HESI QUESTION BANK D. Vomiting. Correct
COMPLETED Vomiting, anorexia and abdominal pain are early indications
of digitalis toxicity. Since Lipitor increases the risk for
digitalis toxicity, this finding requires the most immediate
intervention by the nurse (D). (A, B and C) are expected side
effects of Lipitor
A client with heart failure is prescribed spironolactone
(Aldactone). Which information is most important for the
nurse to provide to the client about diet modifications?
A client is receiving clonidine (Catapres) 0.1 mg/24hr via
transdermal patch. Which assessment finding indicates
that the desired effect of the medication has been
achieved?
A. Client denies recent episodes of angina.
B. Change in peripheral edema from +3 to +1.
C. Client denies recent nausea or vomiting.
D. Blood pressure has changed from 180/120 to 140/70.
Correct
Catapres acts as a centrally-acting analgesic and
antihypertensive agent. (D) indicates a reduction in
hypertension. Catapres does not affect (A, B, or C), so these
findings do not indicate desired outcomes of Catapres
After abdominal surgery, a male client is prescribed low
molecular weight heparin (LMWH). During
administration of the medication, the client asks the nurse
why he is receiving this medication. Which is the best
response for the nurse to provide?
A. This medication is a blood thinner given to prevent
blood clot formation. Correct
B. This medication enhances antibiotics to
prevent infection.
C. This medication dissolves any clots that develop
in the legs. Incorrect
D. This abdominal injection assists in the healing of
the abdominal wound.
Unfractionated heparin or low molecular weight heparin
(LMWH) is an anticoagulant that inhibits thrombin-mediated
conversion of fibrinogen to fibrin and is given
prophylactically to prevent postoperative venous thrombosis
(A) or to treat pulmonary embolism or deep vein thrombosis
following knee and abdominal surgeries. Heparin does not
dissolve clots but prevents clot extension or further clot
formation (C). The anticoagulant heparin does not prevent
infection (B) or influence operative wound healing (D).
A client with coronary artery disease who is taking
digoxin (Lanoxin) receives a new prescription for
atorvastatin (Lipitor). Two weeks after initiation of the
Lipitor prescription, the nurse assesses the client. Which
finding requires the most immediate intervention?
A. Heartburn.
B. Headache.
C. Constipation.
Page 1 of 17
,Do not add salt to foods during preparation.
Refrain for eating foods high in potassium.
Correct Restrict fluid intake to 1000 ml per day.
Increase intake of milk and milk products.
Spironolactone (Aldactone), an aldosterone antagonist, is a
potassium-sparing diuretic, so a diet high in potassium
should be avoided (B), including potassium salt substitutes,
which can lead to hyperkalemia. Although (A) is a common
diet modification in heart failure, the risk of hyperkalemia is
more important with Aldactone. Restriction of fluids (C) or
increasing milk and milk products (D) are not indicated with
this prescription.
A client with a dysrhythmia is to receive procainamide
(Pronestyl) in 4 divided doses over the next 24 hours.
What dosing schedule is best for the nurse to implement?
q6h. Correct
QID.
AC and bedtime.
PC and bedtime.
Pronestyl is a class 1A antidysrhythmic. It should be taken
around-the-clock (A) so that a stable blood level of the drug
can be maintained, thereby decreasing the possibility of
hypotension (an adverse effect) occurring because of too
much of the drug circulating systemically at any particular
time of day. (B, C, and D) do not provide an around-the-clock
dosing schedule. Pronestyl may be given with food if GI
distress is a problem, but an around-the-clock schedule
should still be maintained.
A client who was prescribed atorvastatin (Lipitor) one
month ago calls the triage nurse at the clinic complaining
of muscle pain and weakness in his legs. Which statement
reflects the correct drug-specific teaching the nurse
should provide to this client?
A. Increase consumption of potassium-rich foods
since low potassium levels can cause muscle spasms.
B. Have serum electrolytes checked at the next
scheduled appointment to assess hyponatremia, a cause
of cramping.
C. Make an appointment to see the healthcare provider,
because muscle pain may be an indication of a serious
side effect. Correct
D. Be sure to consume a low-cholesterol diet while
taking the drug to enhance the effectiveness of the
drug.
