HESI PHARMACOLOGY 2020 SPECIALTY

HESI PHARMACOLOGY 2015 SPECIALTY 1.ID: 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: 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: 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 Integrated Process: Nursing Process/Implementation Content Area: Blood administration Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for collaborative care (6th ed.). Philadelphia: W. B. Saunders, p. 919. Awarded 0.0 points out of 1.0 possible points. 4.ID: The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. Place the actions the nurse should perform in the correct order, with number 1 the first action and number 5 the last action: Incorrect Obtaining vital signs/oxygen saturation Documenting the findings Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the healthcare provider Stopping the infusion of blood The correct order is: Stopping the infusion of blood Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the healthcare provider Obtaining vital signs/oxygen saturation Documenting the findings Rationale: If a transfusion reaction is suspected, the transfusion is immediately stopped and NS infused, pending further physician prescriptions. Next, the healthcare provider should be notified. 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. Vital signs and oxygen saturation are monitored closely. Finally, the nurse documents the findings and the client’s response to the interventions. Test-Taking Strategy: Note that the client is experiencing a having a hemolytic transfusion reaction. 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 healthcare provider, check vital signs and oxygen saturation data, and assess the client closely. Once prescriptions from the healthcare provider have been initiated, the nurse should document the event and client’s response. Review the prioritization of interventions for a transfusion reaction if you had difficulty with the question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Blood Administration References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., p. 2016). St. Louis: Saunders. Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 789). St. Louis: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed. p. 707). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 5.ID: A client with heart failure is being given furosemide (Lasix) and digoxin (Lanoxin). The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? Administering an antiemetic Administering the daily dose of digoxin Discontinuing the morning dose of furosemide Checking 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 healthcare provider. The nurse should first check the results of the potassium level, which will provide additional when the nurse calls the physician, 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 physician 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 if you had difficulty with this question. Level of Cognitive Ability: Applyin