HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
Checking the client's blood pressure
Enalapril maleate is prescribed for a hos-
Rationale: Enalapril maleate is an an-
pitalized client. Which assessment does
giotensin-converting enzyme (ACE) in-
the nurse perform as a priority before
hibitor used to treat hypertension. One
administering the medication?
common side effect is postural hypoten-
sion. Therefore the nurse would check
Checking the client's blood pressure
the client's blood pressure immediately
Checking the client's peripheral pulses
before administering each dose. Check-
Checking the most recent potassium lev-
ing the client's peripheral pulses, the re-
el
sults of the most recent potassium level,
Checking the client's intake-and-output
and the intake and output for the previous
record for the last 24 hours
24 hours are not specifically associated
with this mediation.
"I need to drink citrate of magnesia the
night before the test and give myself a
Fleet enema on the morning of the test."
A client is scheduled to undergo an up-
per gastrointestinal (GI) series, and the
Rationale: No special preparation is nec-
nurse provides instructions to the client
essary before a GI series, except that
about the test. Which statement by the
NPO (nothing by mouth) status must be
client indicates a need for further instruc-
maintained for 8 hours before the test.
tion?
An upper GI series involves visualization
of the esophagus, duodenum, and up-
"The test will take about 30 minutes."
per jejunum by means of the use of a
"I need to fast for 8 hours before the test."
contrast medium. It involves swallowing a
"I need to drink citrate of magnesia the
contrast medium (usually barium), which
night before the test and give myself a
is administered in a flavored milkshake.
Fleet enema on the morning of the test."
Films are taken at intervals during the
"I need to take a laxative after the test
test, which takes about 30 minutes. Af-
is completed, because the liquid that I'll
ter an upper GI series, the client is pre-
have to drink for the test can be consti-
scribed a laxative to hasten elimination
pating."
of the barium. Barium that remains in the
colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a
primary health care provider's prescrip-
tions and notes that the dose of a pre-
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
scribed medication is higher than the
normal dose. The nurse calls the primary Ask the answering service to contact the
health care provider's answering service on-call primary health care provider
and is told that the primary health care
provider is off for the night and will be Rationale: The nurse has a duty to
available in the morning. What should the protect the client from harm. A nurse
nurse do next? who believes that a primary health care
provider's prescription may be in error
Call the nursing supervisor is responsible for clarifying the prescrip-
Ask the answering service to contact the tion before carrying it out. Therefore the
on-call primary health care provider nurse would not administer the medica-
Withhold the medication until the primary tion; instead, the nurse would withhold
health care provider can be reached in the medication until the dose can be clar-
the morning ified. The nurse would not wait until the
Administer the medication but consult next morning to obtain clarification. It is
the primary health care provider when he premature to call the nursing supervisor.
becomes available
Ask the ED primary health care provider
to check the client
Rationale: The most appropriate action
An emergency department (ED) nurse
by the nurse would be to ask the ED
is monitoring a client with suspected
health care provider to check the client.
acute myocardial infarction (MI) who is
PVCs are a result of increased irritabil-
awaiting transfer to the coronary inten-
ity of ventricular cells. Peripheral puls-
sive care unit. The nurse notes the sud-
es may be absent or diminished with
den onset of premature ventricular con-
the PVCs themselves because the de-
tractions (PVCs) on the monitor, checks
creased stroke volume of the premature
the client's carotid pulse, and determines
beats may in turn decrease peripheral
that the PVCs are not perfusing. What is
perfusion. Because other rhythms also
the nurse's most appropriate action?
cause widened QRS complexes, it is es-
sential that the nurse determine whether
Document the findings
the premature beats are resulting in per-
Ask the ED primary health care provider
fusion of the extremities. This is done by
to check the client
palpating the carotid, brachial, or femoral
Continue to monitor the client's cardiac
artery while observing the monitor for
widened complexes or by auscultating
for apical heart sounds. In the situation
of acute MI, PVCs may be considered
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
warning dysrhythmias, possibly herald-
ing the onset of ventricular tachycardia
or ventricular fibrillation. Therefore, the
status nurse would not tell the client that the
Inform the client that PVCs are expected PVCs are expected. Although the nurse
after an MI will continue to monitor the client and
document the findings, these are not the
most appropriate actions of those provid-
ed.
