Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
1. Determine who is legally empowered to make decisions.
Rationale:
When death is impending, it is essential for the nurse to determine who is legal-
ly empowered to make decisions regarding the use of life-saving measures for
the client (D). (A) will be abnormal and will worsen without dialysis, so are not
of immediate concern. (B) may help improve the client's quality of life prior
to death, but is of less immediacy than determining whether actions should
be taken to save a client's life. If the nurse remains unable to determine who
is empowered to make decisions in this situation, the nurse may choose to
contact the ethics committee (C) for a resolution.: A 75-year-old client who has a history of end
stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued
the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions.
2. Biofeedback allows the client to control involuntary responses to promote
peripheral vasodilation.
Rationale
Biofeedback involves the use of various monitoring devices that help people
become more aware and able to control their own physiologic responses, such
as heart rate, body temperature, muscle tension, and brain waves. (D) is an
accurate statement concerning its use for clients with Raynaud's disease. (A, B,
and C) do not provide correct information about biofeedback.: A client with Raynaud's
disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the
nurse to provide?
The responses to biofeedback have not been well established and may be a waste of time and money.
, Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses.
Although biofeedback is easily learned, it is most often used to manage exacerbation of symptoms.
Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
3. Drape the top sheet and covers loosely over the bed cradle.
Rationale:
A bed cradle is used to keep the top bedclothes off the client, so the nurse
should drape the top sheet and covers loosely over the cradle (D). A client
using a bed cradle may still be able to ambulate independently (A) and does
not require raised side rails (B). (C) causes the nurse to use poor body mechan-
ics.: When making the bed of a client who needs a bed cradle, which action should the nurse include?
Teach the client to call for help before getting out of bed.
Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle.
4. Ask the client if this decision has been discussed with his healthcare provider.
Advance directives are written statements of a person's wishes regarding med-
ical care, and verbal directives may be given to a healthcare provider with
specific instructions in the presence of two witnesses. To obtain this prescrip-
tion, the client should discuss his choice with the healthcare provider (B). (A)
is insufficient to implement the client's request without legal consequences.
Although (C and D) provide legal protection of the client's wishes, the present
request needs additional action.: A male client with acquired immunodeficiency syndrome (AIDS)
develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What
action should the nurse implement?
Document the client's request in the medical record.
Ask the client if this decision has been discussed with his healthcare provider.
Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts.
Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
, Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
5. Ineffective coping related to response to positive biopsy test results.
Rationale
The first part of the nursing diagnosis statement is the "diagnostic label" and
is followed by "related to" the cause, which should direct the nurse to the
appropriate interventions. (D) best fits this criteria. (A and B) contain a medical
diagnosis. (C) includes an observable cause, but (D) focuses on the client's "re-
sponse," which the nurse can provide support, reflection, and dialogue.: Which
statement is an example of a correctly written nursing diagnosis statement?
Altered tissue perfusion related to congestive heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to client's refusal to turn.
Ineffective coping related to response to positive biopsy test results.
6. Foods and liquids consumed during the past 24 hours.
Rationale
A client's dietary habits should be determined first by the client's dietary recall
(B) before suggesting protein sources or supplements (A and C) as options in
the client's diet. Although grains and legumes (D) contain incomplete proteins
that reduces the essential amino acid pools inside the cells, the client's cultural
preferences should be elicited after confirming the client's dietary history.: A
73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information
should the nurse obtain first?
Amount of liquid protein supplements consumed daily.
Foods and liquids consumed during the past 24 hours.
Usual weekly intake of milk products and red meats.
Grains and legume combinations used by the client.
7. Instruct the client to take slow deep breaths and stop bearing down.
During administration of a rectal suppository, the client is asked to take slow
deep breaths through the mouth to relax the anal sphincter (D). Bearing down
, Hesi Pharmacology 2024 Practice
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(A) will push the suppository out of the rectum, so the suppository should not
be inserted while the client is bearing down (B). Further data is needed before
performing an invasive digital exam to check for fecal impaction (C).: While
preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath
while bearing down. What action should the nurse implement?
Advise the client to continue to bear down without holding his breath.
Gently insert the lubricated suppository four inches into the rectum.
Perform a digital exam to determine if a fecal impaction is present.
Instruct the client to take slow deep breaths and stop bearing down.
8. Flush the lumen with the saline solution and administer the medication
through the lumen.
Rationale: Aspiration of a blood return in the lumen of a central venous catheter
indicates that the catheter is in place and the medication can be administered.
The nurse should flush the tubing with the saline solution, administer the
medication (A), then flush the lumen with saline again. (B and C) are not
necessary. The aspirated blood can be flushed back through the closed system
into the client's bloodstream, but does not need to be withdrawn (D).: When
preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood
return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?
Flush the lumen with the saline solution and administer the medication through the lumen.
Determine if a PRN prescription for a thrombolytic agent is listed on the medication record.
Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing.
Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.
9. Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables,
beans, and vegetarian soups, and the client needs essential amino acids to
provide complete proteins to heal the infected wound. Although a macrobiotic
Study online at https://quizlet.com/_id13o8
1. Determine who is legally empowered to make decisions.
Rationale:
When death is impending, it is essential for the nurse to determine who is legal-
ly empowered to make decisions regarding the use of life-saving measures for
the client (D). (A) will be abnormal and will worsen without dialysis, so are not
of immediate concern. (B) may help improve the client's quality of life prior
to death, but is of less immediacy than determining whether actions should
be taken to save a client's life. If the nurse remains unable to determine who
is empowered to make decisions in this situation, the nurse may choose to
contact the ethics committee (C) for a resolution.: A 75-year-old client who has a history of end
stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued
the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
Review the client's most recent laboratory reports.
Refer the client and family members for hospice care.
Notify the hospital ethics committee of the client situation.
Determine who is legally empowered to make decisions.
2. Biofeedback allows the client to control involuntary responses to promote
peripheral vasodilation.
Rationale
Biofeedback involves the use of various monitoring devices that help people
become more aware and able to control their own physiologic responses, such
as heart rate, body temperature, muscle tension, and brain waves. (D) is an
accurate statement concerning its use for clients with Raynaud's disease. (A, B,
and C) do not provide correct information about biofeedback.: A client with Raynaud's
disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the
nurse to provide?
The responses to biofeedback have not been well established and may be a waste of time and money.
, Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses.
Although biofeedback is easily learned, it is most often used to manage exacerbation of symptoms.
Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.
3. Drape the top sheet and covers loosely over the bed cradle.
Rationale:
A bed cradle is used to keep the top bedclothes off the client, so the nurse
should drape the top sheet and covers loosely over the cradle (D). A client
using a bed cradle may still be able to ambulate independently (A) and does
not require raised side rails (B). (C) causes the nurse to use poor body mechan-
ics.: When making the bed of a client who needs a bed cradle, which action should the nurse include?
Teach the client to call for help before getting out of bed.
Keep both the upper and lower side rails in a raised position.
Keep the bed in the lowest position while changing the sheets.
Drape the top sheet and covers loosely over the bed cradle.
4. Ask the client if this decision has been discussed with his healthcare provider.
Advance directives are written statements of a person's wishes regarding med-
ical care, and verbal directives may be given to a healthcare provider with
specific instructions in the presence of two witnesses. To obtain this prescrip-
tion, the client should discuss his choice with the healthcare provider (B). (A)
is insufficient to implement the client's request without legal consequences.
Although (C and D) provide legal protection of the client's wishes, the present
request needs additional action.: A male client with acquired immunodeficiency syndrome (AIDS)
develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What
action should the nurse implement?
Document the client's request in the medical record.
Ask the client if this decision has been discussed with his healthcare provider.
Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts.
Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
, Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
5. Ineffective coping related to response to positive biopsy test results.
Rationale
The first part of the nursing diagnosis statement is the "diagnostic label" and
is followed by "related to" the cause, which should direct the nurse to the
appropriate interventions. (D) best fits this criteria. (A and B) contain a medical
diagnosis. (C) includes an observable cause, but (D) focuses on the client's "re-
sponse," which the nurse can provide support, reflection, and dialogue.: Which
statement is an example of a correctly written nursing diagnosis statement?
Altered tissue perfusion related to congestive heart failure.
Altered urinary elimination related to urinary tract infection.
Risk for impaired tissue integrity related to client's refusal to turn.
Ineffective coping related to response to positive biopsy test results.
6. Foods and liquids consumed during the past 24 hours.
Rationale
A client's dietary habits should be determined first by the client's dietary recall
(B) before suggesting protein sources or supplements (A and C) as options in
the client's diet. Although grains and legumes (D) contain incomplete proteins
that reduces the essential amino acid pools inside the cells, the client's cultural
preferences should be elicited after confirming the client's dietary history.: A
73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information
should the nurse obtain first?
Amount of liquid protein supplements consumed daily.
Foods and liquids consumed during the past 24 hours.
Usual weekly intake of milk products and red meats.
Grains and legume combinations used by the client.
7. Instruct the client to take slow deep breaths and stop bearing down.
During administration of a rectal suppository, the client is asked to take slow
deep breaths through the mouth to relax the anal sphincter (D). Bearing down
, Hesi Pharmacology 2024 Practice
Study online at https://quizlet.com/_id13o8
(A) will push the suppository out of the rectum, so the suppository should not
be inserted while the client is bearing down (B). Further data is needed before
performing an invasive digital exam to check for fecal impaction (C).: While
preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath
while bearing down. What action should the nurse implement?
Advise the client to continue to bear down without holding his breath.
Gently insert the lubricated suppository four inches into the rectum.
Perform a digital exam to determine if a fecal impaction is present.
Instruct the client to take slow deep breaths and stop bearing down.
8. Flush the lumen with the saline solution and administer the medication
through the lumen.
Rationale: Aspiration of a blood return in the lumen of a central venous catheter
indicates that the catheter is in place and the medication can be administered.
The nurse should flush the tubing with the saline solution, administer the
medication (A), then flush the lumen with saline again. (B and C) are not
necessary. The aspirated blood can be flushed back through the closed system
into the client's bloodstream, but does not need to be withdrawn (D).: When
preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood
return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?
Flush the lumen with the saline solution and administer the medication through the lumen.
Determine if a PRN prescription for a thrombolytic agent is listed on the medication record.
Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing.
Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.
9. Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables,
beans, and vegetarian soups, and the client needs essential amino acids to
provide complete proteins to heal the infected wound. Although a macrobiotic
