HESI Comprehensive Exam | QUESTIONS AD ANSWERS |
LATEST UPDATE
LTerms in this set (263)
Enalapril maleate is prescribed for a hospitalized
Checking the client's blood pressure
client. Which assessment does the nurse perform as a
priority before administering the medication?
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. One common side effect is postural hypotension.
Checking the client's blood pressure
Therefore the nurse would check the client's blood pressure immediately
Checking the client's peripheral pulses
before administering each dose. Checking the client's peripheral pulses, the results
Checking the most recent potassium level
of the most recent potassium level, and the intake and output for the previous 24
Checking the client's intake-and-output record for the
hours are not specifically associated with this mediation.
last 24 hours
A client is scheduled to undergo an upper
"I need to drink citrate of magnesia the night before the test and give myself
gastrointestinal (GI) series, and the nurse provides
a Fleet enema on the morning of the test."
instructions to the client about the test. Which
statement by the client indicates a need for further
Rationale: No special preparation is necessary before a GI series, except that NPO
instruction?
(nothing by mouth) status must be maintained for 8 hours before the test. An upper
GI series involves visualization of the esophagus, duodenum, and upper jejunum
"The test will take about 30 minutes."
by means of the use of a contrast medium. It involves swallowing a contrast
"I need to fast for 8 hours before the test."
medium (usually barium), which is administered in a flavored milkshake. Films are
"I need to drink citrate of magnesia the night before the
taken at intervals during the test, which takes about 30 minutes. After an upper GI
test and give myself a Fleet enema on the morning of the
series, the client is prescribed a laxative to hasten elimination of the barium.
test."
Barium that remains in the colon may become hard and difficult to expel, leading
"I need to take a laxative after the test is completed,
to fecal impaction.
because the liquid that I'll have to drink for the test can
be constipating."
,A nurse on the evening shift checks a primary health
Ask the answering service to contact the on-call primary health care provider
care provider's prescriptions and notes that the dose
of a prescribed medication is higher than the normal
Rationale: The nurse has a duty to protect the client from harm. A nurse who
dose. The nurse calls the primary health care
believes that a primary health care provider's prescription may be in error is
provider's answering service and is told that the primary
responsible for clarifying the prescription before carrying it out. Therefore the
health care provider is off for the night and will be
nurse would not administer the medication; instead, the nurse would withhold the
available in the morning. What should the nurse do
medication until the dose can be clarified. The nurse would not wait until the next
next?
morning to obtain clarification. It is premature to call the nursing supervisor.
Call the nursing supervisor
Ask the answering service to contact the on-call primary
health care provider
Withhold the medication until the primary health care
provider can be reached in the morning
Administer the medication but consult the primary
health care provider when he becomes available
An emergency department (ED) nurse is monitoring a
Ask the ED primary health care provider to check the client
client with suspected acute myocardial infarction (MI)
who is awaiting transfer to the coronary intensive care
Rationale: The most appropriate action by the nurse would be to ask the ED
unit. The nurse notes the sudden onset of premature
health care provider to check the client. PVCs are a result of increased
ventricular contractions (PVCs) on the monitor, checks
irritability of ventricular cells. Peripheral pulses may be absent or diminished
the client's carotid pulse, and determines that the
with the PVCs themselves because the decreased stroke volume of the
PVCs are not perfusing. What is the nurse's most
premature beats may in turn decrease peripheral perfusion. Because other
appropriate action?
rhythms also cause widened QRS complexes, it is essential that the nurse
determine whether the premature beats are resulting in perfusion of the
Document the findings
extremities. This is done by palpating the carotid, brachial, or femoral artery
Ask the ED primary health care provider to check the
while observing the monitor for widened complexes or by auscultating for apical
client
heart sounds. In the situation of acute MI, PVCs may be considered warning
Continue to monitor the client's cardiac status
dysrhythmias, possibly heralding the onset of ventricular tachycardia or
Inform the client that PVCs are expected after an MI
ventricular fibrillation. Therefore, the nurse would not tell the client that the
PVCs are expected. Although the nurse will continue to monitor the client and
document the findings, these are not the most appropriate actions of those
provided.
NPO status is imposed 8 hours before the procedure on a
Administer the antihypertensive with a small sip of water
client scheduled to undergo electroconvulsive
therapy (ECT) at 1 p.m. On the morning of the procedure,
Rationale: The nurse should administer the antihypertensive with a small sip of
the nurse checks the client's record and notes that
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to
the client routinely takes an oral antihypertensive
8 hours before treatment to help prevent aspiration. Exceptions include clients
medication each morning. What action should the
who routinely receive cardiac medications, antihypertensive agents, or histamine
nurse take?
