NURSING 2362 Module 8 Exam/ (100/100) Questions and Answers/ GRADED A.Questions
1.ID: 8482576270A nurse notes that the site of a client’s peripheral
... [Show More] 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: 8482578714A 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 1.0 points out
of 1.0 possible points.
3.ID: 8482574309A 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
1.0 points out of 1.0 possible points.
4.ID: 8482578727A 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: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Reference: Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook
2010 (p. 347). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points.
5.ID: 8482576274A physician prescribes the administration of parenteral nutrition
(PN), 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 PN infusion, the client suddenly complains
of difficulty breathing and chest pain. The nurse immediately:
Obtains blood for culture
Clamps the PN infusion line Correct
Obtains a sample for blood glucose testing
Obtains an electrocardiogram (ECG)
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 PN 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 physician 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.
Test-Taking Strategy: Note the words “after the first 2 hours” and “immediately.”
Focus on the data provided in the question to determine that an embolus has occurred. Eliminate
blood cultures and blood glucose testing, which, respectively, relate to infection and
hyperglycemia, which is not likely to occur during the first 2 hours of PN administration. To
select from the remaining options, focus on the strategic word “immediately”; this will direct you
to the correct option. Review the complications of PN and the associated nursing interventions if
you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Parenteral Nutrition [Show Less]