HESI RN Pharmacology Exam Questions with Answers, Rationales, TestTakingStrategies 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