(H2) blockers, which should be administered several hours before treatment
with a small sip of water. Withholding the antihypertensive and administering it at
Administer the antihypertensive with a small sip of water
bedtime and withholding the antihypertensive and resuming administration on the
Withhold the antihypertensive and administer it at
day after the ECT are incorrect actions, because antihypertensives must be
bedtime
administered on time; otherwise, the risk for rebound hypertension exists. The
Administer the medication by way of the intravenous (IV)
nurse would not administer a medication by way of a route that has not been
route
prescribed.
Hold the antihypertensive and resume its administration
on the day after the ECT
, A client who recently underwent coronary artery bypass
"Tell me more about what you're feeling."
graft surgery comes to the primary health care
provider's office for a follow-up visit. On assessment, the
Rationale: The therapeutic response by the nurse is, "Tell me more about what
client tells the nurse that he is feeling depressed. Which
you're feeling." When a client expresses feelings of depression, it is extremely
response by the nurse is therapeutic?
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
"Tell me more about what you're feeling."
reassurance and avoids addressing the client's feelings. "It will take time, but I
"That's a normal response after this type of surgery."
promise you, you will get over the depression" is also a false reassurance, and it
"It will take time, but I promise you, you will get over
does not encourage the expression of feelings. "Every client who has this surgery
this depression."
feels the same way for about a month" is a generalization that avoids the client's
"Every client who has this surgery feels the same way
feelings.
for about a month."
A client in labor experiences spontaneous rupture of the
Contact the primary health care provider
membranes. The nurse immediately counts the fetal
heart rate (FHR) for 1 full minute and then checks the
Rationale: The priority action is for the nurse to contact the primary health care
amniotic fluid. The nurse notes that the fluid is
provider. The FHR is assessed for at least 1 minute when the membranes rupture.
yellow and has a strong odor. Which action should be
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
the nurse's priority?
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or
strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis
Contact the primary health care provider
and warrants notifying the primary health care provider. A large amount of vernix
Document the findings
in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid
Check the fluid for protein
may be seen in cases of postterm gestation or placental insufficiency.
Continue to monitor the client and the FHR
Checking the fluid for protein is not associated with the data in the question. The
nurse would continue to monitor the client and the FHR and would document
the findings.
A nurse has assisted a primary health care provider
Call the radiography department to obtain a chest x-ray
in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be
Rationale: The nurse should immediately make arrangements to have a chest x-
receiving parenteral nutrition (PN). After insertion of
ray done. One major complication associated with central venous catheter
the catheter what does the nurse immediately do?
placement is pneumothorax, which may result from accidental puncture of the
lung. After the catheter has been placed but before it is used for infusions, its
Call the radiography department to obtain a chest x-ray
placement must be checked with an x-ray. Hanging the prescribed bag of PN and
Check the client's blood glucose level to serve as a
starting the infusion at the prescribed rate and infusing normal saline solution
baseline measurement
through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect
Hang the prescribed bag of PN and start the infusion
because they could result in the infusion of solution into a lung if a pneumothorax
at the prescribed rate
is present. Although the nurse may obtain a blood glucose measurement to serve
Infuse normal saline solution through the catheter at a
as a baseline, this action is not the priority.
rate of 100 mL/hr to maintain patency
A rape victim being treated in the emergency
"Let's talk about the information that you need to determine your risk of
department says to the nurse, "I'm really worried that
contracting HIV."
I've got HIV now." What is the most appropriate
response by the nurse?
Rationale: The most appropriate response by the nurse is the one that encourages
the client to talk about her condition. HIV is a concern of rape victims. Such
"HIV is rarely an issue in rape victims."
concern should always be addressed, and the victim should be given the
"Every rape victim is concerned about HIV."
information needed to evaluate his or her risk. Pregnancy may occur as a result of
"You're more likely to get pregnant than to contract
rape, and pregnancy prophylaxis can be offered in the emergency department or
HIV." "Let's talk about the information that you need
during follow-up, once the results of a pregnancy test have been obtained.
to determine your risk of contracting HIV."
