HESI NOTES
A client is to be discharged on prednisone. Which statement indicates that the client understands how to take the medication?
"I need to wear or carry identification that I am taking prednisone." Explanation: The client needs to wear or carry information containing the name of the drug, dosage, health care provider (HCP) and contact information, and emergency instructions because additional corticosteroid drug therapy would be needed during emergency situations. Prednisone should be taken in the morning because it can cause insomnia and because exogenous corticosteroid suppression of the adrenal cortex is less when it is administered in the morning. Prednisone must never be stopped suddenly. It must be tapered off to allow for the adrenal cortex to recover from drug-induced atrophy so that it can resume its function. Prednisone should be taken with food or milk to prevent stomach irritation
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?
Administer analgesics around the clock. Explanation: Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.6 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?
Atropine decreases salivation and gastric secretions." Explanation: The nurse should tell the client that, when used as preanesthesia medication, atropine and other cholinergic blocking agents reduce salivation and gastric secretions, thus helping to prevent aspiration of secretions during surgery. Atropine increases the heart rate and cardiac contractility, decreases bronchial secretions, and causes bronchodilation. No evidence indicates that the drug enhances the effect of anesthetic agents.
The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN?
Ensure adequate caloric and protein intake. Explanation: Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.
The student nurse is planning to care for a peripheral intravenous (I.V.) site for a client receiving chemotherapy. Which outcome would demonstrate that the student understands the concepts of I.V. care?
If extravasation is suspected, stop the infusion. Explanation: Peripheral venous access devices are commonly used for clients receiving long-term chemotherapy, total parenteral nutrition, or frequent medication or fluids. These devices may remain in place for several weeks to more than 1 year if no complications develop. Extravasation, or infiltration of the drug into surrounding tissue, is an emergency, and the priority action is to stop the infusion. The site could be cleaned and dressing changed more often than every 72 hours depending on the type of dressing, patient's condition, and other factors. Heparin is not used to flush peripheral sites. Nurses monitor I.V. sites more frequently than every 24 hours; the site should be checked at least every 4 hours.
Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. What is the expected outcome of this drug?
Inhibit oral and respiratory secretions. Explanation: Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.
The client has chronic pancreatitis. What should the nurse teach the client to do to monitor the effectiveness of pancreatic enzyme replacement?
Observe stools for steatorrhea. Explanation: If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.
A client is taking phenelzine 15 mg PO three times a day. The nurse is about to administer the next dose when the client tells the nurse about having a throbbing headache. Which action should the nurse do first?
Obtain the client's vital signs. Explanation: The nurse should first take the client's vital signs because the client could be experiencing a hypertensive crisis, which requires prompt intervention. Signs and symptoms of a hypertensive crisis include occipital headache, a stiff or sore neck, nausea, vomiting, sweating, dilated pupils and photophobia, nosebleed, tachycardia, bradycardia, and constricting chest pain. Giving this client an analgesic without taking his vital signs first is inappropriate. After the client's vital signs have been obtained, then the nurse would call the HCP to report the client's problems and vital signs. Administering the client's next dose of phenelzine before taking his vital signs could result in a dangerous situation if the client is experiencing a hypertensive crisis.
The nurse is caring for a client with a nasogastric tube and is preparing to administer the client's medications. Which medications can the nurse safely administer through the tube? Select all that apply.
a liquid medication an emptied capsule mixed with water
A client diagnosed with major depression has started taking amitriptyline hydrochloride, a tricyclic antidepressant. What is a common adverse effect of this drug?
dry mouth Explanation: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain — not loss — is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.
A nurse is reviewing the healthcare provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care
hydroxychloroquine Explanation: Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.
A nurse overhears this conversation between coworkers: "Older people have lost many friends and family and also have health problems. Their anxiety and worries can be so severe that they need higher doses of benzodiazepines than most people." What is the most appropriate response for the nurse to make to the coworkers?
"That's not right. Older people need lower doses than most people because of reduced liver and kidney function." Explanation: Reduced liver and kidney function are expected in older adults; benzodiazepines and many other medications should be administered cautiously to the elderly. Older adults are also at increased risk for falls because of oversedation that can occur with benzodiazepines. While benzodiazepines may be prescribed in lower doses, they can still be used in older adults with monitoring for safety.
