IV therapy questions reward pattern recognition, plus two can't-miss emergencies: air embolism and TPN sugar swings. Work through these 10 practice questions on peripheral IV complications, PICC and port care, the CLABSI bundle, air embolism, and TPN, each with a full rationale.
IV Therapy & Central Lines: Complications, CLABSI & TPN
IV therapy questions reward pattern recognition. For a peripheral IV, learn the two classic site complications: infiltration presents as a cool, swollen, pale site with no blood return, and the response is to stop the infusion, remove the catheter, and elevate the extremity; phlebitis presents as a red, warm, tender palpable cord, and the response is to stop, remove, and apply a warm compress. Also know speed shock (a systemic reaction to a medication pushed too fast), catheter embolism, and extravasation of a vesicant (a drug that causes tissue damage when it leaks). Any therapy that is hyperosmolar, irritating, vesicant, long-term, or ordered when peripheral access is poor belongs in a central line whose tip sits in the superior vena cava (SVC).
Know the central venous access devices and their rules. A PICC tip must be confirmed in the SVC by chest x-ray (or an approved tip-locating technology) before first use. An implanted port is accessed only with a non-coring Huber needle. Non-tunneled (subclavian/IJ), tunneled, and port devices all demand strict sterile technique. Prevent CLABSI with the central-line bundle: hand hygiene, maximal sterile barrier at insertion, chlorhexidine skin prep, avoiding the femoral site, and daily review of whether the line is still needed. Maintain patency with saline flushes and heparin lock per policy (SAS/SASH sequence).
Two can't-miss emergencies: air embolism and TPN swings. Air embolism causes sudden dyspnea, chest pain, hypotension, tachycardia, and anxiety, especially during tubing changes, disconnection, insertion, or removal. Act immediately: clamp the line, place the client in left lateral Trendelenburg (Durant maneuver) to trap air in the right atrium, give 100% oxygen, and call for help. TPN is a hyperosmolar, high-dextrose solution given through a central line; monitor blood glucose closely, never stop it abruptly (taper to prevent rebound hypoglycemia), and hang D10W if the next bag is delayed.
Blood products have their own rules for tubing, filters, and compatible fluids, covered in our blood transfusion reactions guide.
IV Therapy & Central Lines NCLEX Practice Questions
Question 1 · Peripheral IV — infiltration
A nurse assesses a client's peripheral IV site and finds it cool to the touch, swollen, and pale, with no blood return on aspiration. Which action should the nurse take first?
- A Apply a warm compress and continue the infusion at the ordered rate
- B Slow the infusion rate and continue to monitor the site hourly
- C Stop the infusion, remove the catheter, and elevate the extremity
- D Increase the infusion rate to flush the suspected obstruction
Show answer & rationale
Correct answer: C
A cool, swollen, pale site with no blood return is the classic picture of infiltration, meaning the IV fluid is leaking into the surrounding tissue instead of the vein. The correct response is to stop the infusion, remove the catheter, and elevate the extremity to promote reabsorption of the fluid and reduce swelling; a new site is then established as needed. Applying a warm compress while continuing the infusion is wrong because you never continue an infusion into already-infiltrated tissue; that is the real problem with this option. A warm compress itself is actually appropriate for a non-vesicant infiltration (with elevation) to promote reabsorption, and vesicant extravasations follow drug-specific warm or cold protocols. Slowing the rate and monitoring still leaves fluid entering the tissue and delays needed removal, worsening edema and the risk of compartment problems. Increasing the rate to 'flush the obstruction' forces more fluid into the tissue and is potentially dangerous. Clinical pearl: distinguish infiltration from phlebitis quickly. Infiltration is cool, swollen, pale, and blanched with no blood return; phlebitis is red, warm, and tender along a palpable venous cord. Both require stopping and removing the catheter; a non-vesicant infiltration is managed with elevation and a warm or cold compress per the infusate and facility protocol (warm promotes reabsorption; cold limits acute swelling), and phlebitis is managed with a warm compress. Current standards direct prompt discontinuation of any peripheral IV with signs of complication and documentation using a standardized infiltration scale.
Question 2 · Peripheral IV — speed shock
During a rapid IV push of a medication, a client suddenly reports dizziness and chest tightness and develops facial flushing and an irregular pulse. Which complication does the nurse suspect?