However, stating, "You're more likely to get pregnant than to contract HIV" avoids
the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every
rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
LATEST UPDATE
LTerms in this set (263)
Enalapril maleate is prescribed for a hospitalized
Checking the client's blood pressure
client. Which assessment does the nurse perform as a
priority before administering the medication?
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. One common side effect is postural hypotension.
Checking the client's blood pressure
Therefore the nurse would check the client's blood pressure immediately
Checking the client's peripheral pulses
before administering each dose. Checking the client's peripheral pulses, the results
Checking the most recent potassium level
of the most recent potassium level, and the intake and output for the previous 24
Checking the client's intake-and-output record for the
hours are not specifically associated with this mediation.
last 24 hours
A client is scheduled to undergo an upper
"I need to drink citrate of magnesia the night before the test and give myself
gastrointestinal (GI) series, and the nurse provides
a Fleet enema on the morning of the test."
instructions to the client about the test. Which
statement by the client indicates a need for further
Rationale: No special preparation is necessary before a GI series, except that NPO
instruction?
(nothing by mouth) status must be maintained for 8 hours before the test. An upper
GI series involves visualization of the esophagus, duodenum, and upper jejunum
"The test will take about 30 minutes."
by means of the use of a contrast medium. It involves swallowing a contrast
"I need to fast for 8 hours before the test."
medium (usually barium), which is administered in a flavored milkshake. Films are
"I need to drink citrate of magnesia the night before the
taken at intervals during the test, which takes about 30 minutes. After an upper GI
test and give myself a Fleet enema on the morning of the
series, the client is prescribed a laxative to hasten elimination of the barium.
test."
Barium that remains in the colon may become hard and difficult to expel, leading
"I need to take a laxative after the test is completed,
to fecal impaction.
because the liquid that I'll have to drink for the test can
be constipating."
,A nurse on the evening shift checks a primary health
Ask the answering service to contact the on-call primary health care provider
care provider's prescriptions and notes that the dose
of a prescribed medication is higher than the normal
Rationale: The nurse has a duty to protect the client from harm. A nurse who
dose. The nurse calls the primary health care
believes that a primary health care provider's prescription may be in error is
provider's answering service and is told that the primary
responsible for clarifying the prescription before carrying it out. Therefore the
health care provider is off for the night and will be
nurse would not administer the medication; instead, the nurse would withhold the
available in the morning. What should the nurse do
medication until the dose can be clarified. The nurse would not wait until the next
next?
morning to obtain clarification. It is premature to call the nursing supervisor.
Call the nursing supervisor
Ask the answering service to contact the on-call primary
health care provider
Withhold the medication until the primary health care
provider can be reached in the morning
Administer the medication but consult the primary
health care provider when he becomes available
An emergency department (ED) nurse is monitoring a
Ask the ED primary health care provider to check the client
client with suspected acute myocardial infarction (MI)
who is awaiting transfer to the coronary intensive care
Rationale: The most appropriate action by the nurse would be to ask the ED
unit. The nurse notes the sudden onset of premature
health care provider to check the client. PVCs are a result of increased
ventricular contractions (PVCs) on the monitor, checks
irritability of ventricular cells. Peripheral pulses may be absent or diminished
the client's carotid pulse, and determines that the
with the PVCs themselves because the decreased stroke volume of the
PVCs are not perfusing. What is the nurse's most
premature beats may in turn decrease peripheral perfusion. Because other
appropriate action?
rhythms also cause widened QRS complexes, it is essential that the nurse
determine whether the premature beats are resulting in perfusion of the
Document the findings
extremities. This is done by palpating the carotid, brachial, or femoral artery
Ask the ED primary health care provider to check the
while observing the monitor for widened complexes or by auscultating for apical
client
heart sounds. In the situation of acute MI, PVCs may be considered warning
Continue to monitor the client's cardiac status
dysrhythmias, possibly heralding the onset of ventricular tachycardia or
Inform the client that PVCs are expected after an MI
ventricular fibrillation. Therefore, the nurse would not tell the client that the
PVCs are expected. Although the nurse will continue to monitor the client and
document the findings, these are not the most appropriate actions of those
provided.
NPO status is imposed 8 hours before the procedure on a
Administer the antihypertensive with a small sip of water
client scheduled to undergo electroconvulsive
therapy (ECT) at 1 p.m. On the morning of the procedure,
Rationale: The nurse should administer the antihypertensive with a small sip of
the nurse checks the client's record and notes that
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to
the client routinely takes an oral antihypertensive
8 hours before treatment to help prevent aspiration. Exceptions include clients
medication each morning. What action should the
who routinely receive cardiac medications, antihypertensive agents, or histamine
nurse take?
