a nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral iv catheter after which of the following observations should
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Nursing Elites

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HESI Fundamentals Exam Test Bank

1. While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?

Correct answer: A

Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.

2. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

Correct answer: C

Rationale: The nurse should reassure the mother that the child's behavior is normal for their age and situation.

3. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Correct answer: C

Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.

4. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to

Correct answer: C

Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.

5. A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

Correct answer: A

Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.

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