HESI Practice
A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What findings does the nurse expect to identify when performing an admission assessment? Select all that apply. 1 Melena 2 Tachycardia 3 Constipation 4 Clay-colored stools 5 Painful bowel movements
1. Melena 2. Tachycardia Ibuprofen irritates the gastrointestinal (GI) mucosa and can cause mucosal erosion, resulting in bleeding; blood in the stool (melena) occurs as the digestive process acts on the blood in the upper GI tract. Hemoglobin, which carries oxygen to body cells, is decreased with anemia; the heart rate increases as a compensatory response to increase oxygen to body cells. Constipation usually is related to immobility, a low-fiber diet, and inadequate fluid intake, not the data listed in this situation. Clay-colored stools are related to biliary problems, not GI bleeding. Painful bowel movements are related to hemorrhoids, not GI bleeding.
A nurse provides instruction when the beta-blocker atenolol is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? 1 Take the medication before going to bed. 2 Expect to feel drowsy when taking this drug. 3 Count the pulse before taking the medication. 4 Move slowly when changing positions from sitting to standing.
1. Take the medication before going to bed Beta-blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly from sitting to standing to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur with BBs.
While receiving an adrenergic beta 2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? 1 Withhold the drug and notify the healthcare provider. 2 Tell the client not to worry; these are expected side effects from the medicine. 3 Give instructions to breathe slowly and deeply for several minutes. 4 Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.
1. Withhold the drug and notify the healthcare provider These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur, and the drug should be withheld until the healthcare provider is notified. Telling the client not to worry and that these are expected side effects from the medicine is false reassurance and a false statement. Controlled breathing may be helpful in allaying a client's anxiety; however, the drug may be producing adverse effects and should be withheld.
When discussing the therapeutic regimen of vitamin B 12 for pernicious anemia with a client, what teaching does the nurse provide? 1 Weekly Z-trac injections provide needed control. 2 Daily intramuscular injections are required for control. 3 Intramuscular injections once a month will maintain control. 4 Oral vitamin B 12 tablets taken daily will provide symptom control.
3. Intramuscular injections once a month will maintain control Intramuscular injections bypass the vitamin B 12 absorption defect (lack of intrinsic factor, the transport carrier component of gastric juices). A monthly dose usually is sufficient because it is stored in active body tissues, such as the liver, kidney, heart, muscles, blood, and bone marrow. The Z-track method need not be used as it is for iron dextran injections. Because it is stored and only slowly depleted, injections once a month usually are sufficient. Vitamin B 12 cannot be taken by mouth because of the lack of intrinsic factor.
After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip is prescribed. Several hours later, vancomycin intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. 3 Start another IV line for the vancomycin and continue the heparin as prescribed. 4 Hold the vancomycin and tell the healthcare provider that the drug is incompatible with heparin.
3. Start another IV line for the vancomycin and continue the heparin as prescribed. The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the healthcare provider's, to administer them safely.
A primary health care provider prescribes total parenteral nutrition for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the most important reason for using this type of access? 1 Infection is uncommon. 2 It permits free use of the hands. 3 The chance of the infusion infiltrating is decreased. 4 The amount of blood in a major vein helps to dilute the solution.
4. The amount of blood in a major vein helps to dilute the solution. Unless diluted, the highly concentrated solution can cause vein irritation or occlusion. Although it permits free use of the hands, this is not the primary reason for a central line. Infection can occur at any invasive site and requires diligent care to avoid this complication. The chance of the infusion infiltration decreasing is not the primary reason, although the infusion at this site is more secure than a peripheral site and promotes free use of the hands.
When a client exhibits severe bradycardia, which type of drug should the nurse be prepared to administer? 1 Cardiac nitrate 2 Anticholinergic 3 Antihypertensive 4 Cardiac glycoside
2. Anticholinergic An anticholinergic drug will block parasympathetic effects, causing an increased heart rate. Cardiac nitrate will dilate coronary arteries, not increase the heart rate. Antihypertensive drugs will lower the blood pressure and may decrease the heart rate. Cardiac glycoside will improve cardiac contractility but will decrease the heart rate.
