Question 1
The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for
infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the
nurse set the flow rate? (Round to the nearest whole number).
Rationale: Use the IV flow rate formula:
Test-Taking Strategy: Focus on the information in the question. Use the formula for
calculating IV flow rates when answering the question. Remember to convert 24 hours to
minutes and to round the answer to the nearest whole number.
Review: IV infusion rates
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 710-711). St. Louis: Mosby.
Question 2
The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours.
The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow
rate? (Round to the nearest whole number).
Rationale: Use the IV flow rate formula:
Test-Taking Strategy: Focus on the information in the question. Use the formula for
calculating IV flow rates when answering the question. Be careful with the multiplication and
division, and remember to convert 8 hours to minutes (8 × 60 = 480) and round your answer to
the nearest whole number.
Review: IV infusion rates
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 710-711). St. Louis: Mosby.
Question 3
The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours.
The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate?
(Round to the nearest whole number).
Rationale: Use the IV flow rate formula:
Test-Taking Strategy: Focus on the information in the question. Use the formula for
calculating IV flow rates to answer the question. Be careful with the multiplication and division,
and remember to convert 8 hours to minutes (8 × 60 = 480) and round your answer to the nearest
whole number.
Review: IV infusion rates
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 710-711). St. Louis: Mosby.
Question 4
The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G
benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads,
“Penicillin G benzathine, 300,000 units/mL.” How many milliliters of medication does the nurse
prepares to ensure administration of the correct dose? (Round to the nearest tenth.)
Rationale: Use the medication formula:
Test-Taking Strategy: Focus on the information in the question. Follow the formula for
the calculation of the correct dose. It is not necessary to perform a conversion in this problem.
Recheck your work, ensure that the answer makes sense, and remember to round your answer to
the nearest tenth.
Review: medication calculation problems.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Medication Calculations
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., pp. 574-576). St. Louis: Mosby.
Question 5
The health care provider’s prescription for an adult client reads, “Potassium chloride 15 mEq by
mouth.” The label on the medication bottle reads, “20 mEq potassium chloride/15 mL.” How
many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of
medication? (Round to the nearest whole number.)
Rationale: Use the medication formula:
Test-Taking Strategy: Focus on the information in the question. Follow the formula for
calculation of the correct dose. It is not necessary to perform a conversion in this problem.
Recheck your work, ensure that the answer makes sense, and remember to round your answer to
the nearest tenth.
Review: medication calculation problems.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Medication Calculations
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., pp. 574-576). St. Louis: Mosby.
Question 6
The health care provider prescribes 1000 mL of 5% dextrose in water, to be infused over 24
hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow
rate? (Round to the nearest whole number).
Rationale: Use the IV flow rate formula:
Test-Taking Strategy: Focus on the information in the question. Use the formula for
calculating IV flow rates to answer the question. Be careful with the multiplication and division,
and remember to convert 24 hours to minutes (24 × 60 = 1440) and round your answer to the
nearest whole number.
Review: IV infusion rates
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 710-711). St. Louis: Mosby.
Question 7
The health care provider’s prescription reads, “Clindamycin phosphate 0.3 g in 50 mL NS, to be
administered IV over 30 minutes.” The medication label reads, “Clindamycin phosphate 150
mg/mL.” How many milliliters of medication does the nurse prepare to ensure that the correct
dose is administered?
Rationale: Convert 0.3 g to milligrams: 1000 mg = 1 g and therefore 0.3 g = 300 mg. Next, use
the medication formula:
Test-Taking Strategy: Focus on the information in the question. First convert 0.3 gm to
mg. Next follow the formula for the calculation of the correct dose. Recheck your work and
make sure that the answer makes sense.
Review: medication calculation problems.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Medication Calculations
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., pp. 574-576). St. Louis: Mosby.
Question 8
The health care provider’s prescription reads, “Phenytoin 0.1 g by mouth twice daily.” The
medication label indicates that the bottle contains 100-mg capsules. How many capsules does the
nurse prepare for administration of one dose?
