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 in...
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."
"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.
,HESI Comprehensive Exam fully solved &
updated
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.
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
,HESI Comprehensive Exam fully solved &
updated
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
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."
, HESI Comprehensive Exam fully solved &
updated
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.
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts
the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that
the fluid is yellow and has a strong odor. Which action should be the nurse's priority?
Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - answer-Contact the primary health care provider
Rationale: The priority action is for the nurse to contact the primary health care provider. The FHR is
assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity,
color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a
mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests
chorioamnionitis and warrants notifying the primary health care provider. A large amount of vernix in
the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases
of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with
the data in the question. The nurse would continue to monitor the client and the FHR and would
document the findings.
A nurse has assisted a primary health care provider in inserting a central venous access device into a
client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After
insertion of the catheter what does the nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency -
answer-Call the radiography department to obtain a chest x-ray
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