Administer the antihypertensive with a
small sip of water
NPO status is imposed 8 hours be- Rationale: The nurse should adminis-
fore the procedure on a client sched- ter the antihypertensive with a small
uled to undergo electroconvulsive thera- sip of water. General anesthesia is re-
py (ECT) at 1 p.m. On the morning of the quired for ECT, so NPO status is im-
procedure, the nurse checks the client's posed for 6 to 8 hours before treat-
ment to help prevent aspiration. Excep-
record and notes that the client routinely
takes an oral antihypertensive medica- tions include clients who routinely re-
tion each morning. What action should ceive cardiac medications, antihyperten-
the nurse take? sive agents, or histamine (H2) blockers,
which should be administered several
Administer the antihypertensive with a hours before treatment with a small sip
small sip of water of water. Withholding the antihyperten-
Withhold the antihypertensive and ad- sive and administering it at bedtime and
minister it at bedtime withholding the antihypertensive and re-
Administer the medication by way of the suming administration on the day after
intravenous (IV) route the ECT are incorrect actions, because
Hold the antihypertensive and resume its antihypertensives must be administered
administration on the day after the ECT on time; otherwise, the risk for rebound
hypertension exists. The nurse would not
administer a medication by way of a route
that has not been prescribed.
"Tell me more about what you're feeling."
A client who recently underwent coro-
nary artery bypass graft surgery comes Rationale: The therapeutic response by
to the primary health care provider's of- the nurse is, "Tell me more about what
you're feeling." When a client express-
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
es feelings of depression, it is extreme-
fice for a follow-up visit. On assessment, ly important for the nurse to further ex-
the client tells the nurse that he is feeling plore these feelings with the client. In
depressed. Which response by the nurse stating, "This is a normal response after
is therapeutic? this type of surgery" the nurse provides
false reassurance and avoids address-
"Tell me more about what you're feeling." ing the client's feelings. "It will take time,
"That's a normal response after this type but I promise you, you will get over the
of surgery." depression" is also a false reassurance,
"It will take time, but I promise you, you and it does not encourage the expression
will get over this depression." of feelings. "Every client who has this
"Every client who has this surgery feels surgery feels the same way for about a
the same way for about a month." month" is a generalization that avoids the
client's feelings.
Contact the primary health care provider
Rationale: The priority action is for the
nurse to contact the primary health care
provider. The FHR is assessed for at
A client in labor experiences sponta-
least 1 minute when the membranes rup-
neous rupture of the membranes. The
ture. The nurse also checks the quantity,
nurse immediately counts the fetal heart
color, and odor of the amniotic fluid. The
rate (FHR) for 1 full minute and then
fluid should be clear (often with bits of
checks the amniotic fluid. The nurse
vernix) and have a mild odor. Fluid with a
notes that the fluid is yellow and has a
foul or strong odor, cloudy appearance,
strong odor. Which action should be the
or yellow coloration suggests chorioam-
nurse's priority?
nionitis and warrants notifying the prima-
ry health care provider. A large amount of
Contact the primary health care provider
vernix in the fluid suggests that the fetus
Document the findings
is preterm. Greenish, meconium-stained
Check the fluid for protein
fluid may be seen in cases of post-
Continue to monitor the client and the
term gestation or placental insufficiency.
