HESI Comprehensive Exit Exam Answered A+ Solution Guide.2022 1-Enalapril maleate (Vasotec) 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 B. Checking the client's peripheral ...
1-Enalapril maleate (Vasotec) 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
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
{{ANS}}A. Checking the client's blood pressure
Explanation
Checking the client's blood pressure
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.
2-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."
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."
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."
{{ANS}}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."
Explanation
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.
3-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the physician's answering service and is told
that the physician 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 physician
C. Withhold the medication until the physician can be reached in the morning
,D. Administer the medication but consult the physician when he becomes available
{{ANS}}B. Ask the answering service to contact the on-call physician
4.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 physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
{{ANS}}B. Asking the ED physician to check the client
5.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
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the ECT
{{ANS}}A. Administer the antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft surgery comes to the physician'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."
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."
{{ANS}}A. "Tell me more about what you're feeling."
7 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 of the following actions should be the nurse's priority?
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
{{ANS}}A. Contacting the physician Correct
8 A nurse has assisted a physician 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, the
nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed rate
, D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency
{{ANS}}A. Call the radiography department to obtain a chest x-ray
9 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 appropriate response by the nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of contracting HIV."
{{ANS}}D. "Let's talk about the information that you need to determine your risk of contracting HIV."
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain
resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and
indigestion. The nurse should tell the client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
{{ANS}}C. Take the medication with food
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650
mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in
50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at
the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL
at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total
drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour
period? Type your answer in the space provided.
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for
the management of anxiety. The nurse prepares the medication as prescribed and administers the
medication over a period of:
A. 3 minutes
B. 10 seconds
C. 15 seconds
D. 30 minutes
{{ANS}}A. 3 minutes Correct
13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus
infection, asks the client about medications that he is taking. The client tells the nurse that he is taking
nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client
most likely has a history of:
A. Depression
B. Diabetes mellitus
C. Hyperthyroidism
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