265_Morsels_of_Exit_HESI_Goodness/265_Morsels_of_Exit_HESI_Goodness

Document Content and Description Below

265_Morsels_of_Exit_HESI_Goodness/265_Morsels_of_Exit_HESI_Goodness 1.ID: 9476788675 Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priorit... y before administering the medication? A. Checking the client's blood pressure Correct B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours Incorrect 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. Test-Taking Strategy: Focus on the name of the medication and recall that medications that end in the letters “pril” are ACE inhibitors and that these medications are used to treat hypertension. This will direct you to the correct option. Review the action of enalapril maleate if you had difficulty with this question. Reference: Lehne, R. (2013). Pharmacology for nursing care (8th ed., p. 513). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Care Coordination, Safety HESI Concepts:Collaboration/Managing Care, Safety Awarded 0.0 points out of 1.0 possible points. 2.ID: 9476754035 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? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." Incorrect C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Correct D. "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." Rationale: 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. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GIseries, 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. Test-Taking Strategy: Use the process of elimination. Note the strategic words "need for further instruction." These words indicate a negative event query and the need to select the incorrect client statement. Focusing on the word "upper" in the name of the test will direct you to the correct option. Review preprocedure care for an upper GI series if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medicalsurgical nursing: Assessment and management of clinical problems (9th ed., p. 879). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Gastrointestinal Giddens Concepts: Client Education, Clinical Judgment HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Awarded 0.0 points out of 1.0 possible points. 3.ID: 9476790957 A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call health care provider Correct C. Withhold the medication until the health care provider can be reached in the morning D. Administer the medication but consult the health care provider when he becomes available Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a 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. Test-Taking Strategy: Use the process of elimination and your knowledge of the legal responsibilities of the nurse in regard to medication administration and health care provider’s prescriptions. Eliminate the options that are comparable or alike in that they avoid clarification of the prescription (administering the medication and holding the medication). To select from the remaining options, note that it is premature to call the nursing supervisor. Also note that the correct option is the only one that clarifies the prescription. Review legal responsibilities in regard to medication prescriptions if you had difficulty with this question. Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p.585). St. Louis: Mosby. Cognitive Ability: ApplyingClient Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership and Management Giddens Concepts: Clinical Judgment, Leadership HESI Concepts:Collaboration/Managing Care, Clinical Decision Making/Clinical Judgment Awarded 1.0 points out of 1.0 possible points. 4.ID: 9476788615 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 resulting in perfusion. The appropriate action by the nurse is: [Show More]

Last updated: 1 year ago

Preview 1 out of 186 pages