HESI Comprehensive Exam 100% Pass With A+ Grade
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1. 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
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours: 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. There
fore the nurse would check the client's blood pressure immediately before admin-
istering 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.
2. 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.": "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 contra
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.
3. A nurse on the evening shift checks a primary health care provider's pre-
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
scriptions and notes that the dose of a prescribed medication is higher than
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
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: 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.
4. 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 de- termines 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: 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 ventric- ular 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
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
palpating the carotid, brachial, or femoral artery while observing the monitor for
widened complexes or by auscultating for
Study online at https://quizlet.com/_gv4wt7
1. 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
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours: 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. There
fore the nurse would check the client's blood pressure immediately before admin-
istering 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.
2. 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.": "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 contra
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.
3. A nurse on the evening shift checks a primary health care provider's pre-
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
scriptions and notes that the dose of a prescribed medication is higher than
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
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: 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.
4. 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 de- termines 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: 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 ventric- ular 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
, HESI Comprehensive Exam 100% Pass With A+ Grade
Study online at https://quizlet.com/_gv4wt7
palpating the carotid, brachial, or femoral artery while observing the monitor for
widened complexes or by auscultating for
