. A new bag is not available for 30 minutes. The LPN should:

Stop all IV infusions until the new TPN bag arrives
Infuse D10W at the same rate as the TPN to prevent rebound hypoglycemia until the new bag arrives (Correct answer)
Increase oral intake to compensate for the delay
Flush the central line with heparin and clamp it until the new bag arrives

Correct answer: Infuse D10W at the same rate as the TPN to prevent rebound hypoglycemia until the new bag arrives

Abruptly stopping TPN without a dextrose infusion can cause rebound hypoglycemia (the pancreas continues producing insulin from the previous high dextrose load). D10W maintains glucose until the new bag is prepared.

TPN contains concentrated dextrose (15–25%), which stimulates insulin secretion. Abrupt discontinuation causes rebound hypoglycemia as insulin continues acting without substrate. If TPN must be stopped temporarily: infuse D10W at the same rate as the TPN until the new bag is ready. This maintains glucose delivery and prevents hypoglycemia. Blood glucose monitoring should be performed every 30–60 minutes during the transition. Tapering TPN over several hours is recommended when permanently discontinuing. If rebound hypoglycemia is suspected: check blood glucose, administer D50 IV or oral glucose if applicable. The LPN should notify the charge nurse and pharmacy immediately about the supply delay.

Question 33: A client receiving intravenous vancomycin develops a trough level of 22 mcg/mL (target 10–20 mcg/mL). The LPN should:

Administer the next scheduled dose as ordered — this is within normal range
Notify the charge nurse and hold the next dose pending provider review (Correct answer)
Double the interval between doses without notifying the provider
Increase the rate of IV hydration to reduce the vancomycin level

Correct answer: Notify the charge nurse and hold the next dose pending provider review

A vancomycin trough of 22 mcg/mL exceeds the target range (10–20 mcg/mL), increasing risk of nephrotoxicity and ototoxicity. The charge nurse and provider must be notified and the next dose held pending review.

Vancomycin is monitored via trough levels (obtained 30 minutes before the next dose). Target trough for most infections: 10–20 mcg/mL; for serious infections (bacteremia, endocarditis, meningitis): 15–20 mcg/mL. AUC-guided monitoring is increasingly used as the preferred method. Supratherapeutic levels increase risk of: nephrotoxicity (elevated creatinine, decreased urine output) and ototoxicity (high-frequency hearing loss, tinnitus, vestibular disturbance). At 22 mcg/mL, the LPN must: notify the charge nurse and provider; hold the next dose pending provider review and possible dose reduction, extension of dosing interval, or AUC calculation; continue monitoring renal function; document findings. The provider makes all dose adjustment decisions.

Question 34: A client receiving a blood transfusion begins experiencing a severe headache, flank pain, hemoglobinuria (dark tea-colored urine), and a sense of impending doom. The LPN recognizes this presentation as:

Febrile non-hemolytic transfusion reaction
Acute hemolytic transfusion reaction from ABO incompatibility (Correct answer)
Allergic transfusion reaction requiring antihistamines
Transfusion-associated circulatory overload (TACO)

Correct answer: Acute hemolytic transfusion reaction from ABO incompatibility

Severe headache, flank pain, dark urine (hemoglobinuria from RBC destruction), and a sense of impending doom are classic signs of acute hemolytic transfusion reaction from ABO incompatibility — a potentially fatal emergency.

Acute hemolytic transfusion reaction (AHTR) from ABO incompatibility is the most dangerous immediate transfusion reaction. The clinical presentation includes: fever, chills, severe headache, back/flank pain (renal involvement), hypotension, tachycardia, hemoglobinuria (dark urine from intravascular hemolysis), jaundice, and a characteristic sense of 'impending doom.' Fatality occurs from disseminated intravascular coagulation (DIC), acute renal failure, and cardiovascular collapse. STOP the transfusion immediately, maintain IV access with normal saline, notify the charge nurse and provider emergently, send the blood unit and patient samples to the blood bank, monitor for DIC and renal failure. Even 30 mL of incompatible blood can be fatal.

Question 35: A nurse is inserting a peripheral IV in a client's right antecubital fossa. The first attempt fails and blood returns initially but then stops when advancing the catheter. The appropriate next action is to:

Advance the needle further into the vein and re-thread the catheter
Withdraw the catheter slightly and re-thread while injecting saline
Remove the entire device, apply pressure, and attempt a new site (Correct answer)
Rotate the needle 180 degrees and continue advancing

Correct answer: Remove the entire device, apply pressure, and attempt a new site

Once a catheter fails — including when blood returns then stops — the entire device must be removed, pressure applied, and a new attempt made at a different site. Re-advancing a partially inserted needle risks vein injury.

Peripheral IV insertion technique principles: (1) Initial blood flashback confirms the bevel is in the vein; (2) Loss of blood return during catheter advancement indicates the catheter has passed through the posterior wall or the vein has collapsed; (3) The entire IV catheter and needle must be removed as a unit — do NOT withdraw the needle while the catheter is partially inserted (needle can shear the catheter); (4) Apply pressure to the failed site; (5) Attempt a new site — generally moving proximal if using the same vein or switching to the opposite arm; (6) After 2 failed attempts, consider calling a more experienced inserter or vascular access team. Antecubital veins should be used as a last resort (limit arm mobility, high infiltration risk with movement).

Question 36: A client receiving IV therapy develops chills, rigors, and high fever 30 minutes after a new IV line and bag were started. The nurse suspects a contaminated IV line. Which action should the LPN take FIRST?

Slow the infusion rate and apply a warm blanket
Stop the infusion, disconnect the IV line, and save the line and bag for culture analysis (Correct answer)
Switch to a new IV bag while keeping the same tubing
Administer acetaminophen and monitor for improvement

Correct answer: Stop the infusion, disconnect the IV line, and save the line and bag for culture analysis

A contaminated IV line can rapidly cause sepsis. The LPN must stop the infusion immediately, disconnect the line, and preserve both the IV tubing and bag for laboratory culture — critical evidence for diagnosis.

IV-related sepsis from contaminated infusate or tubing is a life-threatening emergency. Key actions: (1) Stop the infusion immediately; (2) Disconnect and save the entire IV administration set and the IV bag for laboratory culture — do not discard; (3) Remove the IV catheter and culture the tip if directed; (4) Notify the charge nurse and provider stat; (5) Obtain peripheral blood cultures before antibiotics; (6) Establish new IV access at a different site with entirely new supplies; (7) Support blood pressure with IV fluids through the new access; (8) Initiate broad-spectrum antibiotics per order. The preserved equipment is essential for identifying the contaminating organism and its source. All steps are time-critical as gram-negative endotoxin release can cause rapid hemodynamic collapse.

LPN IV Therapy and Fluid Management 1

A client's IV site is red, warm, painful, and has a palpable cord along the vein.
The LPN should document this as:

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