Rationale: Convert 0.1 g to milligrams: 1000 mg = 1 g; therefore 0.1 g = 100 mg. Next use the
medication formula:
Test-Taking Strategy: Focus on the information in the question. First, convert 0.1 g to
mg. Next. follow the formula for the calculation of the correct dose. Recheck your work and
ensure that the answer makes sense.
Review: medication calculation problems.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Medication Calculations
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., pp. 574-576). St. Louis: Mosby.
Question 9
A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm,
painful, and slightly edematous near the insertion point of the catheter. On the basis of this
assessment, the nurse should take which action first?
Check for loose catheter connections
Remove the IV catheter
Correct answer
Slow the rate of infusion
Notify the health care provider
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.
Test-Taking Strategy: Note the strategic word, first. Focus on the data in the question.
Eliminate slowing the rate of infusion and checking the connection, because they
are comparable or alike options that indicate continuation of IV therapy. Although the
health care provider would be notified of this occurrence, the word “first” should direct you to
select the option of removing the IV catheter.
Review: the signs of phlebitis and the actions to be taken when it occurs
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Inflammation
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Inflammation
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 707). St. Louis: Mosby.
Question 10
A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned 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 action should the nurse take first?
Shut off the IV infusion
Correct answer
Sit the client up in bed
Slow the rate of infusion
Remove the IV
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.
Test-Taking Strategy: Note the question contains the strategic word “first.” Recognizing
the signs of speed shock and recalling the appropriate interventions should also direct you to the
option of shutting off the IV infusion.
Review: the initial nursing actions for speed shock
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Giddens Concepts: Fluids and Electrolytes, Perfusion
HESI Concepts: Fluids& Electrolyte, Perfusion
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 230). St. Louis: Saunders.
Question 11
A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is
experiencing a transfusion reaction. After discontinuing the transfusion, which action should the
nurse take next?
Contact the health care provider
Correct answer
Obtain a culture of the tip of the catheter device removed from the client
Change the solution to 5% dextrose in water
Remove the IV catheter
Rationale: If the nurse suspects a transfusion reaction, the transfusion is stopped and normal
saline solution infused at a keep-vein-open rate pending further health care provider
prescriptions. The nurse then contacts the health care provider.. Dextrose in water is not used,
because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type
of IV fluid that is compatible with blood. The nurse would not remove the IV catheter, because
then there would be no IV access route through which to treat the reaction. There is no reason to
obtain a culture of the catheter tip; this is done when an infection is suspected.
Test-Taking Strategy: Note the strategic word “next.” Knowing that the IV should not be
removed will assist you in the elimination process. Recalling that normal saline solution is the
only type of IV fluid that is compatible with blood will also help you answer correctly. To select
from the remaining options, note that infection is not the concern; this will help you eliminate the
option of obtaining a culture of the catheter tip.
Review: care of the client experiencing a transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood administration
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 740-741). St. Louis: Mosby.
Question 12
A client with heart failure is being given furosemide and digoxin. The client calls the nurse and
complains of anorexia and nausea. Which action should the nurse take first?
Check the result of laboratory testing for potassium on the sample drawn 3 hours ago
Correct answer
Discontinue the morning dose of furosemide
Administer an antiemetic
Administer the daily dose of digoxin
Rationale: Anorexia and nausea are symptoms commonly associated with digoxin toxicity,
which is compounded by hypokalemia. Early clinical manifestations of digoxin toxicity include
anorexia and mild nausea, but they are frequently overlooked or not associated with digoxin
toxicity. Hallucinations and any change in pulse rhythm, color vision, or behavior should be
investigated and reported to the health care provider. The nurse should first check the results of
the potassium level, which will provide additional when the nurse calls the health care
provider,an important follow-up action. The nurse should also check the digoxin reading if one is
available. The nurse would not administer an antiemetic without further investigating the client’s
problem. Because digoxin toxicity is suspected, the nurse would withhold the digoxin until the
health care provider has been consulted. The nurse would not discontinue a medication without a
prescription to do so.
Test-Taking Strategy: Note the strategic word “first” and use the steps of the nursing
process to answer the question. The correct option is the only one that addresses assessment.
Review: nursing interventions for suspected digoxin toxicity
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Fluids and Electrolytes, Perfusion
HESI Concepts: Fluid & Electrolyte, Perfusion
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
363) St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 753). St. Louis: Saunders.
