NURSING NCLEX MODULE 8 EXAM
Submission Details
• Submission Time: 9:55 PM
• Points Awarded: 115
• Points Missed: 10
• Number of Attempts Allowed: 1
• Not Scored: 0
• Percentage: 92%
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.
TestTaking 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 DecisionMaking/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 500mL 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.
TestTaking 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). Medicalsurgical nursing: Patientcentered
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 keepveinopen 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.
TestTaking 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 DecisionMaking/Clinical Judgment, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques
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 keepveinopen (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.
TestTaking 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
, 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 primary healthcare provider, check vital signs and oxygen saturation data,
and assess the client closely. Once prescriptions from the primary healthcare provider
have been initiated, the nurse should document the event and client’s response.
Review the prioritization of interventions for a transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical DecisionMaking/Clinical Judgment, Collaboration/Managing Care
– Care Coordination
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 740741). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
2. 5.ID: 9476964571
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?
A. Administer an antiemetic
B. Administer the daily dose of digoxin
C. Discontinue the morning dose of furosemide
D. Checkthe 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 followup 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.
TestTaking 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
Level of Cognitive Ability: Applying
Submission Details
• Submission Time: 9:55 PM
• Points Awarded: 115
• Points Missed: 10
• Number of Attempts Allowed: 1
• Not Scored: 0
• Percentage: 92%
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.
TestTaking 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 DecisionMaking/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 500mL 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.
TestTaking 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). Medicalsurgical nursing: Patientcentered
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 keepveinopen 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.
TestTaking 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 DecisionMaking/Clinical Judgment, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques
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 keepveinopen (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.
TestTaking 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
, 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 primary healthcare provider, check vital signs and oxygen saturation data,
and assess the client closely. Once prescriptions from the primary healthcare provider
have been initiated, the nurse should document the event and client’s response.
Review the prioritization of interventions for a transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical DecisionMaking/Clinical Judgment, Collaboration/Managing Care
– Care Coordination
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 740741). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
2. 5.ID: 9476964571
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?
A. Administer an antiemetic
B. Administer the daily dose of digoxin
C. Discontinue the morning dose of furosemide
D. Checkthe 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 followup 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.
TestTaking 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
Level of Cognitive Ability: Applying
