HESI Comprehensive Exam
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 - Exact 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? HESI Comprehensive Exam
"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." - Exact 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.
A nurse on the evening shift checks a primary health care provider's prescriptions and notes that the dose of a prescribed medication is HESI Comprehensive Exam
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 - Exact 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. HESI Comprehensive Exam
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 - Exact 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
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