Question 13
The health care provider (HCP)prescribes the administration of total parenteral nutrition (TPN),
to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian
central line. After the first 2 hours of the TPN infusion, the client suddenly complains of
difficulty breathing and chest pain. The nurse should take which immediate action?
Clamp the TPN infusion line
Correct answer
Obtain a sample for blood glucose testing
Obtain an electrocardiogram (ECG)
Obtain blood for culture
Rationale: One complication of a subclavian central line is embolism, caused by air or
thrombus. Sudden onset of chest pain shortly after the initiation of TPN may mean that this
complication has developed. The infusion is clamped (the line should not be discontinued,
however), the client turned on the left side with the head down, and the HCP notified
immediately. Depending on agency protocol, the rapid response team would also be called.
Blood cultures are not necessary in this situation, because infection is not the concern. Likewise,
there is no useful reason for checking the blood glucose level. An ECG may be obtained, but this
is not the immediate priority. If the client shows signs of an air embolism, the nurse should
examine the catheter to determine whether an open port has allowed air into the circulatory
system.
Test-Taking Strategy: Note the strategic word “immediate.” Focus on the data provided
in the question to determine that an embolus has occurred. Eliminate blood cultures and blood
glucose testing, which, respectively, relate to infection and hyperglycemia, which is not likely to
occur during the first 2 hours of TPN administration. To select from the remaining options, focus
on the strategic word “immediate”; this will direct you to the correct option.
Review: the complications of TPN and the associated nursing interventions
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: TotalParenteral Nutrition
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Perfusion
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 311). St. Louis:
Mosby.
Question 14
A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema
at the insertion site. What should the nurse do first?
Remove the IV
Correct answer
Check for blood return
Measure the area of infiltration
Apply a warm compress
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.
Test-Taking Strategy: Note the strategic word “first.” Although each of these options is
appropriate, it is necessary to prioritize them. The signs presented in the question point to
infiltration. Infiltration indicates that the IV must be removed.
Review: the signs of infiltration and the appropriate initial interventions
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Inflammation
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Inflammation
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 228). St. Louis: Saunders.
Question 15
A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of
total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be
taken by the nurse?
Diluting the solution with sterile water to half-strength
Hanging the IV solution as prescribed
Hanging the IV solution but setting the infusion at just half the prescribed rate
Questioning the health care provider about the prescription
Correct answer
Rationale: TPN solutions containing as much as 10% glucose can be infused through
peripheral vessels. A TPN 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.
Test-Taking Strategy: Focus on the information in the question. Note the words
“peripheral intravenous (IV) line” and “25% glucose.” Recalling that TPN solutions containing
as much as 10% glucose can be infused through peripheral vessels will direct you to the correct
option.
Review: base solutions of TPN and their routes of administration
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts: Collaboration, Safety
HESI Concepts: Collaboration/Managing Care, Safety
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 902). St. Louis:
Mosby.
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing.
(8th ed., p. 905). St. Louis: Mosby
Question 16
The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a
client beginning this nutritional therapy. The solution is to be infused by way of a central line.
Which essential piece of equipment should the nurse obtain before hanging the solution?
Noninvasive blood pressure monitor
Blood glucose meter
Electronic infusion device
Correct answer
Pulse oximeter
Rationale: The nurse obtains an electronic infusion device before hanging a TPN solution.
Because of the high glucose load, it is necessary to use an infusion device to ensure that the
solution does not infuse too rapidly or fall too far behind. Because the client’s blood glucose is
checked every 6 to 8 hours during administration of PN, a blood glucose meter will also be
needed, but it is not essential before the solution is hung. A noninvasive blood pressure cuff is
unnecessary for this procedure. Although oxygen saturation is important, in this situation, it is
not the most important equipment to use at this time.
Test-Taking Strategy: Note the strategic word “essential” and note the words “before
hanging.” This tells you that the correct option identifies the item that is needed to start the
infusion. Use your knowledge of the procedures for TPN administration to eliminate each of the
incorrect options.