- A Speed shock from too-rapid administration
- B Infiltration of the peripheral IV catheter
- C Phlebitis of the vein at the insertion site
- D Embolism from a sheared catheter fragment
Show answer & rationale
Correct answer: A
Speed shock is a systemic reaction that occurs when a medication enters the circulation too rapidly, producing a sudden, body-wide response: flushing, dizziness, headache, chest tightness, hypotension, dysrhythmias, and possible cardiac arrest. The temporal link to a rapid IV push plus systemic symptoms makes this the best answer; the nurse should stop the medication immediately, keep the line open with a slow infusion of a compatible fluid, and summon help. Infiltration is a local problem: the site would be cool, swollen, and pale with no blood return, not a burst of systemic symptoms during a push. Phlebitis is also local, producing redness, warmth, and a tender palpable cord over hours to days, not immediate flushing and an irregular pulse mid-push. A catheter fragment embolism can occur if a piece of catheter breaks off and travels centrally, but it is not the expected result of pushing a drug too fast, and it typically presents with sudden cardiopulmonary distress related to the embolus rather than the medication rate itself. Clinical pearl: prevent speed shock by knowing the safe push rate for every IV medication and using a watch or pump; 'when in doubt, push it slow.' Rate rules matter most for high-alert drugs: potassium is never given by IV push (it is diluted and infused by pump), opioids are pushed slowly over the recommended time, and adenosine is the deliberate exception given as a rapid push.
Question 3 · Central access — PICC
A newly inserted peripherally inserted central catheter (PICC) is in place for a client who needs long-term antibiotics. Before the first infusion, which nursing action is the priority?
- A Aspirate for blood return, then flush the line with heparin
- B Begin the infusion at a slow rate and monitor the client closely
- C Measure and document the external catheter length as a baseline
- D Verify tip placement in the superior vena cava by chest x-ray
Show answer & rationale
Correct answer: D
A PICC is a central venous catheter whose tip must sit in the superior vena cava (SVC). Before the very first infusion, tip placement must be confirmed by chest x-ray (or an approved tip-locating technology), because infusing hyperosmolar or vesicant solutions through a malpositioned tip can cause serious injury. Verifying SVC placement is therefore the priority. Aspirating for blood return and flushing with heparin is part of routine patency checks and is done, but it does not confirm that the tip is in the correct central location; a catheter can give blood return while still being malpositioned. Beginning the infusion, even slowly, before radiographic confirmation risks delivering central-only solutions into the wrong location and skips the required verification step. Measuring the external catheter length is a valuable ongoing assessment that helps detect migration at subsequent shifts, but it is not the safeguard that clears the line for first use. Clinical pearl: 'x-ray before you infuse' for any new central line. The same rule applies to non-tunneled subclavian and internal jugular catheters, where the post-insertion chest x-ray also rules out pneumothorax. Once placement is confirmed, document tip position, external length, and site appearance as your baseline for future comparisons.
Question 4 · Central access — implanted port
A nurse prepares to access a client's implanted subcutaneous port to administer chemotherapy. Which device must the nurse use to access the port?
- A A standard over-the-needle peripheral IV catheter
- B A non-coring Huber needle
- C A winged (butterfly) steel needle
- D A blunt-tip filter needle
Show answer & rationale
Correct answer: B
An implanted port has a self-sealing silicone septum beneath the skin, and it must be accessed only with a non-coring Huber needle. The Huber needle has a deflected, angled tip that slips through the septum without coring out a plug of silicone, preserving the septum's ability to reseal over many hundreds of accesses. Using a standard over-the-needle peripheral IV catheter is wrong because that beveled needle would core the septum, damaging the port and causing leaks; it is also designed for veins, not a subcutaneous reservoir. A winged (butterfly) steel needle likewise has a cutting bevel that would damage the septum and is meant for peripheral venipuncture. A blunt-tip filter needle is used to draw medication from glass ampules to prevent glass-particle aspiration; it has no role in accessing a port and could not penetrate the septum. Clinical pearl: remember 'ports get Huber.' Access with sterile technique, prep with chlorhexidine, stabilize the port between two fingers, insert the Huber needle perpendicular through the septum until it touches the back plate, then confirm blood return and flush. Ports are flushed with heparin per policy after use and are ideal for intermittent long-term therapy such as chemotherapy because they are fully implanted, lowering infection risk between accesses.
