Fundamentals HESI PN 4
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg
per ml. How many ml should the nurse administer?
0.5 ml.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes
ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What
is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the nurse
implement?
Give an around-the-clock schedule for administration of analgesics.
After completing an assessment and determining that a client has a problem, which action should
the nurse perform next?
Determine the etiology of the problem
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the
floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who
is experiencing urinary retention?
Assess for bladder distention.
, A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
While instructing a male client's wife in the performance of passive range-of-motion exercises to
his contracted shoulder, the nurse observes that she is holding his arm above and below the
elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings?
Fowler's.
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be
the nurse's first response?
It is important that you continue your medication while learning to meditate.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the
pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20
minutes. For how many ml/hr should the infusion pump be set to deliver the secondary
infusion?
150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls
these neuro-cognitive functions?
Frontal lobe
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above
the IV access site. Which action should the nurse take at this time?
Initiate an alternate site for the IV infusion of the medication.
A female client asks the nurse to find someone who can translate into her native language
her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg
per ml. How many ml should the nurse administer?
0.5 ml.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a
continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes
ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What
is the best intervention for the nurse to implement?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the nurse
implement?
Give an around-the-clock schedule for administration of analgesics.
After completing an assessment and determining that a client has a problem, which action should
the nurse perform next?
Determine the etiology of the problem
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the
floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.
Which intervention is most important for the nurse to implement for a male client who
is experiencing urinary retention?
Assess for bladder distention.
, A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should
the nurse have for planning care in terms of the client's beliefs?
Blood transfusions are forbidden.
While instructing a male client's wife in the performance of passive range-of-motion exercises to
his contracted shoulder, the nurse observes that she is holding his arm above and below the
elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What is the best client position
for administration of the bolus tube feedings?
Fowler's.
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be
the nurse's first response?
It is important that you continue your medication while learning to meditate.
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the
pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20
minutes. For how many ml/hr should the infusion pump be set to deliver the secondary
infusion?
150
The nurse is completing a mental assessment for a client who is demonstrating slow thought
processes, personality changes, and emotional lability. Which area of the brain controls
these neuro-cognitive functions?
Frontal lobe
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the
infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above
the IV access site. Which action should the nurse take at this time?
Initiate an alternate site for the IV infusion of the medication.
A female client asks the nurse to find someone who can translate into her native language
her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
