2.

NCLEX Style Questions for IV Bolus Med Administration 2014 KEY

1. Which of the following statements made by the nurse best reflects the correct
understanding of the role of unlicensed ancillary staff in the care of a patient prescribed
an intravenous (IV) bolus analgesic medication?

1. Assess the IV site frequently for signs of inflammation.
Incorrect: assessment cannot be delegated to unlicensed ancillary staff
2. Let me know immediately if the patient complains of insertion site pain.
Correct: this may be delegated to unlicensed ancillary staff
3. Ensure that the patient knows what results to expect from the medication.
Incorrect: patient education cannot be delegated to unlicensed ancillary
staff
4. Observe the IV site for sudden swelling after she receives the IV bolus.
Incorrect: assessment cannot be delegated to unlicensed ancillary staff

2. When administering medication by IV bolus to an existing intravenous infusion, the
greatest patient safety issue is that the:
1. Medication being added is mutually compatible with the existing IV
solution.
Correct: the patient is at risk for injury if the medications are incompatible
and a precipitate is formed within the solution
2. Patient does not develop a phlebitis at the insertion site.
Incorrect: although an appropriate concern, this would be a concern no
matter which route the medication is administered
3. Medication is being administered to the correct patient.
Incorrect: although an appropriate concern, this would be a concern no
matter which route the medication is administered
4. Correct medication is being administered.
Incorrect: although an appropriate concern, this would be a concern no
matter which route the medication is administered


3. The patient has been prescribed an IV bolus of a narcotic analgesic medication.
When administrating the medication, the nurse will best minimize the patients risk for
injury by:
1. Injecting the medication at the prescribed rate.
Correct: an injection rate that is to fast may result in injury or death
2. Observing the insertion site for signs of swelling.
Incorrect: although an appropriate action, #1 is a greater priority regarding
the prevention of patient injury related specifically to IV bolus
administration of meds
3. Identifying any history of allergic reactions to the prescribed analgesic.
Incorrect: although an appropriate action, #1 is a greater priority regarding
the prevention of patient injury related specifically to IV bolus
administration of meds
4. Using an alcohol swab to wipe the insertion port on the primary tubing.
Incorrect: although an appropriate action, #1 is a greater priority regarding
the prevention of patient injury related specifically to IV bolus
administration of meds

4. The nurse is preparing to administer an IV bolus of an analgesic. To best minimize
the patients risk for injury, the nurse should:
1. Use the injection port closest to the patient.
Incorrect: although appropriate, #3 is more relevant
2. Assess the IV insertion site for signs of infiltration.
Incorrect: although appropriate, #3 is more relevant regarding IV Bolus
administration of meds
3. Follow aseptic technique during the entire process.
Correct: this will help minimize the patients risk for injury related to
infection
4. Instruct the patient to report any adverse medication reactions.
Incorrect: although appropriate, #3 is more relevant regarding IV Bolus
administration of meds

5. When preparing to administer an IV bolus medication, the nurse does not get blood
return when aspirating the heparin lock. The nurses next action should be to:
1. Reattempt to aspirate the site.
Incorrect: there is little chance that a second attempt will be successful
2. Prepare to access another IV site.
Incorrect: discontinuation is not always appropriate
3. Assess the heparin lock site for signs of infiltration or phlebitis.
Incorrect: option #4 is the higher priority
4. Assess the patency of the line by flushing it with normal saline.
Correct: Patency may be present without blood return