FHR
Checking the fluid for protein is not as-
sociated 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 in inserting a central ve-
nous access device into a client with a
diagnosis of severe malnutrition who will
be receiving parenteral nutrition (PN). Af-
ter insertion of the catheter what does
Study online at https://quizlet.com/_8w46yj
Checking the client's blood pressure
Enalapril maleate is prescribed for a hos-
Rationale: Enalapril maleate is an an-
pitalized client. Which assessment does
giotensin-converting enzyme (ACE) in-
the nurse perform as a priority before
hibitor used to treat hypertension. One
administering the medication?
common side effect is postural hypoten-
sion. Therefore the nurse would check
Checking the client's blood pressure
the client's blood pressure immediately
Checking the client's peripheral pulses
before administering each dose. Check-
Checking the most recent potassium lev-
ing the client's peripheral pulses, the re-
el
sults of the most recent potassium level,
Checking the client's intake-and-output
and the intake and output for the previous
record for the last 24 hours
24 hours are not specifically associated
with this mediation.
"I need to drink citrate of magnesia the
night before the test and give myself a
Fleet enema on the morning of the test."
A client is scheduled to undergo an up-
per gastrointestinal (GI) series, and the
Rationale: No special preparation is nec-
nurse provides instructions to the client
essary before a GI series, except that
about the test. Which statement by the
NPO (nothing by mouth) status must be
client indicates a need for further instruc-
maintained for 8 hours before the test.
tion?
An upper GI series involves visualization
of the esophagus, duodenum, and up-
"The test will take about 30 minutes."
per jejunum by means of the use of a
"I need to fast for 8 hours before the test."
contrast medium. It involves swallowing a
"I need to drink citrate of magnesia the
contrast medium (usually barium), which
night before the test and give myself a
is administered in a flavored milkshake.
Fleet enema on the morning of the test."
Films are taken at intervals during the
"I need to take a laxative after the test
test, which takes about 30 minutes. Af-
is completed, because the liquid that I'll
ter an upper GI series, the client is pre-
have to drink for the test can be consti-
scribed a laxative to hasten elimination
pating."
of the barium. Barium that remains in the
colon may become hard and difficult to
expel, leading to fecal impaction.
A nurse on the evening shift checks a
primary health care provider's prescrip-
tions and notes that the dose of a pre-
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
scribed medication is higher than the
normal dose. The nurse calls the primary Ask the answering service to contact the
health care provider's answering service on-call primary health care provider
and is told that the primary health care
provider is off for the night and will be Rationale: The nurse has a duty to
available in the morning. What should the protect the client from harm. A nurse
nurse do next? who believes that a primary health care
provider's prescription may be in error
Call the nursing supervisor is responsible for clarifying the prescrip-
Ask the answering service to contact the tion before carrying it out. Therefore the
on-call primary health care provider nurse would not administer the medica-
Withhold the medication until the primary tion; instead, the nurse would withhold
health care provider can be reached in the medication until the dose can be clar-
the morning ified. The nurse would not wait until the
Administer the medication but consult next morning to obtain clarification. It is
the primary health care provider when he premature to call the nursing supervisor.
becomes available
Ask the ED primary health care provider
to check the client
Rationale: The most appropriate action
An emergency department (ED) nurse
by the nurse would be to ask the ED
is monitoring a client with suspected
health care provider to check the client.
acute myocardial infarction (MI) who is
PVCs are a result of increased irritabil-
awaiting transfer to the coronary inten-
ity of ventricular cells. Peripheral puls-
sive care unit. The nurse notes the sud-
es may be absent or diminished with
den onset of premature ventricular con-
the PVCs themselves because the de-
tractions (PVCs) on the monitor, checks
creased stroke volume of the premature
the client's carotid pulse, and determines
beats may in turn decrease peripheral
that the PVCs are not perfusing. What is
perfusion. Because other rhythms also
the nurse's most appropriate action?
cause widened QRS complexes, it is es-
sential that the nurse determine whether
Document the findings
the premature beats are resulting in per-
Ask the ED primary health care provider
fusion of the extremities. This is done by
to check the client
palpating the carotid, brachial, or femoral
Continue to monitor the client's cardiac
artery while observing the monitor for
widened complexes or by auscultating
for apical heart sounds. In the situation
of acute MI, PVCs may be considered
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
warning dysrhythmias, possibly herald-
ing the onset of ventricular tachycardia
or ventricular fibrillation. Therefore, the
status nurse would not tell the client that the
Inform the client that PVCs are expected PVCs are expected. Although the nurse
after an MI will continue to monitor the client and
document the findings, these are not the
most appropriate actions of those provid-
ed.