Myopathy, suggested by the leg pain and weakness, is a
serious, and potentially life-threatening, complication of
Lipitor, and should be evaluated immediately by the
healthcare provider (C). Although electrolyte imbalances
such as (A or B) can cause muscle spasms in some cases, this
is not the likely cause of leg pain in the client receiving
Lipitor, and evaluation by the healthcare provider should not
be delayed for any reason. A low-cholesterol diet is
recommended for
Page 2 of 17
, those taking Lipitor since the drug is used to lower total mEq/L). Although hypokalemia is usually associated with
cholesterol (D), but diet is not related to the leg pain symptom. diuretic therapy in heart failure, hyperkalemia is associated
with several heart failure medications, including ARBs.
A category X drug is prescribed for a young adult female Because hyperkalemia may lead to cardiac dysrhythmias, the
client. Which instruction is most important for the nurse nurse should check the apical pulse for rate and rhythm (B),
to teach this client? and the blood pressure. Before repeating the serum study (D),
the nurse should notify the healthcare provider (C) of the
A. Use a reliable form of birth control. Correct findings.
B. Avoid exposure to ultra violet light.
C. Refuse this medication if planning pregnancy. Which change in data indicates to the nurse that the
D. Abstain from intercourse while on this drug. desired effect of the angiotensin II receptor antagonist
valsartan (Diovan) has been achieved?
Drugs classified in the category X place a client who is in the
first trimester of pregnancy at risk for teratogenesis, so A. Dependent edema reduced from +3 to +1.
women in the childbearing years should be counseled to use a B. Serum HDL increased from 35 to 55 mg/dl.
reliable form of birth control (A) during drug therapy. (B) is C. Pulse rate reduced from 150 to 90 beats/minute.
not a specific precaution with Category X drugs. The client D. Blood pressure reduced from 160/90 to 130/80.
should be encouraged to discuss plans for pregnancy with the Correct
healthcare provider, so a safer alternative prescription (C) can
be provided if pregnancy occurs. Although the risk of birth Diovan is an angiotensin receptor blocker, prescribed for the
defects during pregnancy explains the restriction of these treatment of hypertension. The desired effect is a decrease in
drugs during pregnancy, (D) is not indicated. blood pressure (D). (A, B, and C) do not describe effects of
Diovan
A client receiving Doxorubicin (Adriamycin) intravenously
(IV) complains of pain at the insertion site, and the nurse A client with hyperlipidemia receives a prescription for
notes edema at the site. Which intervention is most niacin (Niaspan). Which client teaching is most important
important for the nurse to implement? for the nurse to provide?
A. Assess for erythema. A. Expected duration of flushing. Correct
B. Administer the antidote. B. Symptoms of hyperglycemia.
C. Apply warm compresses. C. Diets that minimize GI irritation. In
D. Discontinue the IV fluids. Correct D. Comfort measures for pruritis
Doxorubicin is an antineoplastic agent that causes Flushing of the face and neck, lasting up to an hour, is a
inflammation, blistering, and necrosis of tissue upon frequent reason for discontinuing niacin. Inclusion of this
extravasation. First, all IV fluids should be discontinued at the effect in client teaching (A) may promote compliance in
site (D) to prevent further tissue damage by the vesicant. taking the medication. While (B, C, and D) are all worthwhile
Erythema is one sign of infiltration and should be noted, but instructions to help clients minimize or cope with normal side
edema and pain at the infusion site require stopping the IV effects associated with niacin (Niaspan), flushing is intense
fluids (A). Although an antidote may be available (B), and causes the most concern for the client.
additional fluids contribute to the trauma of the subcutaneous
tissues. Depending on the type of vesicant, warm or cold
When assessing an adolescent who recently overdosed on
compresses (C) may be prescribed after the infusion is
acetaminophen (Tylenol), it is most important for the
discontinued.
nurse to assess for pain in which area of the body?
The nurse is preparing the 0900 dose of losartan (Cozaar), A. Flank.
an angiotensin II receptor blocker (ARB), for a client with B. Abdomen. Correct
hypertension and heart failure. The nurse reviews the C. Chest.
client's laboratory results and notes that the client's D. Head.
serum potassium level is 5.9 mEq/L. What action should
the nurse take first?
Acetaminophen toxicity can result in liver damage; therefore,
it is especially important for the nurse to assess for pain in the
A. Withhold the scheduled dose. Correct
right upper quadrant of the abdomen (B), which might
B. Check the client's apical pulse.
indicate liver damage. (A, C, and D) are not areas where pain
C. Notify the healthcare provider.
would be anticipated.
