ALL HESI EXIT SET 5 UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
◉ 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?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
"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.".
Answer: "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: No special preparation is necessary before a GI series,
except that NPO (nothing by mouth) status must be maintained for 8
hours before the test. 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.
,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 primary health care
provider's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the
primary health care provider's answering service and is told that the
primary health care provider is off for the night and will be available
in the morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care
provider
Withhold the medication until the primary health care provider can
be reached in the morning
Administer the medication but consult the primary health care
provider when he becomes available. Answer: Ask the answering
service to contact the on-call primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A
nurse who believes that a primary health care provider's
prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not
administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait
,until the next morning to obtain clarification. It is premature to call
the nursing supervisor.
◉ 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 perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI. Answer: Ask
the ED primary health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask
the ED health care provider to check the client. PVCs are a result of
increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the
decreased stroke volume of the premature beats may in turn
decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine
whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or
femoral 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 warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular
fibrillation. Therefore, the nurse would not tell the client that the
PVCs are expected. Although the nurse will continue to monitor the
client and document the findings, these are not the most appropriate
actions of those provided.
◉ 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. What action should the nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day
after the ECT. Answer: Administer the antihypertensive with a small
sip of water
Rationale: The nurse should administer the antihypertensive with a
small sip of water. General anesthesia is required for ECT, so NPO
status is imposed for 6 to 8 hours before treatment to help prevent
aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers,
QUESTIONS AND CORRECT ANSWERS
◉ 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?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
"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.".
Answer: "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: No special preparation is necessary before a GI series,
except that NPO (nothing by mouth) status must be maintained for 8
hours before the test. 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.
,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 primary health care
provider's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the
primary health care provider's answering service and is told that the
primary health care provider is off for the night and will be available
in the morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care
provider
Withhold the medication until the primary health care provider can
be reached in the morning
Administer the medication but consult the primary health care
provider when he becomes available. Answer: Ask the answering
service to contact the on-call primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A
nurse who believes that a primary health care provider's
prescription may be in error is responsible for clarifying the
prescription before carrying it out. Therefore the nurse would not
administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait
,until the next morning to obtain clarification. It is premature to call
the nursing supervisor.
◉ 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 perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI. Answer: Ask
the ED primary health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask
the ED health care provider to check the client. PVCs are a result of
increased irritability of ventricular cells. Peripheral pulses may be
absent or diminished with the PVCs themselves because the
decreased stroke volume of the premature beats may in turn
decrease peripheral perfusion. Because other rhythms also cause
widened QRS complexes, it is essential that the nurse determine
whether the premature beats are resulting in perfusion of the
extremities. This is done by palpating the carotid, brachial, or
femoral 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 warning dysrhythmias, possibly
heralding the onset of ventricular tachycardia or ventricular
fibrillation. Therefore, the nurse would not tell the client that the
PVCs are expected. Although the nurse will continue to monitor the
client and document the findings, these are not the most appropriate
actions of those provided.
◉ 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. What action should the nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day
after the ECT. Answer: Administer the antihypertensive with a small
sip of water
Rationale: The nurse should administer the antihypertensive with a
small sip of water. General anesthesia is required for ECT, so NPO
status is imposed for 6 to 8 hours before treatment to help prevent
aspiration. Exceptions include clients who routinely receive cardiac
medications, antihypertensive agents, or histamine (H2) blockers,
