HESI Safety

The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? 1. Checking for the last bowel movement 2. Checking for residual stomach contents 3. Checking to determine time of last medication for nausea 4. Checking to make sure the head of bed is elevated at least 15 degrees

Checking for residual stomach contents Checking for any residual feeding not absorbed in the client's stomach must be done before introducing any more feeding. Aspiration can occur if a feeding is started with excessive residual. Checking for last bowel movement is important but not as crucial as checking for gastric residual. Knowledge of last nausea medication is not necessary at this time. Clients receiving nasogastric tube feedings must have the head of their bed elevated to at least 30 degrees.

Which drug taken by a pregnant woman shows a delayed teratogenic effect in the offspring, making the effect difficult to identify? 1. Aspirin 2. Heparin 3. Ethyl alcohol 4. Diethylstilbestrol

Diethylstilbestrol Diethylstilbestrol may cause vaginal cancer in a female child 18 or more years after birth. Aspirin suppresses contractions during labor and may cause bleeding in the mother. Heparin does not cause fetal harm but may cause osteoporosis in the mother. Ethyl alcohol causes drug dependence or alcohol withdrawal syndrome in neonates.

A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse? 1. Administration of physostigmine as soon as possible 2. Closer monitoring to prevent further suicidal attempts 3. Gastric lavage with activated charcoal and support of physiologic function 4. Intravenous administration of an anticholinergic in response to changes in vital signs

Gastric lavage with activated charcoal and support of physiologic function Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes. Physostigmine salicylate was used in the past to promote improvement in consciousness. Now its use is contraindicated because it can cause bradycardia, asystole, and seizures in clients with tricyclic antidepressant toxicity. Prevention of suicidal behavior is always advantageous; however, in this case immediate emergency intervention is necessary. The acetylcholine level is depressed as a result of the tricyclic antidepressant; anticholinergics are most effective in managing the side effects of antipsychotic and neuroleptic drugs, not tricyclic antidepressant drugs.

After being hospitalized for a transient ischemic attack (TIA) related to hypertension, a client is discharged with a prescription of hydrochlorothiazide. What should the nurse instruct the client to do when taking this medication? 1. Increase the intake of potassium-rich foods. 2. Drink a protein supplement daily. 3. Avoid eating foods high in insoluble fiber. 4. Resume regular eating habits.

Increase the intake of potassium-rich foods. The client must increase the dietary intake of potassium because of potassium loss associated with hydrochlorothiazide. Protein supplements are not necessary and may be obtained from meat, fish, and dairy products in the diet or complementary vegetable and grain proteins. Foods high in insoluble fiber are part of the food pyramid and should be included in the diet. The client should be taught about medication-induced deficiencies, which may necessitate a change in diet, and not just return to regular eating habits once home.

The primary healthcare provider prescribes a transfusion of 2 units of packed red blood cells for a client. When administering blood, what is the priority nursing intervention? 1. Make sure the client's family has received education. 2. Warm the blood to 98° F (36.7° C) to prevent chills. 3. Infuse the blood at a slow rate during the first 15 minutes. 4. Draw blood samples from the client after each unit is transfused.

Infuse the blood at a slow rate during the first 15 minutes. A slow rate provides time to recognize a reaction that is developing before too much blood is administered. Blood is not warmed to 98° F (36.7° C) to prevent chills; this could cause clotting and hemolysis. Educating the family is important but not a priority. Drawing blood samples from the client after each unit is transfused is not necessary.

Which phase of disaster management involves attempts to limit the disaster's impact on the population? 1. Recovery 2. Response 3. Mitigation 4. Preparedness

Mitigation Mitigation is the phase of disaster management where attempts are made to limit the impact of a disaster on human and community welfare. The recovery phase is associated with stabilizing the community after a disaster. The implementation phase of a disaster plan is the response phase. Preparedness is the protective plan, which assesses the risk and evaluates the damage.

What drug does a nurse anticipate that the primary healthcare provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose? 1. Naloxone 2. Methadone 3. Epinephrine 4. Amphetamine

Naloxone Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.

The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which measure should the nurse take during administration of blood products? 1. Stay with client during first 15 minutes of infusion. 2. Flush packed red blood cells with 5% dextrose and 0.45% normal saline. 3. Discontinue the intravenous catheter if a blood transfusion reaction occurs. 4. Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

Stay with client during first 15 minutes of infusion. The nurse should remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 mL of blood. Blood components are viscous, requiring a large needle to be used for venous access. A 20-gauge needle is not used to access a central catheter line. Normal saline is the solution to administer with blood productions. Lactated Ringer and dextrose in water are not used for infusion because of hemolysis.

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include? 1. Approaching the client from the left side 2. Keeping the client's head turned to the right 3. Teaching the client to use head movements to scan the left field of vision 4. Arranging the furniture in the client's room so that the door is in the right visual field

Teaching the client to use head movements to scan the left field of vision The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. The client should be approached from the right side because the left visual field is impaired. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. Although it may help to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine or trihexyphenidyl in conjunction with the phenothiazine-derivative neuroleptic medications? 1. They reduce postural hypotension. 2. They potentiate the effects of the neuroleptic drug. 3. They combat the extrapyramidal side effects of the neuroleptic drug. 4. They ameliorate the depression that may accompany schizophrenia.