Administer the antihypertensive with a
small sip of water
NPO status is imposed 8 hours be- Rationale: The nurse should adminis-
fore the procedure on a client sched- ter the antihypertensive with a small
uled to undergo electroconvulsive thera- sip of water. General anesthesia is re-
py (ECT) at 1 p.m. On the morning of the quired for ECT, so NPO status is im-
procedure, the nurse checks the client's posed for 6 to 8 hours before treat-
ment to help prevent aspiration. Excep-
record and notes that the client routinely
takes an oral antihypertensive medica- tions include clients who routinely re-
tion each morning. What action should ceive cardiac medications, antihyperten-
the nurse take? sive agents, or histamine (H2) blockers,
which should be administered several
Administer the antihypertensive with a hours before treatment with a small sip
small sip of water of water. Withholding the antihyperten-
Withhold the antihypertensive and ad- sive and administering it at bedtime and
minister it at bedtime withholding the antihypertensive and re-
Administer the medication by way of the suming administration on the day after
intravenous (IV) route the ECT are incorrect actions, because
Hold the antihypertensive and resume its antihypertensives must be administered
administration on the day after the ECT on time; otherwise, the risk for rebound
hypertension exists. The nurse would not
administer a medication by way of a route
that has not been prescribed.
"Tell me more about what you're feeling."
A client who recently underwent coro-
nary artery bypass graft surgery comes Rationale: The therapeutic response by
to the primary health care provider's of- the nurse is, "Tell me more about what
you're feeling." When a client express-
, HESI Comprehensive Exam
Study online at https://quizlet.com/_8w46yj
es feelings of depression, it is extreme-
fice for a follow-up visit. On assessment, ly important for the nurse to further ex-
the client tells the nurse that he is feeling plore these feelings with the client. In
depressed. Which response by the nurse stating, "This is a normal response after
is therapeutic? this type of surgery" the nurse provides
false reassurance and avoids address-
"Tell me more about what you're feeling." ing the client's feelings. "It will take time,
"That's a normal response after this type but I promise you, you will get over the
of surgery." depression" is also a false reassurance,
"It will take time, but I promise you, you and it does not encourage the expression
will get over this depression." of feelings. "Every client who has this
"Every client who has this surgery feels surgery feels the same way for about a
the same way for about a month." month" is a generalization that avoids the
client's feelings.
Contact the primary health care provider
Rationale: The priority action is for the
nurse to contact the primary health care
provider. The FHR is assessed for at
A client in labor experiences sponta-
least 1 minute when the membranes rup-
neous rupture of the membranes. The
ture. The nurse also checks the quantity,
nurse immediately counts the fetal heart
color, and odor of the amniotic fluid. The
rate (FHR) for 1 full minute and then
fluid should be clear (often with bits of
checks the amniotic fluid. The nurse
vernix) and have a mild odor. Fluid with a
notes that the fluid is yellow and has a
foul or strong odor, cloudy appearance,
strong odor. Which action should be the
or yellow coloration suggests chorioam-
nurse's priority?
nionitis and warrants notifying the prima-
ry health care provider. A large amount of
Contact the primary health care provider
vernix in the fluid suggests that the fetus
Document the findings
is preterm. Greenish, meconium-stained
Check the fluid for protein
fluid may be seen in cases of post-
Continue to monitor the client and the
term gestation or placental insufficiency.
FHR
Checking the fluid for protein is not as-
sociated 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 in inserting a central ve-
nous access device into a client with a
diagnosis of severe malnutrition who will
be receiving parenteral nutrition (PN). Af-
ter insertion of the catheter what does
