HESI RN NURSING SOLUTION 2024

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A) Checking the client's blood pressure B) checking the client's peripheral pulses C) checking the most recent potassium level D) checking the client's intake and output record for the last 24 hours A) Checking the client's blood pressure Rationale--enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A) "The test will take about 30 minutes" B) "I need to fast for 8 hours before the test" C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." D) "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." C) "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Rationale An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination 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 physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician if off for the night and will be available the next morning. The nurse should: A) call the nursing supervisor B) Ask the answering service to contact the on-call physician C) Withhold the medication until the physician can be reached in the morning D) Administer the medication but consult the physician when he becomes available B) Ask the answering service to contact the on-call physician An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings B. Asking the ED physician to check the client C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI B. Asking the ED physician to check the client NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT Administer the antihypertensive with a small sip of water A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you're feeling." B. "That's a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month." A. "Tell me more about what you're feeling." Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print C. Complains of seeing a cobweb-type structure in the visual field When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status of the client C. Blurred vision and sensation changes D. Persistent unilateral headache B. Decrease in cognitive status of the client Rationale A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A. Fever, elevated white blood count, elevated platelets B. Fatigue, weight loss and anorexia, elevated red blood cells C. Hyperplasia of the gums, elevated white blood count, weakness D. Hypocellular bone marrow aspirate, fever, decreased hemoglobin level C. Hyperplasia of the gums, elevated white blood count, weakness