A healthcare provider prescribes 2 liters of intravenous (IV) fluid to be administered every 12 hours to a client who sustained a burn injury. The drop factor of the tubing is 10 gtts/mL. The nurse should set the flow rate at how many drops per minute? Record your answer using a whole number. ___ gtts/min
28
An obese client must self-administer insulin at home. The nurse will teach the client to inject insulin at which angle? 1 30-degree angle 2 60-degree angle 3 45-degree angle 4 90-degree angle
4. 90 degree angle Injection should be made at a 90-degree angle for most patients, including those of normal weight. Injecting at a 30-degree angle or a 60-degree angle is not appropriate for the obese, normal weight, the child, or the thin client. If injecting into a child or a thin client, the injection should be made at a 45-degree angle.
A practitioner prescribes penicillin G benzathine suspension 2.4 million units for a client with a sexually transmitted infection. The medication is available in a multidose vial of 10 mL in which 1 mL = 300,000 units. How many milliliters should the nurse administer? Record your answer using a whole number. ___ mL
8 mL
A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. 1 Respiratory depression 2 Distention of the bladder 3 Decreased blood pressure 4 Fine tremor of the fingers 5 High-pitched gurgling bowel sounds
1, 3, 5 Anticholinergic effects of pyridostigmine can cause respiratory depression, bronchospasm, laryngospasm, and respiratory arrest, which are life threatening. Anticholinergic effects of pyridostigmine can cause hypotension tachycardia, bradycardia, dysrhythmias, and cardiac arrest. Pyridostigmine is an anticholinergic that increases the peristaltic activity of the intestines. The result is hyperactive bowel sounds. Bladder distention is not associated with pyridostigmine. Although pyridostigmine can cause incoordination, it does not cause fine tremors of the hands.
A healthcare provider prescribes selegiline 5 mg twice a day for a client with a diagnosis of Parkinson disease. What is most important for the nurse to teach the client? 1 Eat food high in tyramine. 2 Ensure that an opioid is not taken currently. 3 Take the medication in the morning and evening. 4 Monitor for signs of hypoglycemia and hyperglycemia.
2. Ensure that an opioid is not taken currently Selegiline concurrently used with an opioid analgesic can result in a fatal reaction (e.g., excitation, rigidity, hypertension, hypotension, coma). Foods high in tyramine (e.g., cheese, wine, beer, pickled products) should be avoided, not encouraged. When foods high in tyramine are broken down, they release specific biogenic amines. When the breakdown of these biogenic amines is inhibited by monoamine oxidase inhibitors, such as selegiline, pressor substances accumulate in the body, causing a quick increase in blood pressure to excessively high levels, precipitating intracranial bleeding and death. It is recommended that this medication be taken at breakfast and lunch, so its effects are more apparent while the client is awake; it should not be taken in the evening or at bedtime. Selegiline does not influence serum glucose levels. It can produce false-positive or false-negative results for glycosuria.
To minimize the side effects of the vincristine that a client is receiving, what does the nurse expect the dietary prescription to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue
3. High in fluids A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Dietary plans that are low in fat, high in iron, and low in residue will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.
A client has surgery for the insertion of an implanted infusion port for chemotherapy. The client asks, "The doctor said after my chemotherapy is finished, the port will stay in, but it needs to be flushed routinely. How often does this have to be done?" What should the nurse tell the client about how often the port will most likely need to be flushed when not in use? 1 Every day 2 Once a week 3 Every month 4 Twice a year
3. every month Once-a-month flushes usually are adequate to keep an implanted infusion port from clotting. Every day or once a week is unnecessary. Twice a year may jeopardize the viability of the port.
A healthcare provider has prescribed isoniazid for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark, concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize gastrointestinal (GI) upset. 4 Drinking alcohol daily can cause drug-induced hepatitis.
4. Drinking alcohol daily can cause drug-induced hepatitis Daily alcohol intake can cause drug-induced hepatitis. Prolonged use does not cause dark, concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.
