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1 265 Morsels of HESI EXIT Goodness-
University of Texas Arlington NURS 3347
Exams Guide
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Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client’s blood pressure immediately before administering each dose. Checking the client’s peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation. Test-Taking Strategy: Focus on the name of the medication and recall that medications that end in the letters “pril” are ACE inhibitors and that these medications are used to treat hypertension. This will direct you to the correct option. Review the action of enalapril maleate if you had difficulty with this question. Reference: Lehne, R. (2013). Pharmacology for nursing care (8th^ ed., p. 513). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Care Coordination, Safety HESI Concepts:Collaboration/Managing Care, Safety
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series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction. Test-Taking Strategy: Use the process of elimination. Note the strategic words "need for further instruction." These words indicate a negative event query and the need to select the incorrect client statement. Focusing on the word "upper" in the name of the test will direct you to the correct option. Review preprocedure care for an upper GI series if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th^ ed., p. 879). St. Louis: Mosby. Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Gastrointestinal Giddens Concepts: Client Education, Clinical Judgment HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a health care provider’s prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor. Test-Taking Strategy: Use the process of elimination and your knowledge of the legal responsibilities of the nurse in regard to medication administration and health care provider’s prescriptions. Eliminate the options that are comparable or alike in that they avoid clarification of the prescription (administering the medication and holding the medication). To select from the remaining options, note that it is premature to call the nursing supervisor. Also note that the correct option is the only one that clarifies the prescription. Review legal responsibilities in regard to medication prescriptions if you had difficulty with this question. Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th^ ed., p.585). St. Louis: Mosby. Cognitive Ability: Applying
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Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H 2 ) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed. Test-Taking Strategy: Use the process of elimination. Use your knowledge of the principles of medication administration to help eliminate the option that involves administering the medication by way of a route other than the prescribed one. Recalling that antihypertensives must be administered on a regular schedule will assist you in eliminating the options that involve withholding the medication. Review preprocedure care for the client scheduled for ECT if you had difficulty with this question. Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th^ ed.,p. 597). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Mental Health Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment, Safety
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Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client’s feelings. "It will take time, but, I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client’s feelings. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the options that are nontherapeutic and do not encourage the client to express feelings. Remember to always focus on the client’s feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th^ ed., p.841). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Cardiovascular Giddens Concepts: Communication, Mood and Affect HESI Concepts: Communication, Mood and Affect Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the health care provider. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium- stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the health care provider is the priority. Test-Taking Strategy: Focus on the data in the question and note the strategic word "priority." Noting the words "yellow and has a strong odor" will direct you to the correct option. Review the expected findings after rupture of the membranes if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th^ ed., p.645). St. Louis: Elsevier. Cognitive Ability: Applying
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Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the health care provider is premature, because the client’s complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food. Test-Taking Strategy: Use guidelines related to medication administration to assist you to eliminate the options that indicate to stop the medication or adjust the prescribed dose. To select from the remaining options, think about the side Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained. However, stating, “You’re more likely to get pregnant than to contract HIV” avoids the client’s concern. Similarly, "HIV is rarely an issue in rape victims” and "Every rape victim is concerned about HIV" are generalized responses that avoid the client’s concern. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Eliminate the options that are comparable or alike in that the nurse avoids addressing the client’s concern. Review the psychosocial issues of the rape victim if you had difficulty with this question. References: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. ( revised reprint ) ) (2nd ed., pp. 439-440). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Mental Health Giddens Concepts: Communication, Immunity HESI Concepts: Communication, Immunity
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effects of the medication. Review the side effects of ibuprofen and the measures to relieve them if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook
2015. (pp. 594-595) St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Rationale: The client’s 24-hour total oral intake is 1570 mL, and the IV intake totals 100 mL (50 mL of normal saline solution every 12 hours). Therefore the 24- hour intake total is 1670 mL. Test-Taking Strategy: Focus on the subject, the client’s total intake in a 24 - hour period. Add the oral intake and then note that every 12 hours the client is receiving an IV antibiotic that is diluted in 50 mL of normal saline solution. Therefore the total IV intake is 100 mL in 24 hours. Review calculation of intake and output if you had difficulty with this question. Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th^ ed., pp. 898 - 900, 1052). St. Louis: Mosby. Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fluids & Electrolytes Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision Making/Clinical Judgment, Fluid and Electrolytes 1670 mL
