HESI-PN Module 8
Carbamazepine is prescribed for a client with trigeminal neurlagia. Which side effects does the nurse reinforce to the client to report to the HCP? SATA A) Fever B) Nausea C) Headache D) Sore throat E) Mouth sores
A, D, E 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 health care provider should be notified.
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 Rationale: Approximately 5 to 60 days after starting an antipsychotic medication, the client may exhibit the side effect of akathisia, manifested by motor restlessness (continually tapping a foot, rocking back and forth in a chair, or shifting weight from one foot to another). Pelvic thrusts, athetoid limbs, and a protruding tongue are effects that may occur after 6 to 24 months of an antipsychotic medication.
A nurse is monitoring 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. the nurse should ask the husband about the client's history of which disorder? A) Dementia B) Seizure disorder C) Diabetes mellitus D) PTSD
A) Dementia Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic function by increasing the concentration of acetylcholine, slowing the progression of Alzheimer disease. The disorders in the other options are not treated with this medication.
A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side/adverse effect of the medication does the nurse monitor the client's laboratory results? A. Hypokalemia B. Hypocalcemia C. Hypernatremia D. Hypermagnesemia
A) Hypokalemia Rationale: The client taking a potassium-wasting diuretic such as hydrochlorothiazide must be monitored for reductions in the potassium level. Other fluid and electrolyte imbalances that may occur with use of this medication are hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. The nurse should also educate the client about foods that are rich in potassium.
A nurse suspects that a client receiving PN through a central line has an air embolism. The nurse immediately positions the client in which way? 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 Rationale: When air embolism is suspected, the client should be placed in a left side-lying position with the head lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the other options are incorrect.
An LPN is following a plan of care for a client hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? A) Monitoring intake and output B) Monitoring the client's pupillary response C) Placing the client in a right side lying position D) Checking the client's hemoglobin level daily
A) Monitoring intake and output Rationale: Urine retention is a side effect of benztropine mesylate (Cogentin). The nurse must be alert for infrequent voiding of small amounts, which may be indicative of urine retention, dysuria, abdominal distention, or overflow incontinence. This monitoring is also an important intervention for the client with heart failure. Monitoring pupillary response, changing the client's position and checking the client's hemoglobin level daily, are not interventions specific to this medication.
A nurse is monitoring a peripheral IV site and notes blanching, coolness and edema at the insertion site. What should the nurse do first? A) Remove the IV B) Apply a warm compress C) Check for blood return D) Measure the area of infiltration
A) Remove the IV Rationale: Blanching, coolness, and edema of the IV site are all signs of infiltration. Because infiltration may result in damage to the surrounding tissue, the nurse must first remove the IV cannula to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because blood return may be present even if the cannula is only partially in the vein. Compresses may be used, but the compress (warm or cool) depends on the type of solution infusing and health care provider preference. The nurse should measure the area of infiltration after the IV has been removed so that further tissue damage is prevented.
A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse performs which action first? A) Removes the IV cath B) Slows the rate of infusion C) Notifies the HCP D) Checks or loose cath connections
A) Removes the IV catheter Rationale: Phlebitis is an inflammatory process in the vein. Phlebitis at an IV site may be indicated by client discomfort at the site or by redness, warmth, and swelling in the area of the catheter. The IV catheter should be removed and a new IV line inserted at a different site. Slowing the rate of infusion and checking for loose catheter connections are not correct responses. The health care provider would be notified if phlebitis were to occur, but this is not the initial action.
A home care nurse has been assigned a client who has been discharged home with a prescription for parenteral nutrition. Which of the following parameters does the nurse plan to check at each visit as a means of identifying complications of the PN therapy? SATA A) Weight B) Glucose Test C) Temperature D) Peripheral pulses E) HgB and HCT
A, B, C Weight Glucose Test Temp Rationale: When a client is receiving PN therapy, the nurse monitors the client's weight to determine the effectiveness of the therapy. The nurse should weigh the client at each visit to make sure that the client has not gained or lost an excessive amount of weight. Because the formula contains a large amount of dextrose, the health care provider should check the client's glucose level frequently. The nurse caring for a client receiving PN at home should also monitor the temperature to detect infection, which is a potential complication of this therapy. An infection in the intravenous line could result in sepsis because the catheter is in a blood vessel. The peripheral pulses and hemoglobin and hematocrit readings may provide data but are unrelated to complications associated with PN therapy.
A nurse has just hung transfusion of packed rbcs and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs? A) Rash B) Chills C) Fatigue D) Backache E) Tiredness
A, B, D Rationale: The nurse should instruct the client to report signs of a transfusion reaction, such as a backache, chills, itching, or rash, immediately. If a transfusion reaction occurs, the nurse would stop the transfusion immediately. Fatigue, tiredness, and nausea are not specifically related to a transfusion reaction.
