EXTRA CREDIT HESI MODULE 8A 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 cat...
extra credit hesi module 8 extra credit hesi module 8 1 questions 1 1id 9476967734 a nurse notes that the site of a client’s peripheral intravenous iv catheter is reddened
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EXTRA CREDIT HESI MODULE 8
, Extra Credit HESI Module 8
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.
Incorrect
A. Stopping the infusion of blood
B. Obtaining vital signs/oxygen saturation
C. Hanging an IV bag of normal saline solution (NS) at a keep-vein-
open (KVO) rate
D. Notifying the health care provider
E. Documenting the findings
The correct order is:
F. Stopping the infusion of blood
G. Hanging an IV bag of normal saline solution (NS) at a keep-vein-
open (KVO) rate
H. Notifying the health care provider
I. Obtaining vital signs/oxygen saturation
J. 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
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