Review: the procedures for initiating a TPN infusion
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts: Fluids and Electrolytes, Safety
HESI Concepts: Fluid & Electrolyte, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 805). St. Louis: Mosby.
Question 17
A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which signs and
symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a
complication?
Nausea, thirst, and increased urine output
Correct answer
Sweating, chills, and decreased urine output
Nausea, vomiting, and oliguria
Pallor, weak pulse, and anuria
Rationale: The high glucose concentration in TPN 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.
Test-Taking Strategy: Focus on the subject, signs and symptoms of hyperglycemia.
Remembering the “three P’s” (polyuria, polydipsia, and polyphagia) will direct you to the correct
option. Also note that this option is the only one that includes increased urine output.
Review: the signs of hyperglycemia
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Total Parenteral Nutrition
Giddens Concepts: Fluids and Electrolytes, Glucose Regulation
HESI Concepts: Fluid & Electrolyte, Metabolism
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 798). St. Louis: Mosby.
Question 18
At 1600 the nurse checks a client’s total parenteral nutrition (TPN) infusion bag and notes that
the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The
nurse plans to change the infusion bag and tubing this evening at what time?
1800
Correct answer
1700
2100
2000
Rationale: The TPN solution should be changed every 24 hours as a means of helping prevent
infection. Infection is also prevented with the use of aseptic technique during bag and tubing
changes. Most agencies recommend that tubing be changed every 24 hours along with the TPN
infusion bag. Specific agency policies should always be followed. Therefore the remaining
options are incorrect.
Test-Taking Strategy: Focus on the information in the question and the subject, the
time to change the infusion bag. Recalling that the infusion bag should be changed every 24
hours will direct you to the correct option.
Review: the principles of TPN administration
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Total Parenteral Nutrition
Giddens Concepts: Clinical Judgment, Infection
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Infection
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 803). St. Louis: Mosby.
Question 19
A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN).
The nurse notes moisture under the dressing covering the catheter insertion site. What should the
nurse assess next?
Expiration date on the infusion bag
Time of the last dressing change
Tightness of the tubing connections
Correct answer
Temperature
Rationale: A loose tubing connection — the most obvious cause of the moisture that could be
readily detected and fixed by the nurse — is the first thing the nurse should look for. The client’s
temperature would be assessed if the nurse were looking for signs of infection. The expiration
date on the infusion bag and the time of the last dressing change are routine observations but
have nothing to do with the subject of the question.
Test-Taking Strategy: The strategic word in the question is “next.” Also note the
relationship between the subject of the question, moisture under the dressing, and tightness of the
tubing connections.
Review: care of the client receiving TPN
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts: Clinical Judgment, Infection
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Infection
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 803-804). St. Louis: Mosby.
Question 20
A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be
piggybacked to the TPN 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?
Shake the bottle vigorously
Rotate the bottle gently back and forth to mix the globules
Run the bottle under warm water until the globules disappear
Request a new bottle from the pharmacy
Correct answer
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 TPN 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.
Test-Taking Strategy: Remember that comparable or alike options are not likely to be
correct. With this in mind, eliminate rotating the bag and shaking the bottle first. To select from
the remaining options, think about the significance of seeing fat globules in the solution and
imagine the potential adverse effect of fat globules in the client’s bloodstream. This will direct
you to the correct option.
Review: the procedures for administration of fat emulsion
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p.
525). St. Louis: Mosby.
Question 21
A nurse is preparing a client for the insertion of a central intravenous line into the subclavian
vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and
prepares to assist the health care provider with the procedure. As further preparation for the
procedure, the nurse places the client in which position?
In a slight Trendelenburg position
Correct answer
Flat on the left side
In the prone position
In the supine position
Rationale: Unless contraindicated, the client is placed in a slight Trendelenburg position. This
position is used to increase dilation of the veins and positive pressure in the central veins,
reducing the risk of air embolus during insertion. Note that Trendelenburg position is
contraindicated in clients with head injuries, increased intracrainial pressure, certain respiratory
conditions, and spinal cord injuries. If the client had any of these conditions then an alternative
position as prescribed would need to be used for insertion. The other options are incorrect
because they will not achieve this goal.
