AND ANSWERS 2024/2025 BEST EXAM SOLUTION TOP
RANKED A+ FOR SUCCESS
1. ID: 9476788675
hEnalaprilllmaleatellisllprescribedllforllallhospitalizedllclient.llWhichllassessmentll
doesthellnursellperformllasllallpriorityllbeforelladministeringllthellmedication?
A. Checking the client's blood pressure Correct
B. Checkingllthellclient'sllperipheralllpulses
C. Checkingll thell mostll recentl l potassiumll level
D. Checkingllthellclient'sllintake-and-
outputllrecordllforllthelllastll24hoursllIncorrect
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. Checking the client’s peripheral pulses, the results of
the most recent potassium level, and the intake and output for the previous 24
hours are not specifically associated with this mediation.
Test-Taking Strategy: Focus on the name of the medication and recall that
medications that end in the letters “pril” are ACE inhibitors and that these
medications are used to treat hypertension. This will direct you to the correct
option. Review the action of enalapril maleate if you had difficulty with this
question.
Reference: Lehne, R. (2013). Pharmacology for nursing care (8th ed., p. 513). St.
Louis: Saunders.
Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Care Coordination, Safety
HESI Concepts:Collaboration/Managing Care, Safety
Awardedll0.0llpointslloutllofll1.0llpossiblellpoints.
2. ID: 9476754035
Allclientllisllscheduledlltollundergollanllupperllgastrointestinalll(GI)llseries,llandl l th
ellnursellprovidesllinstructionslltollthellclientllaboutllthelltest.llWhichllstatementllb
ylltheclientllindicatesllallneedllforllfurtherllinstruction?
A. "Thelltestllwilllltakellaboutll30llminutes."
B. "Illneedlltollfastllforll8llhoursllbeforellthelltest."llIncorrect
C. "Illneedlltolldrinkllcitratellofllmagnesiallthellnightllbeforellthelltest
, andgivellmyselfllallFleetllenemallonllthellmorningllofllthelltest."llCorrect
D.
"Illneedlltolltakellalllaxativellafterllthelltestllisllcompleted,llbecausellthellliqui
Rationale: An upper
dllthat GI series
llI’llllhave involves
lltolldrink visualization
llforllthe ofllconstipating."
lltestllcanllbe 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.
Test-Taking Strategy: Use the process of elimination. Note the strategic words
"need for further instruction." These words indicate a negative event query and
the need to select the incorrect client statement. Focusing on the word "upper" in
the name of the test will direct you to the correct option. Review preprocedure
care for an upper GI series if you had difficulty with this question.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., p.
879). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Gastrointestinal
Giddens Concepts: Client Education, Clinical Judgment
HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and
Learning/Patient Education
Awardedll0.0llpointslloutllofll1.0llpossiblellpoints.
3. ID: 9476790957
Allnursel l onl l thel l eveningllshiftllchecksl l allhealthl l carel l provider'sl l prescriptionslla
ndllnotesllthatllthelldosellofllallprescribedllmedicationllisllhigherllthanllthellnormalll
dose.llThellnursellcallsllthellhealthllcarellprovider'sllansweringllservicellandllislltoldll
thatllthellhealthllcarellproviderllislloffllforllthellnightllandllwillllbellavailablellinllthell
morning.llThenursellshould:
A. Calll l thellnursingllsupervisor
B. Askllthellansweringllservicelltollcontactllthellon-callllhealthllcare
providerllCorrect
C.
Withholdllthellmedicationlluntilllthellhealthllcarellproviderllcanllbere
achedllinllthellmorning
D.
Administerllthellmedicationllbutllconsultllthellhealthllcarellproviderllwhe
Rationale:nllThe nurse has
hellbecomes a duty to protect the client from harm. A nurse who
llavailable
believes that a 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.
Test-Taking Strategy: Use the process of elimination and your knowledge of the
legal responsibilities of the nurse in regard to medication administration and
health care provider’s prescriptions. Eliminate the options that are comparable or
alike in that they avoid clarification of the prescription (administering the
medication and holding the medication). To select from the remaining options,
note that it is premature to call the nursing supervisor. Also note that the correct
option is the only one that clarifies the prescription. Review legal responsibilities
in regard to medication prescriptions if you had difficulty with this question.
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M.
(2013). Fundamentals of nursing. (8th ed., p.585). St. Louis: Mosby.
Cognitive Ability: Applying