(H2) blockers, which should be administered several hours before treatment
with a small sip of water. Withholding the antihypertensive and administering it at
Administer the antihypertensive with a small sip of water
bedtime and withholding the antihypertensive and resuming administration on the
Withhold the antihypertensive and administer it at
day after the ECT are incorrect actions, because antihypertensives must be
bedtime
administered on time; otherwise, the risk for rebound hypertension exists. The
Administer the medication by way of the intravenous (IV)
nurse would not administer a medication by way of a route that has not been
route
prescribed.
Hold the antihypertensive and resume its administration
on the day after the ECT
, A client who recently underwent coronary artery bypass
"Tell me more about what you're feeling."
graft surgery comes to the primary health care
provider's office for a follow-up visit. On assessment, the
Rationale: The therapeutic response by the nurse is, "Tell me more about what
client tells the nurse that he is feeling depressed. Which
you're feeling." When a client expresses feelings of depression, it is extremely
response by the nurse is therapeutic?
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
"Tell me more about what you're feeling."
reassurance and avoids addressing the client's feelings. "It will take time, but I
"That's a normal response after this type of surgery."
promise you, you will get over the depression" is also a false reassurance, and it
"It will take time, but I promise you, you will get over
does not encourage the expression of feelings. "Every client who has this surgery
this depression."
feels the same way for about a month" is a generalization that avoids the client's
"Every client who has this surgery feels the same way
feelings.
for about a month."
A client in labor experiences spontaneous rupture of the
Contact the primary health care provider
membranes. The nurse immediately counts the fetal
heart rate (FHR) for 1 full minute and then checks the
Rationale: The priority action is for the nurse to contact the primary health care
amniotic fluid. The nurse notes that the fluid is
provider. The FHR is assessed for at least 1 minute when the membranes rupture.
yellow and has a strong odor. Which action should be
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
the nurse's priority?
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or
strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis
Contact the primary health care provider
and warrants notifying the primary health care provider. A large amount of vernix
Document the findings
in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid
Check the fluid for protein
may be seen in cases of postterm gestation or placental insufficiency.
Continue to monitor the client and the FHR
Checking the fluid for protein is not associated with the data in the question. The
nurse would continue to monitor the client and the FHR and would document
the findings.
A nurse has assisted a primary health care provider
Call the radiography department to obtain a chest x-ray
in inserting a central venous access device into a client
with a diagnosis of severe malnutrition who will be
Rationale: The nurse should immediately make arrangements to have a chest x-
receiving parenteral nutrition (PN). After insertion of
ray done. One major complication associated with central venous catheter
the catheter what does the nurse immediately do?
placement is pneumothorax, which may result from accidental puncture of the
lung. After the catheter has been placed but before it is used for infusions, its
Call the radiography department to obtain a chest x-ray
placement must be checked with an x-ray. Hanging the prescribed bag of PN and
Check the client's blood glucose level to serve as a
starting the infusion at the prescribed rate and infusing normal saline solution
baseline measurement
through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect
Hang the prescribed bag of PN and start the infusion
because they could result in the infusion of solution into a lung if a pneumothorax
at the prescribed rate
is present. Although the nurse may obtain a blood glucose measurement to serve
Infuse normal saline solution through the catheter at a
as a baseline, this action is not the priority.
rate of 100 mL/hr to maintain patency
A rape victim being treated in the emergency
"Let's talk about the information that you need to determine your risk of
department says to the nurse, "I'm really worried that
contracting HIV."
I've got HIV now." What is the most appropriate
response by the nurse?
Rationale: The most appropriate response by the nurse is the one that encourages
the client to talk about her condition. HIV is a concern of rape victims. Such
"HIV is rarely an issue in rape victims."
concern should always be addressed, and the victim should be given the
"Every rape victim is concerned about HIV."
information needed to evaluate his or her risk. Pregnancy may occur as a result of
"You're more likely to get pregnant than to contract
rape, and pregnancy prophylaxis can be offered in the emergency department or
HIV." "Let's talk about the information that you need
during follow-up, once the results of a pregnancy test have been obtained.
to determine your risk of contracting HIV."
However, stating, "You're more likely to get pregnant than to contract HIV" avoids
the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every
rape victim is concerned about HIV" are generalized responses that avoid the
client's concern.
