UPDATE!!!2025/2026|GUARANTEED
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 -
ANSWER 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."
1
,"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." - ANSWER "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 - ANSWER 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.
2
,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 - ANSWER 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
3
, Hold the antihypertensive and resume its administration on the day after the ECT -
ANSWER 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." -
ANSWER "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.
4
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 -
ANSWER 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."
1
,"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." - ANSWER "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 - ANSWER 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.
2
,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 - ANSWER 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
3
, Hold the antihypertensive and resume its administration on the day after the ECT -
ANSWER 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." -
ANSWER "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.
4
