HESI PN Fundamentals 3
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of
aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide
(Naturetin) Demecarium
bromide (Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem.Instruct the client to attempt to avoid situations that cause
irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem.Instruct the client to attempt to avoid situations that cause
irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a
cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for
these interventions is to:
Promote equalization of osmotic
pressures. Prevent hypoxia associated
with diaphoresis. Promote integrity of
intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12
hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will
yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50
mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and
repositioning Impaired skin integrity, related to the effects of
pressure and shearing force
,1
,A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to
the underlying fascia. The nurse should document the assessment finding as whichstage of pressure
ulcer?
Stage I
Stage II
Stage III
Unstageabl
e
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed
before thewound can be staged. A stage I pressure ulcer is defined as an area of persistent
redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound
with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present
as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue
loss with visible subcutaneousfat. Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure
that a medication reconciliation is completed? Select all that apply.
After reporting severe
pain On admission to the
hospital
Upon entering the operating room
Before transfer to a rehabilitation
facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking
and comparing it to the health care provider's prescriptions on admission or when there is a
transfer to adifferent setting or service, or discharge. A change in status does not require
medication reconciliation. A medication reconciliation should be completed long before
entering the operating room. Total hip replacement is elective surgery, and scheduling takes
place before admission; medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider forwhich
of the following laboratory values?
White blood cell (WBC) count of 15,000
mm3 Negative protein in the urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0
seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to
10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and
these arenormal values.
Often when a family member is dying, the client and the family are at different stages ofgrieving.
During which stage of a client's grieving is the family likely to require more emotional nursing care
than the client?
Ange
, r
Denia
l
2
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of
aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide
(Naturetin) Demecarium
bromide (Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem.Instruct the client to attempt to avoid situations that cause
irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem.Instruct the client to attempt to avoid situations that cause
irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a
cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for
these interventions is to:
Promote equalization of osmotic
pressures. Prevent hypoxia associated
with diaphoresis. Promote integrity of
intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12
hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will
yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50
mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and
repositioning Impaired skin integrity, related to the effects of
pressure and shearing force
,1
,A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to
the underlying fascia. The nurse should document the assessment finding as whichstage of pressure
ulcer?
Stage I
Stage II
Stage III
Unstageabl
e
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed
before thewound can be staged. A stage I pressure ulcer is defined as an area of persistent
redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound
with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present
as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue
loss with visible subcutaneousfat. Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure
that a medication reconciliation is completed? Select all that apply.
After reporting severe
pain On admission to the
hospital
Upon entering the operating room
Before transfer to a rehabilitation
facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking
and comparing it to the health care provider's prescriptions on admission or when there is a
transfer to adifferent setting or service, or discharge. A change in status does not require
medication reconciliation. A medication reconciliation should be completed long before
entering the operating room. Total hip replacement is elective surgery, and scheduling takes
place before admission; medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider forwhich
of the following laboratory values?
White blood cell (WBC) count of 15,000
mm3 Negative protein in the urine
Blood urea nitrogen (BUN) of 20
mg/dL Prothrombin of 12.0
seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to
10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and
these arenormal values.
Often when a family member is dying, the client and the family are at different stages ofgrieving.
During which stage of a client's grieving is the family likely to require more emotional nursing care
than the client?
Ange
, r
Denia
l
2
