HESI Exit Exam Review (Nightingale College)

HESI Exit Exam Review (Nightingale College) 1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking th ...

HESI Exit Exam Review (Nightingale College) 1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure Correct B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Correct D. "I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for the test can be constipating." 2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call physician Correct C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available 4. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings B. Asking the ED physician to check the client Correct C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI 5. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water Correct B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT 6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you’re feeling." Correct B. "That’s a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month." 7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? A. Contacting the physician Correct B. Documenting the findings C. Checking the fluid for protein D. Continuing to monitor the client and the FHR 8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray Correct B. Check the client's blood glucose level to serve as a baseline measurement C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency E. 9 A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse? A. "HIV is rarely an issue in rape victims." B. "Every rape victim is concerned about HIV." C. "You’re more likely to get pregnant than to contract HIV." D. "Let's talk about the information that you need to determine your risk of contracting HIV." Correct 10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: A. Contact the physician B. Stop taking the medication C. Take the medication with food Correct D. Take the medication twice a day instead of four times 11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided. Answer: ________mL Correct Responses: "1670" 12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A. 3 minutes Correct B. 10 seconds C. 15 seconds D. 30 minutes 13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A. Depression Correct B. Diabetes mellitus C. Hyperthyroidism D. Coronary artery disease 14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: A. Dry mouth B. Restlessness C. Feelings of depression D. Neck stiffness or soreness Correct 15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication? A. The client has a history of cataracts. B. The client has a history of hypothyroidism. C. The client takes a prescribed antihypertensive. Correct D. The client is allergic to acetylsalicylic acid (aspirin). ..........CONTINUED