D. Repeat the serum potassium level.
In teaching a client who had a liver transplant about
The nurse should first withhold the scheduled dose of Cozaar
cyclosporine (Sandimmune), the nurse should encourage
(A) because the client is hyperkalemic (normal range 3.5 to 5
the client to report which adverse response to the
Page 3 of 17
COMPLETED Vomiting, anorexia and abdominal pain are early indications
of digitalis toxicity. Since Lipitor increases the risk for
digitalis toxicity, this finding requires the most immediate
intervention by the nurse (D). (A, B and C) are expected side
effects of Lipitor
A client with heart failure is prescribed spironolactone
(Aldactone). Which information is most important for the
nurse to provide to the client about diet modifications?
A client is receiving clonidine (Catapres) 0.1 mg/24hr via
transdermal patch. Which assessment finding indicates
that the desired effect of the medication has been
achieved?
A. Client denies recent episodes of angina.
B. Change in peripheral edema from +3 to +1.
C. Client denies recent nausea or vomiting.
D. Blood pressure has changed from 180/120 to 140/70.
Correct
Catapres acts as a centrally-acting analgesic and
antihypertensive agent. (D) indicates a reduction in
hypertension. Catapres does not affect (A, B, or C), so these
findings do not indicate desired outcomes of Catapres
After abdominal surgery, a male client is prescribed low
molecular weight heparin (LMWH). During
administration of the medication, the client asks the nurse
why he is receiving this medication. Which is the best
response for the nurse to provide?
A. This medication is a blood thinner given to prevent
blood clot formation. Correct
B. This medication enhances antibiotics to
prevent infection.
C. This medication dissolves any clots that develop
in the legs. Incorrect
D. This abdominal injection assists in the healing of
the abdominal wound.
Unfractionated heparin or low molecular weight heparin
(LMWH) is an anticoagulant that inhibits thrombin-mediated
conversion of fibrinogen to fibrin and is given
prophylactically to prevent postoperative venous thrombosis
(A) or to treat pulmonary embolism or deep vein thrombosis
following knee and abdominal surgeries. Heparin does not
dissolve clots but prevents clot extension or further clot
formation (C). The anticoagulant heparin does not prevent
infection (B) or influence operative wound healing (D).
A client with coronary artery disease who is taking
digoxin (Lanoxin) receives a new prescription for
atorvastatin (Lipitor). Two weeks after initiation of the
Lipitor prescription, the nurse assesses the client. Which
finding requires the most immediate intervention?
A. Heartburn.
B. Headache.
C. Constipation.
Page 1 of 17
,Do not add salt to foods during preparation.
Refrain for eating foods high in potassium.
Correct Restrict fluid intake to 1000 ml per day.
Increase intake of milk and milk products.
Spironolactone (Aldactone), an aldosterone antagonist, is a
potassium-sparing diuretic, so a diet high in potassium
should be avoided (B), including potassium salt substitutes,
which can lead to hyperkalemia. Although (A) is a common
diet modification in heart failure, the risk of hyperkalemia is
more important with Aldactone. Restriction of fluids (C) or
increasing milk and milk products (D) are not indicated with
this prescription.
A client with a dysrhythmia is to receive procainamide
(Pronestyl) in 4 divided doses over the next 24 hours.
What dosing schedule is best for the nurse to implement?
q6h. Correct
QID.
AC and bedtime.
PC and bedtime.
Pronestyl is a class 1A antidysrhythmic. It should be taken
around-the-clock (A) so that a stable blood level of the drug
can be maintained, thereby decreasing the possibility of
hypotension (an adverse effect) occurring because of too
much of the drug circulating systemically at any particular
time of day. (B, C, and D) do not provide an around-the-clock
dosing schedule. Pronestyl may be given with food if GI
distress is a problem, but an around-the-clock schedule
should still be maintained.
A client who was prescribed atorvastatin (Lipitor) one
month ago calls the triage nurse at the clinic complaining
of muscle pain and weakness in his legs. Which statement
reflects the correct drug-specific teaching the nurse
should provide to this client?
A. Increase consumption of potassium-rich foods
since low potassium levels can cause muscle spasms.
B. Have serum electrolytes checked at the next
scheduled appointment to assess hyponatremia, a cause
of cramping.
C. Make an appointment to see the healthcare provider,
because muscle pain may be an indication of a serious
side effect. Correct
D. Be sure to consume a low-cholesterol diet while
taking the drug to enhance the effectiveness of the
drug.
Myopathy, suggested by the leg pain and weakness, is a
serious, and potentially life-threatening, complication of
Lipitor, and should be evaluated immediately by the
healthcare provider (C). Although electrolyte imbalances
such as (A or B) can cause muscle spasms in some cases, this
is not the likely cause of leg pain in the client receiving
Lipitor, and evaluation by the healthcare provider should not
be delayed for any reason. A low-cholesterol diet is
recommended for
Page 2 of 17
, those taking Lipitor since the drug is used to lower total mEq/L). Although hypokalemia is usually associated with
cholesterol (D), but diet is not related to the leg pain symptom. diuretic therapy in heart failure, hyperkalemia is associated
with several heart failure medications, including ARBs.
