HESI Comprehensive Exam Questions & Answers

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 - ANSWERSRationale: 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." - ANSWERSNo 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? Ask the answering service to contact the on-call primary health care provider - ANSWERSThe 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? Ask the ED primary health care provider to check the client - ANSWERSThe 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 w/the PvCs themselves b/c the decreased stroke vol of the premature beats may in turn decrease peripheral perfusion. B/c other rhythms also cause widened QrS complexes, its 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 wouldnt tell the client that the PvCs are expected. Although the nurse will continue to monitor the client & document the findings, these arent 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 - ANSWERSThe 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, 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 primary 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." - ANSWERSThe therapeutic response by the nurse is, "Tell me more about what you're feeling." 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. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action should be the nurse's priority? Contact the primary health care provider - ANSWERSThe priority action is for the nurse to contact the primary health care provider. FhR is assessed for at least 1 min when the membranes rupture. The nurse also checks the quantity, color, & odor of the amniotic fluid. The fluid should be clear(often w/ bits of vernix)& have a mild odor. Fluid w/a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis & warrants notifying the primary health care provider. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein isnt associated w/the data in the question. The nurse would continue to monitor the client & the FHR and would document the findings. A nurse has assisted a primary health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter what does the nurse immediately do? Call the radiography department to obtain a chest x-ray - ANSWERSThe nurse should immediately make arrangements to have a chest x-ray done. One major complication associated w/central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before its used for infusions, its placement must be checked w/an x-ray. Hanging the prescribed bag of PN & starting the infusion @the prescribed rate & infusing normal saline solution through the catheter @a rate of 100 mL/hr to maintain patency are all incorrect b/c they could result in the infusion of solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority. A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the most appropriate response by the nurse? "Let's talk about the information that you need to determine your risk of contracting HIV." - ANSWERSThe most appropriate response by the nurse is the 1 that encourages the client to talk about her condition. HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the info needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency dep or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern. A client is taking prescribed ibuprofen 200 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. What should the nurse tell the client? "Take the medication with food." - ANSWERSIbuprofen is a nonsteroidal antinflamatory medication. Side effects include nausea(with or without vomiting)and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse wouldnt instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions arent within the legal scope of the role of the nurse. Contacting the primary health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food. The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take? Notify the primary health care provider immediately of the amount of drainage. - ANSWERSThe nurse must immediately notify the primary health care provider of this excessive amount of drainage. The primary health care provider must also be immediately notified of any saturated head dressings. The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the suction from the J-P drain isnt an option and isnt done. Also, just documenting the amount in the client's record isnt correct even though the nurse would document that the primary health care provider was notified of the total drain amount. Just continuing to monitor the amount of drainage is also not an option. Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed. Over what period of time should the nurse administer this medication?3 minutes - ANSWERSRationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period. A nurse, conducting an assessment of a client being seen in the clinic for signs/symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride. On the basis of this information, the nurse determines that the client most likely has a history of what problem?Depression - ANSWERSRationale: The client is most likely suffering from depression. Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication. Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the primary health care provider immediately if he/she experiences what sign/symptom? Neck stiffness or soreness - ANSWERSThe client is taught to immediately contact the primary health care provider if the client experiences any occipital headache radiating frontally and neck stiffness or soreness, which could be the first sign of a hypertensive crisis. Phenelzine sulfate, a monoamine oxidase inhibitor(MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. Dry mouth and restlessness are common side effects of the medication. Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing primary health care provider before administering the medication? The client takes a prescribed antihypertensive. - ANSWERSRisperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin doesnt affect the administration of this medication. A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Tongue protrusion - ANSWERSThe clinical manifestations include abnormal movs(dyskinesia) and involuntary movs of the mouth, tongue ("flycatcher tongue"), and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the primary health care provider who is scheduled to perform the ECT?Recent stroke - ANSWERSSeveral conditions pose risks in the client scheduled for ECT. Among them are recent myocardial infarction or stroke and cerebrovascular malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease are not contraindications to this treatment. The nurse is caring for a client who just returned to the surgical unit after having a suprapubic prostatectomy. What type of medication does the nurse expect to be ordered? Antispasmodics - ANSWERSAntispasmodics are prescribed for bladder spasms related to a suprapubic prostatectomy. This surgery involves removal of the prostate gland by an abdominal incision with a bladder incision. Phenothiazines are a class of antipsychotic medications. Antidyskinetics have an anticholinergic action and are used to treat Parkinson's disease and some of the acute mov disorders that may be caused by antipsychotic agents. Benzodiazepines are central nervous system(CNS)depressants and can cause sedation and psychomotor slowing. They can also intensify depression caused by other drugs. Benzodiazepines have some potential for abuse and should be used with caution in clients known to abuse alcohol or other psychoactive medications. A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster? Select all that apply. - ANSWERSSeek medical advice if you find a skin lesion. Wear a hat, opaque clothing, and sunglasses when out in the sun. A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? - ANSWERSRationale: Peau d'orange (French for "orange peel") is the term used to describe skin dimpling, resembling the skin of an orange, at the location of a breast mass. This change, along with increased vascularity, nipple retraction, or ulceration, may indicate advanced disease. Erythema, or reddening, of the breast indicates inflammation such as that resulting from cellulitis or a breast abscess. Paget's disease is a rare type of breast cancer that is manifested as a red, scaly nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy. The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. What does the nurse tell the mother after providing information to the mother about diet, exercise, insulin, and blood glucose control? That the child should eat a carbohydrate snack about a half-hour before each soccer game - ANSWERSThe child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the primary health care provider. There is no reason for the child to avoid participating in sports. A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? Powerlessness - ANSWERSPowerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any sig way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when theres an alteration in the way the client perceives his or her own body image.