Question 5 · Air embolism — emergency positioning
While changing the IV tubing on a client's central venous catheter, the nurse notes the client suddenly becomes dyspneic and reports chest pain; the blood pressure drops and the heart rate rises. After clamping the catheter and applying 100% oxygen, in which position should the nurse place the client?
- A High Fowler's position
- B Right side-lying with the head of the bed elevated
- C Left lateral (side-lying) in Trendelenburg
- D Supine with both legs elevated
Show answer & rationale
Correct answer: C
The scenario, sudden dyspnea, chest pain, hypotension, and tachycardia during a central-line tubing change, describes an air embolism. Air entrained into the venous system travels to the right heart, where it can form an air lock in the pulmonary outflow tract. The emergency response is to clamp/occlude the line, give 100% oxygen, call for help, and position the client in the left lateral position with the head down (Trendelenburg), known as the Durant maneuver. This traps air in the apex of the right atrium and away from the pulmonary artery, buying time for the air to be absorbed or aspirated. High Fowler's raises the client's head, which encourages air to move toward the pulmonary and even cerebral circulation and is the opposite of what is needed. Right side-lying with the head elevated fails on both counts: the client must be on the left side and head-down. Supine with legs elevated (a shock position) does not trap air in the right atrium and does not address the embolus. Clinical pearl: memorize 'air embolism = left side, head down.' Prevent it by clamping the catheter during tubing changes, insertion, and removal, priming tubing to remove air, using Luer-lock connections, and having the client perform the Valsalva maneuver (bear down) during these high-risk moments to raise intrathoracic pressure and reduce air entry.
Question 6 · TPN — preventing hypoglycemia
A client is receiving total parenteral nutrition (TPN). The current bag is nearly empty, and the pharmacy reports the next TPN bag will be delayed by two hours. Which action should the nurse take?
- A Discontinue the TPN and flush the central line with heparin until the bag arrives
- B Slow the current bag to a keep-vein-open rate to make it last two hours
- C Change to an infusion of 0.9% sodium chloride at the ordered TPN rate
- D Hang dextrose 10% in water (D10W) at the ordered rate until the TPN is available
Show answer & rationale
Correct answer: D
TPN is a high-dextrose, hyperosmolar solution. Because the client's body has adjusted to a steady, high glucose load (often with correspondingly higher insulin output), an abrupt interruption can cause rebound hypoglycemia. When the next bag is delayed, the standard safeguard is to hang dextrose 10% in water (D10W) at the ordered rate to keep glucose delivery going and prevent hypoglycemia while awaiting the TPN. Discontinuing the TPN and locking the line removes all dextrose and invites rebound hypoglycemia, so it is unsafe. Slowing the current bag to a keep-vein-open rate sharply drops the glucose being delivered and also alters the prescribed infusion, again risking hypoglycemia and undernutrition. Switching to plain 0.9% sodium chloride provides no dextrose at all and does not protect against hypoglycemia. Clinical pearl: never stop TPN abruptly, taper it down when discontinuing, and reach for D10W when a bag is delayed. Monitor blood glucose closely throughout TPN therapy (both hyperglycemia early and hypoglycemia if interrupted), infuse through a dedicated central line/lumen with an in-line filter, use sterile technique, and never try to 'catch up' a lagging TPN infusion by increasing the rate, which would cause hyperglycemia and osmotic diuresis.
Question 7 · Central access — indications
Which prescribed therapy most strongly indicates the need for a central venous access device rather than a peripheral IV?
