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HESI PN Fundamentals
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of
aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide (Humorsol)
A client receiving s...
1 hesi pn fundamentals which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of aqueous humor for a client with glaucoma chlorothiazide diuril acetazolamide
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HESI PN Fundamentals
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of
aqueous humor for a client with glaucoma?
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.Instruct the
client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,
and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.Instruct the
client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a
cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for
these interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with diaphoresis.
Promote integrity of intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12
hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will
yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50
mL IVPB bag? Record your answer using one decimal place. mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning Impaired
skin integrity, related to the effects of pressure and shearing force
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,A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to
the underlying fascia. The nurse should document the assessment finding as whichstage of pressure
ulcer?
Stage I Stage
II Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before thewound
can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin
integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis,
or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure
ulcer involves full thickness tissue loss with visible subcutaneousfat. Bone, tendon, and muscle are not
exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure that
a medication reconciliation is completed? Select all that apply.
After reporting severe pain On
admission to the hospital
Upon entering the operating room Before
transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it
to the health care provider's prescriptions on admission or when there is a transfer to adifferent setting or
service, or discharge. A change in status does not require medication reconciliation. A medication
reconciliation should be completed long before entering the operating room. Total hip replacement is elective
surgery, and scheduling takes place before admission; medication reconciliation takes place when the client
is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider forwhich of
the following laboratory values?
White blood cell (WBC) count of 15,000 mm3
Negative protein in the urine
Blood urea nitrogen (BUN) of 20 mg/dL
Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3
for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these arenormal values.
Often when a family member is dying, the client and the family are at different stages ofgrieving.
During which stage of a client's grieving is the family likely to require more emotional nursing care
than the client?
Anger
Denial
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, Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment and may become indifferent
to family members. In addition, the family may take longer to accept the inevitable death than does the client.
Although the family may not understand the anger, dealing with the resultant behavior may serve as a
diversion. Denial often is exhibited by the client and family members at thesame time. During depression, the
family often is able to offer emotional support, which meets theirneeds.
The client asks the nurse to recommend foods that might be included in a diet for diverticulardisease.
Which foods would be appropriate to include in the teaching plan? Select all that apply.
Whole grains
Cooked fruit and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber
should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggshave no fiber
content but are good sources of protein. In clients with diverticular disease, nuts and seeds are
contraindicated as they may be retained and cause inflammation and infection, which is known as
diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe knee.
What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside tablePain
pattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and
quality and helps the nurse to identify what pain means to the client. The pattern of painincludes time of onset,
duration, and recurrence of pain and its assessment helps the nurse anticipateand meet the needs of the
client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking
may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to
be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the
client directly instead of accepting statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What actionshould the
nurse take?
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