NURS 3345-265 Morsels of Exit HESI
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1.ID: 9476788675
Enalapril maleate is prescribed for a hospitalized client. Which assessment does
the nurse perform as a priority 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 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.
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). Medical-
surgical 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: Applying
,Client 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:
A. Documenting the findings
B. Asking the ED health care provider to check the client Correct
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
Rationale: 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. The most appropriate action would be to ask the ED health care
provider to check the client.
Test-Taking Strategy: Use the process of elimination. Recalling the significance of
PVCs after acute MI and noting the strategic words "not perfusing" will direct you
to the correct option. Review the significance of PVCs after acute MI if you had
difficulty with this question.
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-
surgical nursing: Assessment and management of clinical problems (9th ed., p.
799). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making/Clinical Judgment, Perfusion
Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476763527
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. The nurse should:
A. Administer the antihypertensive with a small sip of water Correct
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV)
route Incorrect
D. Hold the antihypertensive and resume its administration on the day
after the ECT
Rationale: 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.
Test-Taking Strategy: Use the process of elimination. Use your knowledge of the
principles of medication administration to help eliminate the option that involves
administering the medication by way of a route other than the prescribed one.
Recalling that antihypertensives must be administered on a regular schedule will
assist you in eliminating the options that involve withholding the medication.
Review preprocedure care for the client scheduled for ECT if you had difficulty
with this question.
Reference: Stuart, G. (2013). Principles & practice of psychiatric
nursing (10th ed.,p. 597). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making/Clinical Judgment, Safety
Awarded 0.0 points out of 1.0 possible points.
6.ID: 9476755914
A client who recently underwent coronary artery bypass graft surgery comes to
the 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?
A. "Tell me more about what you’re feeling." Correct
B. "That’s a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this
depression."
D. "Every client who has this surgery feels the same way for about a
month."
