Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
HESI RN Pharmacology Exam
VERSION 27
1.ID: 383695688
A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the
nurse first:
Removes the IV catheter Correct
Slows the rate of infusion
Notifies the healthcare provider
Checks for loose catheter connections
Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The healthcare provider would be notified if phlebitis were to occur, but this is not the initial action.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Eliminate slowing the rate of infusion and checking the connection, because they are comparable or alike in that they indicate continuation of IV therapy. Although the healthcare provider would be notified of this occurrence, the word “first” should direct you to select the option of removing the IV catheter. Review the signs of phlebitis and the actions to be taken when it occurs if you had difficulty with this question. 1 / 4
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., p. 227). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
2.ID: 383697107
A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which of the following actions should the nurse take first?
Removing the IV
Sitting the client up in bed
Shutting off the IV infusion Correct
Slowing the rate of infusion
Rationale: The client’s symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes.The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client’s breathing and then immediately notify the healthcare provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Note the question contains the strategic word “first.” Recognizing the signs of speed shock and recalling the appropriate interventions should also direct you to the option of shutting off the IV infusion. Review the initial nursing actions for speed shock if you had difficulty with this question. 2 / 4
reaction if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered
collaborative care (6th ed., p. 230). St. Louis: Saunders.
Awarded 0.0 points out of 1.0 possible points.
3.ID: 383694318
A nurse discontinues infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which of the following actions does the nurse take next?
Removing the IV catheter
Contacting the healthcare provider Correct
Changing the solution to 5% dextrose in water
Obtaining a culture of the tip of the catheter device removed from the client
Rationale: If the nurse suspects a transfusion reaction, the transfusion is stopped and normal saline solution infused at a keep-vein-open rate pending further physician prescriptions. The nurse then contacts the physician. Dextrose in water is not used, because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type of IV fluid that is compatible with blood. The nurse would not remove the IV catheter, because then there would be no IV access route through which to treat the reaction. There is no reason to obtain a culture of the catheter tip; this is done when an infection is suspected.
Test-Taking Strategy: Use the process of elimination, focusing on the strategic word “next.” Knowing that the IV should not be removed will assist you in the elimination process. Recalling that normal saline solution is the only type of IV fluid that is compatible with blood will also help you answer correctly. To select from the remaining options, note that infection is not the concern; this will help you eliminate the option of obtaining a culture of the catheter tip. Review care of the client experiencing a transfusion 3 / 4
Integrated Process: Nursing Process/Implementation
Content Area: Blood administration
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for
collaborative care (6th ed.). Philadelphia: W. B. Saunders, p. 919.
Awarded 0.0 points out of 1.0 possible points.
4.ID: 383747596
The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. Place the actions the nurse should perform in the correct order, with
number 1 the first action and number 5 the last action:
Incorrect
Obtaining vital signs/oxygen saturation Documenting the findings Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the healthcare provider Stopping the infusion of blood
The correct order is:
Stopping the infusion of blood
Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the healthcare provider Obtaining vital signs/oxygen saturation Documenting the findings Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further physician prescriptions. Next, the healthcare provider should be notified. Ensuring patent IV access also helps maintain the client’s intravascular volume. NS is the solution of choice, rather than solutions containing dextrose, because red blood cells do not clump with NS. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client’s response to the interventions.
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