An LPN is following a plan of are for a client with renal colic who is receiving meperidine hydrochloride for pain. Which side effects does the nurse make a note of needing to be alert to in the plan of care? SATA A) Hypotension B) Constipation C) Bradycardia D) Urine retention E) Respiratory depression
A, B, D, E Rationale: Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention
At 1300, the nurse is documenting the receipt of a unit of packed blood cells from the hospital blood bank. The nurse calculates that the transfusion must be started by what time? A) 1315 B) 1330 C) 1345 D) 1400
B) 1330 Rationale Blood must be hung within 30 minutes after obtaining it from the blood bank. After that time, the temperature of the blood becomes warm and could be unsafe for use. Therefore 1345 and 1400 are incorrect. It is not necessary to hang the blood within 15 minutes of receiving it from the blood bank.
A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. The LPN reinforces which instruction? 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 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 Rationale: Nitroglycerin is a coronary vasodilator used in the management of angina pectoris. The client is generally advised to apply a new patch at the same time each day (usually each morning) and leave in place for 12 to 16 hours as per health care provider directions. This prevents the client from developing tolerance (such as that which happens with 24-hour use). The client should avoid placing patches in skin folds or excoriated areas. The client benefits from removing the patch for sleep as well because the nitroglycerin may cause a headache, which could disrupt sleep. The client may apply a new patch if the old one is dislodged because the dose is released continuously in small amounts through the skin.
A client receiving PN requires fat emulsion (lipids), which will be piggybacked to the PN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? A) Shake the bottle vigorously B) Request new bottle from pharmacy C) Rotate the bottle gently back and forth to mix the globules D) Running the bottle under warm water until the globules disappear
B) Request new bottle from the pharmacy Rationale: The nurse should not hang a fat emulsion that contains visible fat globules. Another bottle of solution should be obtained and used in its place. When PN is combined with fat emulsion, the solution should not be used if there is a visible "ring" noted in the container of solution. The actions in the other options are incorrect.
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 form the pharmacy. Which action should the nurse take first? A) Call the HCP B) Notify the RN so that a solution of 10% dex in water can be hung C) Hang a solution of 10% dex in water D) Hang a solution of 5% dex in 0.9% NaCl
C) Hang a solution of 10% dex in water Rationale: The solution containing the highest amount of dextrose should be hung until the new bag of PN becomes available. Because PN solutions contain high-glucose concentrations, the 10% dextrose solution is the best solution to infuse because it will minimize the risk of hypoglycemia. The pharmacy and health care provider should also be called, but care of the client is the immediate priority of the nurse.
A nurse is monitoring a client who is receiving parenteral nutrition. Which 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 Rationale: The high glucose concentration in PN puts the client at risk for hyperglycemia. Signs of hyperglycemia include polyuria, polydipsia, polyphagia, blurred vision, nausea and vomiting, and abdominal pain. The nurse checks the blood glucose level immediately if these symptoms develop. The signs and symptoms identified in the other options are unrelated to hyperglycemia.
A client with a peripheral IV line in place has a new prescription for infusion of parenteral nutrition (PN), a solution containing 25% glucose. Which of the following actions should be taken by the nurse? A) Hanging the IV solution as prescribed B) Diluting the solution with sterile water to half-strength C) Questioning the RN about the appropriateness of the order D) Hanging the IV solution but setting the infusion at just half the prescribed rate
C) Questioning the RN about the appropriateness of the order Rationale: PNsolutions containing as much as 10% glucose can be infused through peripheral vessels. A PN solution containing 25% glucose is hypertonic. The nurse should question the prescription in the absence of a central venous catheter or a peripherally inserted central catheter. Diluting the solution with sterile water to half-strength and hanging the IV solution as prescribed are both inappropriate. The nurse must not alter a prescribed solution independently.
A 500 mL bag of IV fluid is hung for a 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 infusion Rationale: The client's symptoms are indicative of speed shock, which results from the rapid infusion of drugs or a bolus infusion. In this case, the nurse would note that 400 mL has infused over 60 minutes. The first action on the part of the nurse is shutting off the IV infusion. Other actions may follow in rapid sequence: The nurse may elevate the head of the bed to aid the client's breathing and then immediately notify the health care provider. Slowing the infusion rate is inappropriate because the client will continue to receive fluid. The IV does not need to be removed. It may be needed to manage the complication.
Disulfiram 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, D Rationale: Disulfiram is used as an adjunct treatment for selected clients with alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important question is when the client had his last drink of alcohol. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in cases of severe heart disease, psychosis, or hypersensitivity to the medication.