- A A course of total parenteral nutrition (TPN)
- B A one-time 1,000 mL bolus of 0.9% sodium chloride
- C A single intermittent IV push of an antiemetic
- D Two days of maintenance isotonic IV fluids
Show answer & rationale
Correct answer: A
Central venous access is indicated for solutions that are hyperosmolar, strongly irritating, or vesicant, for long-term therapy, and when peripheral access is poor. Total parenteral nutrition fits perfectly: it is a hyperosmolar, high-dextrose formula that would damage small peripheral veins and cause thrombophlebitis, so it must be delivered into the superior vena cava through a central line where high blood flow rapidly dilutes it. A one-time 1,000 mL bolus of isotonic 0.9% sodium chloride is a routine peripheral infusion; isotonic fluid does not require central access. A single intermittent IV push of an antiemetic is easily given through a standard peripheral IV. Two days of maintenance isotonic fluids is short-term and isotonic, again appropriate for a peripheral line. Clinical pearl: think 'central for the harsh and the long haul.' Classic central-line indications include TPN, vesicant chemotherapy, hyperosmolar or highly irritating drugs (for example, concentrated potassium replacement or certain vasopressors), long courses of IV antibiotics, frequent blood sampling, and clients with exhausted or fragile peripheral veins. Matching the therapy to the right device protects the veins and prevents extravasation injury, and it is why devices like PICCs, tunneled catheters, and implanted ports exist.
Question 8 · Central line — CLABSI bundle
A nurse is caring for a client with a central venous catheter and wants to reduce the risk of a central-line-associated bloodstream infection (CLABSI). Which actions are consistent with the central-line bundle? Select all that apply.
- A Preferentially select the femoral vein for catheter insertion
- B Perform hand hygiene before handling the catheter or hub
- C Perform routine dressing changes using clean, non-sterile technique
- D Prep the skin with a chlorhexidine-based antiseptic
- E Use maximal sterile barrier precautions during line insertion
- F Review daily whether the line is still needed and remove it when it is not
Show answer & rationale
Correct answer: B, D, E, F
The evidence-based central-line bundle bundles several practices proven to lower CLABSI. Hand hygiene before touching the catheter or hub is foundational and correct. Maximal sterile barrier precautions at insertion, cap, mask, sterile gown, sterile gloves, and a full-body sterile drape, are a core bundle element and correct. Chlorhexidine skin antisepsis (chlorhexidine-alcohol) is the preferred prep and correct. Daily review of line necessity with prompt removal of any line that is no longer needed is correct and one of the highest-yield ways to cut infections, because the safest line is the one that is taken out. Preferentially selecting the femoral vein is incorrect: the femoral site carries higher infection and thrombosis risk, so the bundle directs avoiding the femoral site and favoring the subclavian in adults when feasible. Performing dressing changes with clean, non-sterile technique is incorrect: central-line dressing changes require strict sterile technique. Clinical pearl: remember the bundle as hand hygiene, maximal barriers, chlorhexidine, avoid femoral, and daily line review, plus daily chlorhexidine bathing and scrubbing the hub ('scrub the hub' for 15 seconds) before every access. Sterile technique for all dressing and tubing changes rounds out safe central-line care.
Question 9 · TPN — nursing care
A nurse is managing total parenteral nutrition (TPN) for a hospitalized client. Which nursing interventions are appropriate? Select all that apply.
- A Piggyback IV antibiotics into the TPN line to conserve venous access
- B Monitor the client's blood glucose closely during therapy
- C Taper the infusion rate before discontinuing to prevent rebound hypoglycemia
- D Abruptly discontinue the infusion if the bag empties before the next arrives
- E Infuse the TPN with an in-line filter in place
- F Maintain sterile technique during tubing and dressing changes
Show answer & rationale
Correct answer: B, C, E, F
TPN is hyperosmolar, high in dextrose, and an excellent medium for microbial growth, so its care centers on glucose control and infection prevention. Monitoring blood glucose closely is correct, because high dextrose causes hyperglycemia and abrupt interruption causes hypoglycemia. Tapering the rate before discontinuing is correct and prevents rebound hypoglycemia after the body has adjusted to a steady glucose load. Using an in-line filter is correct; TPN (and lipid-containing formulas per policy) is infused through an appropriate filter to catch particulates. Maintaining sterile technique during tubing and dressing changes is correct, given the high infection risk. Piggybacking antibiotics into the TPN line is incorrect: TPN should run through a dedicated line or lumen, both to avoid incompatibilities and to reduce contamination; other medications and blood products are not routinely mixed into it. Abruptly discontinuing the infusion when the bag empties is incorrect and is exactly what causes rebound hypoglycemia; if the next bag is delayed, hang D10W and never stop TPN suddenly. Clinical pearl: TPN care is 'sugar and sterility', watch the glucose, taper on and off, dedicate the line, filter it, keep it sterile, change tubing and dressings per policy, and monitor temperature and the site for signs of infection.
