HESI Extra Credit Module 8 Exam Pharmacology and Intravenous Therapies [NEW!!] 2022 (65 Pages)100%
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HESI MODULE 8 QUESTIONS
1.
Questions
1. 1.ID: 4
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 should take which action fir...
hesi extra credit module 8 exam pharmacology and intravenous therapies new 2022 65 pages100
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HESI MODULE 8 QUESTIONS
1.
Questions
1. 1.ID: 9476967734
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 should take which action first?
A. Remove the IV catheter Correct
B. Slow the rate of infusion
C. Notify the health care provider
D. Check 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 health care provider would be notified if phlebitis were to occur, but this is not
the initial action.
Test-Taking Strategy: Note the strategic word, first. Focus 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 health care 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Inflammation
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Inflammation
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 707). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9476963098
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 action should the nurse take first?
A. Remove the IV
B. Sit the client up in bed
C. Shut off the IV infusion Correct
D. Slow 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 health care 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: 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
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Giddens Concepts: Fluid and Electrolytes, Perfusion
HESI Concepts: Fluid and Electrolytes, Perfusion
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 230). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9476961248
A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is
experiencing a transfusion reaction. After discontinuing the transfusion, which action should
the nurse take next?
A. Remove the IV catheter
B. Contact the health care provider Correct
C. Change the solution to 5% dextrose in water
D. Obtain 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 health care provider
prescriptions. The nurse then contacts the health care provider.. 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: Note 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 reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
, Integrated Process: Nursing Process/Implementation
Content Area: Blood administration
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 740-741). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9476963017
The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction
while receiving a blood transfusion. The nurse should perform these actions in
which priority order? Arrange the actions in the order that they should be performed.
All options must be used.
Correct
A. Stopping the infusion of blood
B. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open
(KVO) rate
C. Notifying the health care provider
D. Obtaining vital signs/oxygen saturation
E. Documenting the findings
Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS
infused, pending further primary health care provider prescriptions. 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. Next, the primary
health care provider should be notified because this is an emergency situation. Vital signs and
oxygen saturation are monitored closely. Finally, the nurse documents the findings and the
client’s response to the interventions.
Test-Taking Strategic: Note the strategic word, priority. Note that the client is experiencing a
hemolytic transfusion reaction an emergency condition. The question sets forth the problem;
the nurse must determine the order in which interventions should be performed. First, the
blood transfusion is stopped and an isotonic solution infused. Next the nurse should notify the
primary healthcare provider, check vital signs and oxygen saturation data, and assess the
client closely. Once prescriptions from the primary healthcare provider have been initiated, the
nurse should document the event and client’s response. Review the prioritization of
interventions for a transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care
Coordination
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th
ed., pp. 740-741). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
, 2. 5.ID: 9476964571
A client with heart failure is being given furosemide and digoxin. The client calls the nurse and
complains of anorexia and nausea. Which action should the nurse take first?
A. Administer an antiemetic
B. Administer the daily dose of digoxin
C. Discontinue the morning dose of furosemide
D. Checkthe result of laboratory testing for potassium on the sample
drawn 3 hours ago Correct
Rationale: Anorexia and nausea are symptoms commonly associated with digoxin toxicity,
which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include
anorexia and mild nausea, but they are frequently overlooked or not associated with digoxin
toxicity. Hallucinations and any change in pulse rhythm, color vision, or behavior should be
investigated and reported to the health care provider. The nurse should first check the results
of the potassium level, which will provide additional when the nurse calls the health care
provider,an important follow-up action. The nurse should also check the digoxin reading if one
is available. The nurse would not administer an antiemetic without further investigating the
client’s problem. Because digoxin toxicity is suspected, the nurse would withhold the digoxin
until the health care provider has been consulted. The nurse would not discontinue a
medication without a prescription to do so.
Test-Taking Strategy: Note the strategic word “first” and use the steps of the nursing process to
answer the question. The correct option is the only one that addresses assessment. Review
nursing interventions for suspected digoxin toxicity
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Clinical Judgment
HESI Concepts: Cellular Regulation, Clinical Decision-Making/Clinical Judgment
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 363)
St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 753). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
2. 6.ID: 9476961282
The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN),
to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian
central line. After the first 2 hours of the TPN infusion, the client suddenly complains of
difficulty breathing and chest pain. The nurse should take which immediate action?
A. Obtain blood for culture
B. Clamp the TPN infusion line Correct
C. Obtain an electrocardiogram (ECG)
D. Obtain a sample for blood glucose testing
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