nurse notes that the site of a client’s peripheral intravenous (IV)
catheter is reddened, warm, painful, and slightly edematous near the
insertion
... [Show More] point of the catheter. On the basis of this assessment, the nurse
should take which action first?Check for loose catheter connectionsSlow the rate of infusionNotify the health care provider
Remove the IV catheter
Correct!Correct!
12/11/21, 8:50 PM Session 2 Exam 1 - Pharmacology and Intravenous Therapies: NCLEX Remediation Course Nov 2021
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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.
Test-Taking 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 Decision-Making/Clinical Judgment,
Inflammation
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical
nursing skills & techniques (8 ed., p. 707). St. Louis: Mosby.th
1 / 1 ptsQuestion 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 action should the nurse take first?
Shut off the IV infusion
Correct!Correct!
12/11/21, 8:50 PM Session 2 Exam 1 - Pharmacology and Intravenous Therapies: NCLEX Remediation Course Nov 2021
https://jerseycollege.instructure.com/courses/2491/quizzes/27617 3/115Slow the rate of infusionSit the client up in bedRemove the IV
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.
Test-Taking 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). Medical-
surgical nursing: Patient-centered collaborative care. (7 ed., p.
230). St. Louis: Saunders.
th
1 / 1 ptsQuestion 3
12/11/21, 8:50 PM Session 2 Exam 1 - Pharmacology and Intravenous Therapies: NCLEX Remediation Course Nov 2021
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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?Change the solution to 5% dextrose in waterObtain a culture of the tip of the catheter device removed from the client
Contact the health care providerCorrect!Correct!Remove the IV catheter
12/11/21, 8:50 PM Session 2 Exam 1 - Pharmacology and Intravenous Therapies: NCLEX Remediation Course Nov 2021
https://jerseycollege.instructure.com/courses/2491/quizzes/27617 5/115
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 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.
Test-Taking 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 Decision-Making/Clinical Judgment,
Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical
nursing skills & techniques (8 ed., pp. 740-741). St. Louis: Mosby.th
1 / 1 ptsQuestion 4
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? [Show Less]