A client is receiving intravenous mannitol for treatment of a brain tumor. The client's intracranial pressure before administration of the mannitol was 14 mm Hg. Which assessment finding indicates that the medication is attaining a therapeutic effect?
intracranial pressure of 10 mm Hg Explanation: An expected finding with this osmotic diuretic is an intracranial pressure of 5-15 mm Hg. The medication is not administered to decrease agitation, lower systolic blood pressure, or decrease peripheral edema. The main therapeutic effect in brain tumor management is to decrease intracranial pressure.
A client is taking paroxetine 20 mg PO every morning. The nurse should monitor the client for which adverse effect?
sexual problems Explanation: The nurse should monitor the client taking paroxetine, a selective serotonin reuptake inhibitor, for sexual problems, such as decreased libido, impotence, and ejaculatory disturbances, because these adverse effects can occur frequently and lead to medication noncompliance. Sleep disturbances can occur with an SSRI such as paroxetine. However, this client is taking the drug every morning, which would not affect nighttime sleep. Hypertensive crisis is associated with the ingestion of foods rich in tyramine when a client is taking a monoamine oxidase inhibitor. Orthostatic hypotension is a potential adverse effect of tricyclic antidepressants.
A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering
vasopressin. Explanation: Vasopressin is given subcutaneously to manage diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.
A client is scheduled to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is checked, what other assessments/actions would the nurse be responsible for? Select all that apply.
Assess the client for chills or low back pain. Stop the transfusion for reports of dyspnea or itching. Explanation: Checking for the possibility of transfusion reactions is an important responsibility. Chills can be associated with blood contamination, low back pain can be associated with incompatible blood, and dyspnea and skin itching can be associated with an allergic reaction. The transfusion would need to be stopped. Rapidly transfusing blood is incorrect because the transfusion is started slowly for the first 15 minutes to detect abnormal reactions. Transfusing blood over a prolonged period, e.g., 5 hours, increases the risk of blood contamination. Transfusion of a unit of red blood cells can take up to 4 hours, and there are no restrictions on intake of food or fluid during the transfusion.
A client who is receiving a blood transfusion suddenly experiences chills and a temperature of 101° F (38° C) The client also reports a headache and appears flushed. In what order, from first to last, should the nurse perform the actions? All options must be used.
Stop the blood infusion. Infuse normal saline to keep the vein open. Obtain a blood culture from the client. Send the blood bag and administration set to the blood bank. Explanation: The client is experiencing a septic reaction to the blood transfusion. The nurse first stops the infusion and notifies the health care provider (HCP) and blood bank; then the nurse uses an infusion of normal saline to keep the vein open, and follows by obtaining a sample of the client's blood for a blood culture. Lastly, the nurse sends the blood bag and the administration set to the blood bank for culture.
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?
Wear protective clothing. Explanation: A nurse must wear two layers of chemotherapy-approved disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. Reconstituted oral forms of chemotherapy, such as powders, should be prepared in the pharmacy and delivered in a sealed syringe. The nurse should use two layers of chemotherapy-approved gloves and a sterile gauze pad when priming IV tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or performing other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes, IV tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.
The nurse is changing a peripheral venous access dressing. Place the steps in the order that the nurse should perform them.
Put on gloves. Hold the catheter in place with nondominant hand. Carefully remove old dressing and discard. Inspect intravenous site for phlebitis, infection, or infiltration. Place sterile transparent dressing over venipuncture site. Label the intravenous dressing with date, time of change, and initials. Explanation: The first step is to put on gloves to prevent contact with a client's body fluids. The second step is to hold the catheter in place with nondominant hand to stabilize the catheter and prevent it from displacing. The third step is to carefully remove the old dressing and discard to prevent spread of microorganisms. The fourth step is to inspect the intravenous site for phlebitis, infection, or infiltration. If any of these are present, the catheter would need to be removed because there is tissue trauma. The fifth step is to place a sterile transparent dressing over the venipuncture site so the site can be visually assessed and the catheter is stabilized. The sixth step is to label the intravenous dressing with date, time of change, and initials so other healthcare professionals providing care and utilizing the catheter will know when it was inserted and when the dressing was changed.
