HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
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HESI
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HESI
HESI COMPREHENSIVE EXAM 3 QUESTION AND ANSWERS 2024/2025 UPDATED
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 puls...
HESI COMPREHENSIVE EXAM 3 QUESTION
AND ANSWERS 2024/2025 UPDATED
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
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."
"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.
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
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
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 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
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."
"Tell me more about what you're feeling."
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
, 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
Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the catheter
has been placed but before it is used for infusions, its placement must be checked with
an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed
rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency are all incorrect because they could result in the infusion of solution
into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose
measurement to serve as a baseline, this action is not the priority.
A rape victim being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the most appropriate response by
the nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
"Let's talk about the information that you need to determine your risk of
contracting HIV."
"Let's talk about the information that you need to determine your risk of contracting
HIV."
Rationale: The most appropriate response by the nurse is the one that encourages the
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