NCLEX Comprehensive Exam

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - 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. 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. 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? - "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 health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should: - Ask the answering service to contact the on-call health care provider Rationale: The nurse has a duty to protect the client from harm. A nurse who 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. 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: - Asking the ED health care provider to check the client Rationale: 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. The most appropriate action would be to ask the ED health care provider 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: - Administer the antihypertensive with a small sip of water Rationale: 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, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed. A client who recently underwent coronary artery bypass graft surgery comes to the health care provider'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? - "Tell me more about what you're feeling." Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but, I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.