Module 8 Exam HESI
A nurse is changing the central line dressing of a client receiving TPN. The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? A Temperature B Time of the last dressing change C Expiration date on the infusion bag D Tightness of the tubing connection
D Tightness of the tubing connection
Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse should tell the client: A To avoid salt while taking this medication B That it is best to take the medication with food C To drink at least 2 glasses of orange juice every day D To increase fluid intake to 2000 mL to 3000 mL/day
D To increase fluid intake to 2000 mL to 3000 mL/day
Intravenous tobramycin sulfate (Tobrex) is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? A Nausea B Vertigo C Vomiting D Hypotension
B Vertigo
A physician s prescription for an adult client reads, Potassium chloride 15 mEq by mouth. The label on the medication bottle reads, 20 mEq potassium chloride/15 mL. How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round your answer to the nearest whole number.)
11
A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. The nurse tells the client to: A Place the patch in the area of a skin fold to promote adherence B Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed C If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. D Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication
B Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed
A nurse is making initials rounds on a group of assigned clients. Which of the following clients should the nurse see first? A A client receiving parenteral nutrition (PN) at a rate of 50 mL/hr for the last 24 hours B A client receiving PN at a rate of 50 mL/hr whose temp was 99° F on the previous shift C A client receiving PN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void D A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating
D A client whose PN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating
The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen (Tylenol). Which medication does the nurse ensure is available? A Pancreatin B Protamine sulfate C Phytonadione (vitamin K) D Acetylcysteine (Mucomyst)
D Acetylcysteine (Mucomyst)
A nurse is providing dietary instructions to a client taking spironolactone (Aldactone). Which of the following foods does the nurse instruct the client to avoid? Select all that apply. A Rice B Cereal C Carrots D Bananas E Citrus fruits
D Bananas E Citrus fruits
Betaxolol (Betoptic) eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic: A To have her weight checked B To give a sample for urinalysis C To have the blood glucose level checked D For measurement of blood pressure and apical pulse
D For measurement of blood pressure and apical pulse
The nurse is preparing to change the solution bag and intravenous tubing of a client receiving parenteral nutrition (PN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A Turn the head to the left B Turn the head to the right C Exhale slowly and evenly D Take a deep breath and hold it
D Take a deep breath and hold it
A client taking metronidazole (Flagyl) for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark. The nurse should tell the client: A To increase her fluid intake B To discontinue the medication C To report to the clinic to see the physician D That darkening of the urine is a harmless side effect
D That darkening of the urine is a harmless side effect
Methylergonovine (Methergine) intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will:
Prevent postpartum bleeding
A physician s prescription reads, Clindamycin phosphate (Cleocin Phosphate) 0.3 g in 50 mL NS, to be administered IV over 30 minutes. The medication label reads, Clindamycin phosphate (Cleocin Phosphate) 150 mg/mL. How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered?
2
The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse will initially: A Document the normal value on the chart B Call the healthcare provider immediately C Call the rapid response team to help with the emergency D Call the pharmacy to alert the pharmacist regarding the client's theophylline level
A Document the normal value on the chart
Metoprolol (Lopressor) has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client? Select all that apply. A Fatigue B Dry eyes C Weakness D Impotence E Nightmares
A Fatigue C Weakness D Impotence
Carbamazepine (Tegretol) is prescribed for a client with trigeminal neuralgia. Which of the following side effects does the nurse instruct the client to report to the physician? Select all that apply. A Fever B Nausea C Headache D Sore throat E Mouth sores Rationale: Drowsiness, headache, nausea, and vomiting are frequent side effects of carbamazepine. Adverse reactions include blood dyscrasias; fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain may be indicative of a blood dyscrasia, and the physician should be notified.