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Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication. Test-Taking Strategy: Use the process of elimination and focus on the subject, the symptoms that should prompt the client to contact the health care provider immediately. Recalling that the medication is an MAOI and the common and adverse effects of the medication will help direct you to the correct option. Review the side effects and adverse effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2013). Pharmacology for nursing care (8th^ ed., pp. 378- 379). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Mental Health Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication. Test-Taking Strategy: Knowledge of the contraindications to the use of risperidone
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is required to answer this question correctly. It is important to remember that one such contraindication is therapy with an antihypertensive medication. If you are unfamiliar with the contraindications to the use of risperidone, review this content. Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th^ ed., p.271). St. Louis: Mosby. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue (“flycatcher tongue”), and face. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia. Test-Taking Strategy: Knowledge of the clinical manifestations associated with tardive dyskinesia is needed to answer this question correctly. Recalling that the clinical manifestations of tardive dyskinesia include abnormal movements and involuntary movements will direct you to the correct option. If you had difficulty with this question, review the characteristics of tardive dyskinesia. Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th^ ed., p. 268). St. Louis: Mosby. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Psychosis HESI Concepts: Clinical Decision Making/Clinical Judgment, Cogintion-Psychosis
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Rationale: Measures to prevent skin cancer include avoiding sun exposure between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat, opaque clothing, and sunglasses when out in the sun; and examining the body every month for possibly cancerous or precancerous lesions. The client should also seek medical advice if any changes in a skin lesion are noted. Test-Taking Strategy: Focus on the subject, the prevention of skin cancer. Read each option carefully. Eliminate the option that includes the words “low sun protection factor.” Next eliminate the option that includes “every 6 months.” To select from the remaining options, recall that the skin should be protected from the sun even more carefully between the hours of 10 a.m. and 4 p.m. Review the risk factors associated with skin cancer if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th^ ed., p.503). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Adult Health/Oncology Giddens Concepts: Cellular Regulation, Health Promotion HESI Concepts: Cellular Regulation, Health, Wellness, and Illness-Health Promotion Incorrect
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before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the health care provider. There is no reason for the child to avoid participating in sports. Test-Taking Strategy: Focus on the data in the question. First, eliminate the option that contains the closed-ended word "always." Next, recall the importance of the child’s participation in activities, which will help you eliminate the option involving avoidance of activities. To select from the remaining options, recall the association of insulin, diet, and exercise in the control of the blood glucose level, which will direct you to the correct option. Review the diet, exercise, and medication in the treatment of diabetes mellitus if you had difficulty with this question. Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th^ ed. pp. 1527-1528, 1537). St Louis: Mosby. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Child Health – Metabolic/Endocrine Giddens Concepts: Glucose Regulation, Client Education HESI Concepts: Metabolism/Glucose Regulation, Teaching and Learning/Patient Education Rationale: Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image. Test-Taking Strategy: Use the process of elimination. Note that the statement "It doesn’t really matter what I do .... " implies that the client has a sense of no control of the situation. This will direct you to the correct option. Review the defining characteristics of powerlessness if you had difficulty with this question.
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Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical- surgical nursing: Assessment and management of clinical problems (9th^ ed., p. 1111). St. Louis: Mosby. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Adult Health/Renal Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision Making/Clinical Judgment, Mood and Affect Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren’t talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and nontherapeutic. Test-Taking Strategy: Use your knowledge of therapeutic communication techniques to answer the question. Remembering to focus on the client’s feelings will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th^ ed., p. 1111). St. Louis: Mosby. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th^ ed., pp. 320-322). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Renal Giddens Concepts: Communication, Palliation HESI Concepts: Communication, Grief and Loss
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attempt if you had difficulty with this question. Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th^ ed., p. 195). St. Louis: Elsevier. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Collaboration/Managing Care, Oxygentation/Gas Exchange Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one’s role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health. Test-Taking Strategy: Use the process of elimination. Focusing on the data in the question and noting the words “upset” and “worried” will direct you to the correct option. Review the defining characteristics of anxiety if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th^ ed., pp. 621, 627-628). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Anxiety HESI Concepts: Clinical Decision Making/Clinical Judgment, Mood and Affect- Anxiety
Correct Responses: "0.625, .625" Rationale: Use the medication calculation formula. Formula:
Test-Taking Strategy: Follow the formula to calculate the correct dose. Recheck your multiplication and division and note because the question does not ask you to round the answer, you should type exactly what you calculated. Verify your answer with the use of a calculator to ensure that the answer is correct and that it makes sense. Review medication calculation problems if you had difficulty with this question.
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013).
Fundamentals of nursing. (8
th ed., pp. 92 5 - 926). St. Louis: Mosby..
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing
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Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are related to the use of tobacco. To select correctly from the remaining options, it is necessary to recall that silicosis is caused by exposure to dust. Review the causes of silicosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th^ ed., p.629). St. Louis: Saunders. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Assessment, Oxygenation/Gas Exchange
