LATEST FUNDAMENTAL PN HESI SPECIALTY V2
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
1. The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a
day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse’s priority?
a. Change the dose to one that is within range.
b. Administer the medication because it is within the therapeutic range.
Notify the health care provider that the prescribed dose is in the toxic
c. range.
Notify the health care provider that the prescribed dose is below the
d. therapeutic range.
ANS: D
The dosage range is 200 to 400 mg a day (5 × 40 = 200 and 10 × 40 = 400). The
prescribed dose is 100 mg/day (4 × 25 = 100), which is below therapeutic range.
The nurse should notify the health care provider first and ask for clarification on the
order. The dose is not above the therapeutic range and is not at a toxic level. The
nurse should never alter an order without the prescriber’s approval and consent.
2. The supervising nurse is observing several different nurses. Which action will
cause the supervising nurse to intervene?
a. A nurse administers a vaccine without aspirating.
A nurse gives an IV medication through a 22-gauge IV needle without
b. blood return.
A nurse draws up the NPH insulin first when mixing a short-acting
c. and intermediate-acting insulin.
A nurse calls the health care provider for a patient with nasogastric
d. suction and orders for oral meds.
ANS: C
The supervising nurse must intervene with the nurse who is drawing up the NPH
insulin first; if regular and intermediate-acting (NPH) insulin is ordered, prepare
the regular insulin first to prevent the regular insulin from becoming contaminated
with the intermediate-acting insulin. All the other actions are appropriate and do
not need follow-up. The CDC no longer recommends aspiration when
administering immunizations to reduce discomfort. In some cases, especially with
a smaller gauge (22) IV needle, blood return is not aspirated, even if the IV is
patent. If the IV site shows no signs of infiltration and IV fluid is infusing without
difficulty, proceed with IV push slowly. Oral meds are contraindicated in patients
with nasogastric suction.
3. A nurse is caring for a patient who is receiving pain medication through a
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
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1
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saline lock. After obtaining a good blood return when the nurse is flushing the
patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse
notices a red streak that is warm and tender to the touch. What is the
nurse’s initial action?
a. Do not administer the pain medication.
b. Administer the pain medication slowly.
c. Apply a warm compress to the site.
d. Apply a cool compress to the site.
ANS: A
The patient has phlebitis; the initial nursing action is do not administer the
medication. The medication should not be given slowly. A cool or warm compress
may be used later depending upon protocol, but it is not the first action.
4. The nurse is preparing to administer medications to two patients with the
same last name. After the administration, the nurse realizes that did not check
the identification of the patient before administering medication. Which
action should the nurse complete first?
a. Return to the room to check and assess the patient.
b. Administer the antidote to the patient immediately.
c. Alert the charge nurse that a medication error has occurred.
Complete proper documentation of the medication error in the
d. patient’s chart.
ANS: A
When an error occurs, the patient’s safety and well-being are the top priorities. You
first assess and examine the patient’s condition and notify the health care provider
of the incident as soon as possible. The nurse’s first priority is to establish the
safety of the patient by assessing the patient. Second, notify the charge nurse and
the health care provider. Administer antidote if required. Finally, the nurse needs to
complete proper documentation.
5. The nurse is caring for two patients with the same last name. In this situation
which right of medication administration is the priority to reduce the chance of
an error?
a. Right medication
b. Right patient
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
1. The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a
day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse’s priority?
a. Change the dose to one that is within range.
b. Administer the medication because it is within the therapeutic range.
Notify the health care provider that the prescribed dose is in the toxic
c. range.
Notify the health care provider that the prescribed dose is below the
d. therapeutic range.
ANS: D
The dosage range is 200 to 400 mg a day (5 × 40 = 200 and 10 × 40 = 400). The
prescribed dose is 100 mg/day (4 × 25 = 100), which is below therapeutic range.
The nurse should notify the health care provider first and ask for clarification on the
order. The dose is not above the therapeutic range and is not at a toxic level. The
nurse should never alter an order without the prescriber’s approval and consent.
2. The supervising nurse is observing several different nurses. Which action will
cause the supervising nurse to intervene?
a. A nurse administers a vaccine without aspirating.
A nurse gives an IV medication through a 22-gauge IV needle without
b. blood return.
A nurse draws up the NPH insulin first when mixing a short-acting
c. and intermediate-acting insulin.
A nurse calls the health care provider for a patient with nasogastric
d. suction and orders for oral meds.
ANS: C
The supervising nurse must intervene with the nurse who is drawing up the NPH
insulin first; if regular and intermediate-acting (NPH) insulin is ordered, prepare
the regular insulin first to prevent the regular insulin from becoming contaminated
with the intermediate-acting insulin. All the other actions are appropriate and do
not need follow-up. The CDC no longer recommends aspiration when
administering immunizations to reduce discomfort. In some cases, especially with
a smaller gauge (22) IV needle, blood return is not aspirated, even if the IV is
patent. If the IV site shows no signs of infiltration and IV fluid is infusing without
difficulty, proceed with IV push slowly. Oral meds are contraindicated in patients
with nasogastric suction.
3. A nurse is caring for a patient who is receiving pain medication through a
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
, LATEST FUNDAMENTAL PN HESI SPECIALTY V2
1
LATEST FUNDAMENTAL PN HESI SPECIALTY V2
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saline lock. After obtaining a good blood return when the nurse is flushing the
patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse
notices a red streak that is warm and tender to the touch. What is the
nurse’s initial action?
a. Do not administer the pain medication.
b. Administer the pain medication slowly.
c. Apply a warm compress to the site.
d. Apply a cool compress to the site.
ANS: A
The patient has phlebitis; the initial nursing action is do not administer the
medication. The medication should not be given slowly. A cool or warm compress
may be used later depending upon protocol, but it is not the first action.
4. The nurse is preparing to administer medications to two patients with the
same last name. After the administration, the nurse realizes that did not check
the identification of the patient before administering medication. Which
action should the nurse complete first?
a. Return to the room to check and assess the patient.
b. Administer the antidote to the patient immediately.
c. Alert the charge nurse that a medication error has occurred.
Complete proper documentation of the medication error in the
d. patient’s chart.
ANS: A
When an error occurs, the patient’s safety and well-being are the top priorities. You
first assess and examine the patient’s condition and notify the health care provider
of the incident as soon as possible. The nurse’s first priority is to establish the
safety of the patient by assessing the patient. Second, notify the charge nurse and
the health care provider. Administer antidote if required. Finally, the nurse needs to
complete proper documentation.
5. The nurse is caring for two patients with the same last name. In this situation
which right of medication administration is the priority to reduce the chance of
an error?
a. Right medication
b. Right patient
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