Module 8 Exam
1.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?
Remove the IV catheter Correct
Slow the rate of infusion
Notify the health care provider
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.
2. 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?
Remove the IV
Sit the client up in bed
Shut off the IV infusion Correct
, 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.
3. 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?
Remove the IV catheter
Contact the health care provider Correct
Change the solution to 5% dextrose in water
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.
,4. 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.
The correct order is:
1. Stopping the infusion of blood
2. Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate
3. Notifying the health care provider
4. Obtaining vital signs/oxygen saturation
5. 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.
5.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?
Administer an antiemetic
Administer the daily dose of digoxin
Discontinue the morning dose of furosemide
Check the 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.
6.The health care provider (HCP) prescribes the administration of total parenteral 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?
Obtain blood for culture
Clamp the TPN infusion line Correct
Obtain an electrocardiogram (ECG)
Obtain a sample for blood glucose testing Rationale: One complication of a
subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest
pain shortly after the initiation of TPN may mean that this complication has developed.
The infusion is clamped (the line should not be discontinued, however), the client turned
on the left side with the head down, and the HCP notified immediately. Depending on
agency protocol, the rapid response team would also be called. Blood cultures are not
necessary in this situation, because infection is not the concern. Likewise, there is no
useful reason for checking the blood glucose level. An ECG may be obtained, but this is
not the immediate priority. If the client shows signs of an air embolism, the nurse should
examine the catheter to determine whether an open port has allowed air into the
circulatory system.
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