A Fever D Sore throat E Mouth sores
A nurse is preparing a plan of care for a client with renal colic who is receiving meperidine hydrochloride (Demerol) for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A Hypotension B Constipation C Bradycardia D Urine retention E Respiratory depression
A Hypotension B Constipation D Urine retention E Respiratory depression
A client with tuberculosis is being started on isoniazid (INH), and the nurse stresses the importance of returning to the clinic for follow-up blood testing. Which blood test will be performed? A Liver enzymes B Serum creatinine C Blood urea nitrogen D Red blood cell count
A Liver enzymes
Phenelzine sulfate (Nardil) is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which of the following medications should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? A Phentolamine B Protamine sulfate C Calcium gluconate D Acetylcysteine (Mucomyst)
A Phentolamine
A nurse suspects that a client receiving parenteral nutrition (PN) through a central line has an air embolism. The nurse immediately positions the client on the: A Left side with the head lower than the feet B Left side with the head higher than the feet C Right side with the head lower than the feet D Right side with the head higher than the feet
A Left side with the head lower than the feet
A home care nurse has been assigned a client who has been discharged home with a prescription for parenteral nutrition (PN). Which of the following parameters does the nurse plan to check at each visit as a means of identifying complications of the PN therapy? Select all that apply. A Weight B Glucose test C Temperature D Peripheral pulses E Hemoglobin and hematocrit
A Weight B Glucose test C Temperature
A nurse is caring for a client with a diagnosis of chronic renal failure who is receiving dialysis. Epoetin alfa (Epogen), to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. The nurse should prepare the medication by: A Shaking the vial before drawing up the medication B Drawing up the medication and discarding the unused portion C Obtaining the medication from the medication freezer and allowing it to thaw D Mixing the medication with 0.1 mL of heparin before administration to prevent clotting
B Drawing up the medication and discarding the unused portion
A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. The nurse should tell the client to: A Decrease fluid intake B Maintain a high-fiber diet C Avoid all exercise to help prevent lightheadedness D Avoid the use of stool softeners to help prevent diarrhea
B Maintain a high-fiber diet
A client who is taking bupropion (Wellbutrin) in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? A Insomnia B Seizures C Weight gain D Orthostatic hypotension
B Seizures
A client who has undergone adrenalectomy is prescribed prednisone. Which of the following findings indicates that the client is experiencing an adverse effect of the medication? A Dry mouth B Tarry stools C Hypotension D Hypoglycemia
B Tarry stools
A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client? Select all that apply. A Tinnitus B Tarry stools C Slowed pulse D Bleeding from the gums E Increased blood pressure
B Tarry stools D Bleeding from the gums
A nurse has taught a client who is taking lithium carbonate (Lithobid) about the medication. The nurse determines that the client needs additional teaching if the client states that: A The medication should be taken with meals B The lithium blood levels must be monitored very closely C It is important to decrease fluid intake while taking the medication to avoid nausea D The physician must be called if excessive diarrhea, vomiting, or diaphoresis occurs
C It is important to decrease fluid intake while taking the medication to avoid nausea
Disulfiram (Antabuse) is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A "When did you have your last full meal?" B "Do you have a history of diabetes insipidus?" C "When was your last drink of alcohol?" D "Do you have a history of thyroid problems?" E "Do you have a history of cancer in your family?"
C "When was your last drink of alcohol?" D "Do you have a history of thyroid problems?"
A nurse answers a call bell and finds that the parenteral nutrition (PN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which of the following actions should the nurse take first? A Calling the healthcare provider B Calling the pharmacy for further instructions C Hanging a solution of 10% dextrose in water D Hanging a solution of 5% dextrose in 0.9% sodium chloride
C Hanging a solution of 10% dextrose in water
A nurse is monitoring a client who is receiving parenteral nutrition (PN). Which of the following signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A Pallor, weak pulse, and anuria B Nausea, vomiting, and oliguria C Nausea, thirst, and increased urine output D Sweating, chills, and decreased urine output
C Nausea, thirst, and increased urine output
A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which of the following actions should the nurse take first? A Removing the IV B Sitting the client up in bed C Shutting off the IV infusion D Slowing the rate of infusion
C Shutting off the IV
A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride (Aricept). The nurse should ask the husband about the client's history of which disorder? A Dementia B Seizure disorder C Diabetes mellitus D Posttraumatic stress disorder
A Dementia
A client with heart failure being discharged home will be taking furosemide (Lasix). Which of the following statements by the client indicates to the nurse that the teaching has been effective? A "I'll weigh myself every day." B "I'll take my pulse every day." C "I'll measure my urine output." D "I'll check my ankles every day for swelling."
A "I'll weigh myself every day."
A client with a thoracic spinal cord injury is receiving dantrolene sodium (Dantrium). Which statement by the client indicates to the nurse that the client is experiencing an undesired effect of the medication? A "I'm feeling really drowsy." B "My legs are very relaxed." C "I can't seem to get enough to eat." D "I urinate about the same amount as I always did."
A "I'm feeling really drowsy."
A nurse is caring for a group of adult clients on an acute care nursing unit. Which of the following clients does the nurse recognize as the most likely candidate for parenteral nutrition (PN)? A A client with pancreatitis B A client with severe sepsis C A patient with renal caliculi D A client who has undergone repair of a hiatal hernia E A client with a severe exacerbation of ulcerative colitis
A A client with pancreatitis B A client with severe sepsis E A client with a severe exacerbation of ulcerative colitis
A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? A Akathisia B Pelvic thrusts C Athetoid limbs D Protruding tongue
A Akathisia
A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? A Atropine sulfate B Protamine sulfate C Acetylcysteine (Mucomyst) D Pyridostigmine bromide (Mestinon)
A Atropine sulfate
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F. What should the nurse do next? A Call the healthcare provider B Begin the transfusion as prescribed C Administer an antihistamine and begin the transfusion D Administer 2 tablets of acetaminophen (Tylenol) and begin the transfusion
A Call the healthcare provider
A client is receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the PN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A Chills B Pallor C Headache D Chest and back pain E Nausea and vomiting F Subnormal temperature
A Chills C Headache D Chest and back pain E Nausea and vomiting