A category X drug is prescribed for a young adult female Because hyperkalemia may lead to cardiac dysrhythmias, the
client. Which instruction is most important for the nurse nurse should check the apical pulse for rate and rhythm (B),
to teach this client? and the blood pressure. Before repeating the serum study (D),
the nurse should notify the healthcare provider (C) of the
A. Use a reliable form of birth control. Correct findings.
B. Avoid exposure to ultra violet light.
C. Refuse this medication if planning pregnancy. Which change in data indicates to the nurse that the
D. Abstain from intercourse while on this drug. desired effect of the angiotensin II receptor antagonist
valsartan (Diovan) has been achieved?
Drugs classified in the category X place a client who is in the
first trimester of pregnancy at risk for teratogenesis, so A. Dependent edema reduced from +3 to +1.
women in the childbearing years should be counseled to use a B. Serum HDL increased from 35 to 55 mg/dl.
reliable form of birth control (A) during drug therapy. (B) is C. Pulse rate reduced from 150 to 90 beats/minute.
not a specific precaution with Category X drugs. The client D. Blood pressure reduced from 160/90 to 130/80.
should be encouraged to discuss plans for pregnancy with the Correct
healthcare provider, so a safer alternative prescription (C) can
be provided if pregnancy occurs. Although the risk of birth Diovan is an angiotensin receptor blocker, prescribed for the
defects during pregnancy explains the restriction of these treatment of hypertension. The desired effect is a decrease in
drugs during pregnancy, (D) is not indicated. blood pressure (D). (A, B, and C) do not describe effects of
Diovan
A client receiving Doxorubicin (Adriamycin) intravenously
(IV) complains of pain at the insertion site, and the nurse A client with hyperlipidemia receives a prescription for
notes edema at the site. Which intervention is most niacin (Niaspan). Which client teaching is most important
important for the nurse to implement? for the nurse to provide?
A. Assess for erythema. A. Expected duration of flushing. Correct
B. Administer the antidote. B. Symptoms of hyperglycemia.
C. Apply warm compresses. C. Diets that minimize GI irritation. In
D. Discontinue the IV fluids. Correct D. Comfort measures for pruritis
Doxorubicin is an antineoplastic agent that causes Flushing of the face and neck, lasting up to an hour, is a
inflammation, blistering, and necrosis of tissue upon frequent reason for discontinuing niacin. Inclusion of this
extravasation. First, all IV fluids should be discontinued at the effect in client teaching (A) may promote compliance in
site (D) to prevent further tissue damage by the vesicant. taking the medication. While (B, C, and D) are all worthwhile
Erythema is one sign of infiltration and should be noted, but instructions to help clients minimize or cope with normal side
edema and pain at the infusion site require stopping the IV effects associated with niacin (Niaspan), flushing is intense
fluids (A). Although an antidote may be available (B), and causes the most concern for the client.
additional fluids contribute to the trauma of the subcutaneous
tissues. Depending on the type of vesicant, warm or cold
When assessing an adolescent who recently overdosed on
compresses (C) may be prescribed after the infusion is
acetaminophen (Tylenol), it is most important for the
discontinued.
nurse to assess for pain in which area of the body?
The nurse is preparing the 0900 dose of losartan (Cozaar), A. Flank.
an angiotensin II receptor blocker (ARB), for a client with B. Abdomen. Correct
hypertension and heart failure. The nurse reviews the C. Chest.
client's laboratory results and notes that the client's D. Head.
serum potassium level is 5.9 mEq/L. What action should
the nurse take first?
Acetaminophen toxicity can result in liver damage; therefore,
it is especially important for the nurse to assess for pain in the
A. Withhold the scheduled dose. Correct
right upper quadrant of the abdomen (B), which might
B. Check the client's apical pulse.
indicate liver damage. (A, C, and D) are not areas where pain
C. Notify the healthcare provider.
would be anticipated.
D. Repeat the serum potassium level.
In teaching a client who had a liver transplant about
The nurse should first withhold the scheduled dose of Cozaar
cyclosporine (Sandimmune), the nurse should encourage
(A) because the client is hyperkalemic (normal range 3.5 to 5
the client to report which adverse response to the
Page 3 of 17