Question 10 · Air embolism — prevention
A nurse wants to prevent air embolism while caring for a client with a central venous catheter. Which actions help prevent air from entering the venous system? Select all that apply.
- A Prime the IV tubing to remove air before connecting it
- B Leave catheter hubs open to air to relieve pressure in the line
- C Clamp the catheter during tubing changes
- D Ensure all connections are secured with Luer-lock devices
- E Position the client upright in high Fowler's during catheter removal
- F Have the client perform the Valsalva maneuver during tubing changes and catheter removal
Show answer & rationale
Correct answer: A, C, D, F
Air embolism is prevented by keeping the venous system closed and using pressure and gravity to your advantage during high-risk moments (insertion, tubing changes, disconnection, and removal). Clamping the catheter during tubing changes is correct: a clamped line cannot entrain air when it is briefly open. Having the client perform the Valsalva maneuver (bear down and hold) during tubing changes and removal is correct, because raising intrathoracic pressure keeps blood, not air, moving toward the heart at the moment the system is open. Ensuring all connections are secured with Luer-lock devices is correct, since loose connections are a common source of air entry. Priming the tubing to remove air before connecting is correct and eliminates air already in the line. Leaving catheter hubs open to air is incorrect and dangerous; hubs must be capped or clamped, never left open. Positioning the client upright in high Fowler's during removal is incorrect: for catheter removal the client should be supine or in Trendelenburg so that venous pressure at the site is higher than atmospheric pressure, discouraging air entry. Clinical pearl: 'clamp, bear down, and lie the client down' during any central-line disconnection. If an air embolism still occurs, clamp the line, place the client in left lateral Trendelenburg (Durant maneuver), give 100% oxygen, and call for help.
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IV Therapy & Central Lines FAQ
What is the difference between IV infiltration and phlebitis?
Infiltration means IV fluid is leaking into the surrounding tissue instead of the vein. The site looks cool, swollen, and pale, and there is no blood return. Phlebitis is inflammation of the vein and looks red, warm, and tender, often with a palpable cord along the vein. Both require stopping the infusion and removing the catheter. A non-vesicant infiltration is treated by elevating the extremity and applying a warm or cold compress per the infusate and facility protocol (warm aids reabsorption; cold limits acute swelling), while vesicant extravasation follows drug-specific protocols; phlebitis is treated with a warm compress. On NCLEX, match the color and temperature clues: cool and pale points to infiltration, red and warm points to phlebitis.
Why does a PICC line need a chest x-ray before it is used?
A PICC is a central catheter, so its tip must rest in the superior vena cava. A chest x-ray (or an approved tip-locating technology) confirms correct tip placement before the first infusion. This matters because central lines carry hyperosmolar, vesicant, and irritating solutions that can cause serious injury if the tip is malpositioned. A catheter can even give a blood return while still being in the wrong location, so aspiration alone does not confirm placement. The rule to remember is simple: x-ray to confirm the tip in the superior vena cava before you infuse anything.
What are the signs of an air embolism from a central line, and what do I do first?
Air embolism causes sudden dyspnea, chest pain, hypotension, tachycardia, and anxiety, often during tubing changes, disconnection, insertion, or removal. Act immediately: clamp or occlude the line to stop more air from entering, place the client in the left lateral position with the head down (Trendelenburg), also called the Durant maneuver, to trap air in the right atrium, administer 100% oxygen, and call for help. Prevent it by clamping the catheter and having the client perform the Valsalva maneuver during tubing changes and removal, priming tubing to clear air, and using secure Luer-lock connections.
Why can't TPN be stopped suddenly?
Total parenteral nutrition is a high-dextrose, hyperosmolar solution, and the body adjusts to the steady glucose load, often with higher insulin output. If TPN stops abruptly, that circulating insulin can drive the blood sugar down and cause rebound hypoglycemia. To prevent this, taper the infusion when discontinuing it rather than stopping it all at once. If the next TPN bag is delayed, hang dextrose 10% in water (D10W) at the ordered rate to keep glucose flowing. Throughout therapy, monitor blood glucose closely, use a dedicated central line with an in-line filter, and maintain strict sterile technique to prevent infection.