HESI PHARMACOLOGY
SPECIALTY exam
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.
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.
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. 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
reaction if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
SPECIALTY exam
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.
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.
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. 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
reaction if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