They combat the extrapyramidal side effects of the neuroleptic drug. Benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian drugs. These drugs do not reduce postural hypotension, nor do they potentiate phenothiazine derivatives or have an effect on depression.

A client who has been taking a conventional antipsychotic for several days comes to the clinic complaining of neck spasms. The figure illustrates the client's physical status observed by the nurse. What extrapyramidal side effect has the client developed? 1. Torticollis 2. Tardive dyskinesia 3. Pseudoparkinsonism 4. Neuroleptic malignant syndrome

Torticollis Torticollis is an acute dystonia that involves muscle spasms of the head and neck. Torticollis develops within 1 to 5 days after beginning therapy with a conventional antipsychotic. Tardive dyskinesia is involuntary repetitious tonic muscular spasms that involve the face, tongue, lips, limbs, and trunk. Tardive dyskinesia takes several months to years to develop after the start of therapy with a conventional antipsychotic. Pseudoparkinsonism is an extrapyramidal tract response that includes masklike facies, shuffling gait, pill-rolling tremors, stooped posture, and drooling. Pseudoparkinsonism develops within several days to 1 month after the start of therapy with a conventional antipsychotic. Neuroleptic malignant syndrome is a severe, potentially fatal (10%) response to conventional antipsychotics. It is believed to be caused by an acute reduction in brain dopamine activity, precipitating hyperthermia, tachycardia, tachypnea, unstable blood pressure, hypertonicity, dyskinesia, incontinence, decreased level of consciousness, and pulmonary congestion. Neuroleptic malignant syndrome can occur during the first week of therapy but often occurs later during therapy.

The nursing student is learning about submersion injuries. Which component of sea water does the nurse know to be responsible for making it hypertonic compared to body fluids? 1. Salt 2. Mud 3. Algae 4. Chlorine

salt Salt makes sea water hypertonic compared to body fluids. Mud, algae, and chlorine are present in abundance in freshwater, which is hypotonic.

A registered nurse is educating a client with acquired immune deficiency syndrome about safe sexual practices. Which statement made by the client indicates a need for further education? 1. "I should use a dental dam during oral sex." 2. "I can participate in anal intercourse safely without using condoms." 3. "I should ask my partner to use a female condom while engaging in sexual activity." 4. "I should use condoms even while receiving highly active antiretroviral therapy (HAART)."

"I can participate in anal intercourse safely without using condoms."

A laboring client who is positive for group B Streptococcus (GBS) is given an initial dose of 2 g of ampicillin at 9 AM. According to established guidelines for intrapartum management of this client, what should the next dose be? 1. 2 g given at 10 AM 2. 1 g given at 11 AM 3. 2 g given at noon 4. 1 g given at 1 PM

1 g given at 1 PM The established guidelines for intrapartum antibiotic prophylaxis for a client infected with GBS is an initial dose of 2 g followed by a 1-g dose every 4 hours.

What are the steps of performing a primary survey according to priority to assess a client with severe injuries from a bomb blast?

1. airway 2. breathing 3. circulation 4. disability 5. exposure

Which drugs may cause an increase in the serum clozapine level? Select all that apply. 1. Rifampin 2. Phenytoin 3. Ketoconazole 4. Erythromycin 5. Bromocriptine

Answer: Ketoconazole and erythromycin Ketoconazole and erythromycin increase clozapine levels in the blood by inhibiting P450 isoenzymes. Rifampin and phenytoin reduce clozapine levels in the blood by inducing cytochrome P450 isoenzymes. Bromocriptine is a direct dopamine receptor agonist that activates dopamine receptors.

Which treatment for anthrax should be included in the biologic agent portion of a disaster plan for terrorist attacks? 1. Antivirals 2. Antitoxins 3. Antibiotics 4. Vaccinations

Antibiotics Anthrax is treated effectively with antibiotics if sufficient supplies are available and the organisms are not resistant. Antivirals would not be effective against anthrax, and there is no established treatment for most viruses that cause hemorrhagic fever. Botulism is treated with antitoxin, though several vaccines are being studied. Smallpox can be prevented or the incidence reduced by vaccination, even when first given after exposure.

The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. The nurse determines that the appropriate priority action will be to stop the antibiotic infusion and then do what? 1. Notify the physician immediately about the client's condition. 2. Take the client's blood pressure. 3. Obtain the client's pulse oximetry. 4. Assess the client's respiratory status.

Assess the client's respiratory status. The client is experiencing an allergic reaction that may progress to *anaphylaxis*. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the physician. In most facilities, the rapid response team will be called to assist the client. Another staff member can notify the physician of the client's condition while the nurse assesses the client. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care? 1. Start an intravenous (IV) line, get blood for typing and crossmatching, and obtain a history 2. Assess vital signs, obtain a history, and arrange for emergency x-ray films 3. Conduct a thorough physical assessment, assess vital signs, and cover open wounds 4. Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

Assess vital signs, control accessible bleeding, and determine the presence of critical injuries A thorough physical assessment is too time-consuming initially; open wounds can be covered at a later time. Initial rapid assessment will determine priorities of care and subsequent actions. IV therapy and transfusions will be prescribed, but baseline data are needed to assess the client's present condition and the significance of future responses. Although important, obtaining a history and x-ray films can be postponed until bleeding is controlled and injuries are assessed.