HESI RN Pharmacology Exam Questions with Answers, Rationales, Test-
TakingStrategies and References.
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 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. 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. 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. 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
TakingStrategies and References.
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 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. 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. 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. 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
