HESI EXIT COMPREHENSIVE REVIEW A
1. The nurse is correct in withholding an older adult client's dose of
nifedipine if which assessment finding is obtained?
A. Blood pressure of 90/56 mm Hg
B. Apical pulse rate of 68
...
HESI EXIT COMPREHENSIVE REVIEW A
1. The nurse is correct in withholding an older adult client's dose of
nifedipine if which assessment finding is obtained?
A. Blood pressure of 90/56 mm Hg
B. Apical pulse rate of 68 beats/min
C. Potassium level of 3.3 mEq/L
D. Urine output of 200 mL in 4 hours
Rationale:
Nifedipine is a calcium channel blocker that causes a decrease in blood
pressure. It should be withheld if the blood pressure is lowered, and
90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60
beats/min is an indication to withhold the drug. A potassium level of 3.3
mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect
the administration of Procardia. Urine output of more than 30 mL/hr, or
120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is
slightly less than normal and warrants follow-up, it is not an indication
to withhold a nifedipine (Procardia) dose.
2. Until the census on the obstetrics (OB) unit increases, an
unlicensed assistive personnel (UAP) who usually works in labor
and delivery and the newborn nursery is assigned to work on the
postoperative unit. Which client would be best for the charge nurse
to assign to this UAP?
A. An adolescent who was readmitted to the
hospital because of a postoperative
infection
B. A woman with a new colostomy who
requires discharge teaching
C. A woman who had a hip replacement and
may be transferred to the home care unit
D. A man who had a cholecystectomy andcurrently has a nasogastric tube set to
intermittent suction
Rationale:
A hip replacement is considered a clean case, and transferring the client
to another unit is likely to involve physically moving the client and her
belongings. The charge nurse will be responsible for providing a report
to the home care unit if the transfer occurs. The adolescent client is
infected, and an employee who works on an OB unit should be assigned
to clean cases in case the employee is required to return to the OB unit.
This requires the skills of a registered nurse (RN) to do discharge
teaching and provide emotional support. This may require skills beyond
the level of this UAP
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