Hesi rn comprehensive predictor exam,.m
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. 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?
"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 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?
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.
-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?
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 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.
-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
Withhold the antihypertensive and administer it at bedtime
,Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT - -Administer
the antihypertensive with a small sip of water
Rationale: The 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."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." - -"Tell me more
about what you're feeling."
Rationale: The 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
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - -Contact the primary health care provider
Rationale: The priority action is for the nurse to contact the primary health care provider. The
FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the
, quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and 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 is not associated with the data in the question. The nurse would continue to
monitor the client and 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
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency -
-Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray done. One
major complication associated with central venous catheter placement is pneumothorax, which
may result from accidental puncture of the lung. After the catheter has been placed but before
it is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed
bag of PN and starting the infusion at the prescribed rate and infusing normal saline solution
through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because 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?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
"Let's talk about the information that you need to determine your risk of contracting HIV." -
-"Let's talk about the information that you need to determine your risk of contracting HIV."
Rationale: The most appropriate response by the nurse is the one 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 information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the
emergency department 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
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. 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?
"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 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?
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.
-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?
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 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.
-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
Withhold the antihypertensive and administer it at bedtime
,Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT - -Administer
the antihypertensive with a small sip of water
Rationale: The 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."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." - -"Tell me more
about what you're feeling."
Rationale: The 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
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - -Contact the primary health care provider
Rationale: The priority action is for the nurse to contact the primary health care provider. The
FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the
, quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of
vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow
coloration suggests chorioamnionitis and 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 is not associated with the data in the question. The nurse would continue to
monitor the client and 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
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency -
-Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray done. One
major complication associated with central venous catheter placement is pneumothorax, which
may result from accidental puncture of the lung. After the catheter has been placed but before
it is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed
bag of PN and starting the infusion at the prescribed rate and infusing normal saline solution
through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because 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?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
"Let's talk about the information that you need to determine your risk of contracting HIV." -
-"Let's talk about the information that you need to determine your risk of contracting HIV."
Rationale: The most appropriate response by the nurse is the one 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 information needed to evaluate his or her risk.
Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the
emergency department 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
