WGU D236 HESI VERSION 2 PRACTICE QUESTIONS WITH WELL DETAILED SOLUTIONS-
GRADED A+
An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent
motion sickness while on a cruise. Which information should the nurse provide to the
client?
Drink no more than 2 alcoholic drinks during the cruise.
Place the patch on a hairless area at the base of the skull.
Change the patch every other day while on the cruise.
Apply the patch at least 4 hours prior to departure.
Apply the patch at least 4 hours prior to departure.
Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak
onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours
before departure on the cruise ship. The duration of the transdermal patch is 72 hours.
Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so
the best application site of the patch is behind the ear. Anticholinergic medications are
CNS depressants, so the client should be instructed to avoid alcohol while using the patch.
An adolescent with suspected bacterial meningitis is admitted after a lumbar puncture
specimen is collected and sent to the laboratory. Which action is most important for the
nurse to implement next?
Administer pain medication.
Insert an indwelling urinary catheter.
Collect blood for serum electrolytes.
,Place on droplet precautions.
Place on droplet precautions.
Meningococcal meningitis, diagnosed by culture of cerebrospinal fluid, is transmitted via
droplet transmission. Until laboratory results confirm the etiological organism, the client
(pediatric or adult) with meningococcal meningitis should be placed on droplet
precautions until 24 hours of appropriate antibiotic therapy is completed.
The nurse is assessing a client who was discharged home after management of chronic
hypertension. Which equipment should the nurse instruct the client to use at home?
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.
Exercise bicycle.
Sphygomanometer
Self-awareness is the best way for a client to manage chronic hypertension, so the client
should obtain a sphygmomanometer and learn how to monitor blood pressure daily and
maintain a record.
In preparing to administer intravenous albumin to a client following surgery, what is the
priority nursing intervention? (Select all that apply.)
A. Compare the client's blood type with the label on the albumin.
,B. Set the infusion pump to infuse the albumin within four hours.
C. Assess for increased bleeding after administration.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assign a UAP to monitor blood pressure q15 minutes.
B, C, D, E
Albumin should be infused within four hours because it does not contain any preservatives.
Any fluid remaining after four hours should be discarded. Albumin administration does not
require blood typing. Vital signs should be monitored periodically to assess for fluid volume
overload. A large gauge catheter allows for fast infusion rate, which may be necessary.
Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB
and HCT levels should be monitored. While monitoring for bleeding because of the
increased blood volume and blood pressure
A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting
respirations that are rapid and deep. Which descriptive term should the nurse use to
document the client's breathing pattern?
Apnea.
Kussmaul respirations.
Orthopnea.
Cheyne stokes respirations.
B. Kussmaul respirations.
, Metabolic acidosis in DKA causes compensatory responses to increase the blood pH
which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The
nurse should document the client's respiratory rate and Kussmaul respiratory pattern.
The nurse is assessing a client prior to administering the prescribed dose of atenolol
(Tenormin) PO. The client's blood pressure is 120/68, and the telemetry monitor shows
sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Based on this
assessment, what intervention should the nurse implement?
Prepare to administer atropine sulfate IVP.
Give the medication as prescribed and continue to monitor the client.
Lower the head of the bed and assess the client for orthostatic vital sign changes.
Hold the prescribed dose and contact the healthcare provider.
B.Give the medication as prescribed and continue to monitor the client.
Since the BP is within normal limits, and the pulse is above 50 with a first degree block, the
medication can be administered. Atenolol (Tenormin) is a beta-blocker that slows the heart
rate and lowers the blood pressure; this drug is generally held if the heart rate is less than
50 or the client exhibits dizziness related to hypotension
The nurse is teaching a client with cancer about opioid management for intractable pain
and tolerance related side effects. The nurse should prepare the client for which side effect
that is most likely to persist during long-term use of opioids?
GRADED A+
An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent
motion sickness while on a cruise. Which information should the nurse provide to the
client?
Drink no more than 2 alcoholic drinks during the cruise.
Place the patch on a hairless area at the base of the skull.
Change the patch every other day while on the cruise.
Apply the patch at least 4 hours prior to departure.
Apply the patch at least 4 hours prior to departure.
Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak
onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours
before departure on the cruise ship. The duration of the transdermal patch is 72 hours.
Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so
the best application site of the patch is behind the ear. Anticholinergic medications are
CNS depressants, so the client should be instructed to avoid alcohol while using the patch.
An adolescent with suspected bacterial meningitis is admitted after a lumbar puncture
specimen is collected and sent to the laboratory. Which action is most important for the
nurse to implement next?
Administer pain medication.
Insert an indwelling urinary catheter.
Collect blood for serum electrolytes.
,Place on droplet precautions.
Place on droplet precautions.
Meningococcal meningitis, diagnosed by culture of cerebrospinal fluid, is transmitted via
droplet transmission. Until laboratory results confirm the etiological organism, the client
(pediatric or adult) with meningococcal meningitis should be placed on droplet
precautions until 24 hours of appropriate antibiotic therapy is completed.
The nurse is assessing a client who was discharged home after management of chronic
hypertension. Which equipment should the nurse instruct the client to use at home?
Sphygmomanometer.
Blood glucose monitor.
Weekly medication box.
Exercise bicycle.
Sphygomanometer
Self-awareness is the best way for a client to manage chronic hypertension, so the client
should obtain a sphygmomanometer and learn how to monitor blood pressure daily and
maintain a record.
In preparing to administer intravenous albumin to a client following surgery, what is the
priority nursing intervention? (Select all that apply.)
A. Compare the client's blood type with the label on the albumin.
,B. Set the infusion pump to infuse the albumin within four hours.
C. Assess for increased bleeding after administration.
D. Administer through a large gauge catheter.
E. Monitor hemoglobin and hematocrit levels.
F. Assign a UAP to monitor blood pressure q15 minutes.
B, C, D, E
Albumin should be infused within four hours because it does not contain any preservatives.
Any fluid remaining after four hours should be discarded. Albumin administration does not
require blood typing. Vital signs should be monitored periodically to assess for fluid volume
overload. A large gauge catheter allows for fast infusion rate, which may be necessary.
Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB
and HCT levels should be monitored. While monitoring for bleeding because of the
increased blood volume and blood pressure
A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting
respirations that are rapid and deep. Which descriptive term should the nurse use to
document the client's breathing pattern?
Apnea.
Kussmaul respirations.
Orthopnea.
Cheyne stokes respirations.
B. Kussmaul respirations.
, Metabolic acidosis in DKA causes compensatory responses to increase the blood pH
which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The
nurse should document the client's respiratory rate and Kussmaul respiratory pattern.
The nurse is assessing a client prior to administering the prescribed dose of atenolol
(Tenormin) PO. The client's blood pressure is 120/68, and the telemetry monitor shows
sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Based on this
assessment, what intervention should the nurse implement?
Prepare to administer atropine sulfate IVP.
Give the medication as prescribed and continue to monitor the client.
Lower the head of the bed and assess the client for orthostatic vital sign changes.
Hold the prescribed dose and contact the healthcare provider.
B.Give the medication as prescribed and continue to monitor the client.
Since the BP is within normal limits, and the pulse is above 50 with a first degree block, the
medication can be administered. Atenolol (Tenormin) is a beta-blocker that slows the heart
rate and lowers the blood pressure; this drug is generally held if the heart rate is less than
50 or the client exhibits dizziness related to hypotension
The nurse is teaching a client with cancer about opioid management for intractable pain
and tolerance related side effects. The nurse should prepare the client for which side effect
that is most likely to persist during long-term use of opioids?
