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
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