Test-Taking Strategy: Eliminate the comparable or alike options that indicate that the
client should be positioned flat.
Review: the procedure for the insertion of a central intravenous line into the subclavian vein
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 728). St. Louis: Mosby.
Question 22
The nurse is preparing to change the solution bag and intravenous tubing of a client receiving
total parenteral nutrition (TPN) through a left subclavian central venous line.
Which essential action does the nurse ask the client to perform just before switching the
tubing?
Take a deep breath and hold it
Correct answer
Turn the head to the left
Exhale slowly and evenly
Turn the head to the right
Rationale: The nurse must ask the client to take a deep breath and hold it. This effectively
achieves the Valsalva maneuver during tubing changes, which helps prevent air embolism. If the
line is on the left, it may be helpful to have the client turn the head to the right and vice versa.
This allows more room for the nurse to work. However, it is not the most essential action. The
other options are incorrect.
Test-Taking Strategy: Note that the question contains the strategic word “essential.”
Recalling that there is a risk of air embolism during tubing changes will direct you to the correct
option.
Review: the procedure for TPN bag and tubing changes
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts: Perfusion, Safety
HESI Concepts: Perfusion, Safety
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 225). St. Louis: Saunders.
Question 23
A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has
an air embolism. The nurse immediately places the client in which position?
Left side with the head lower than the feet
Correct answer
Right side with the head lower than the feet
Right side with the head higher than the feet
Left side with the head higher 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.
Test-Taking Strategy: Note the strategic word, immediately. To answer this question
correctly, you must have specific knowledge of client positioning during the management of this
complication. Think about the effect of air embolism and how an embolism travels to answer
correctly.
Review: immediate interventions when air embolism is suspected
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Critical Care
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 798). St. Louis: Mosby.
Question 24
A nurse is making initial rounds on a group of assigned clients. Which client should the nurse
see first?
A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours
A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F (37.2°C) on the previous
shift
A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of
weakness, headache, and sweating
Correct answer
A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to
the bathroom to void
Rationale: The nurse should assess the client complaining of weakness, headache, and
sweating first, because these are signs of hypoglycemia, which could be caused by the decrease
in the TPN rate. The client who has been receiving TPN at a rate of 50 mL/hr for the last 24
hours should be assessed but does not need to be seen first. The client who complains of frequent
trips to the bathroom should be assessed for hyperglycemia, one of the side effects of TPN, but
should not take precedence over the client showing signs of hypoglycemia. A client with an
increased temperature should be monitored closely but does not take precedence over the client
exhibiting signs of hypoglycemia.
Test-Taking Strategy: Note the strategic word, first. Read each client description carefully.
Think about the complications of TPN. Noting the words “decreased to a rate of 25 mL/hr who is
now complaining of weakness, headache, and sweating” will direct you to this option as the
priority client.
Review: the complications of TPN and the associated signs and symptoms
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Prioritizing
Giddens Concepts: Fluids and Electrolytes, Glucose Regulation
HESI Concepts: Care Coordination, Fluid & Electrolyte, Metabolism
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., pp. 798-799). St. Louis: Mosby.
Question 25
A nurse answers a call bell and finds that the total parenteral nutrition (TPN) 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 from the pharmacy. Which action should the nurse take first?
Hang a solution of 5% dextrose in 0.9% sodium chloride
Call the pharmacy for further instructions
Hang a solution of 10% dextrose in water
Correct answer
Call the health care provider
Rationale: The solution containing the highest amount of dextrose should be hung until the
new bag of TPN becomes available. Because TPN 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.
Test-Taking Strategy: Note the strategic word “first” and focus on the data in the
question. Eliminate calling the pharmacy or health care provider first, because these options do
not directly address the client. To select from the remaining options, recall the concentration of a
TPN solution and remember that this client is at risk for hypoglycemia; this will direct you to the
correct option.
Review: care of the client receiving TPN
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Total Parenteral Nutrition
Giddens Concepts:Fluids and Electrolytes, Glucose Regulation
HESI Concepts: Fluid & Electrolye, Metabolism
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 802). St. Louis: Mosby.
Question 26
A young female client with schizophrenia says to the nurse, “Since I started on olanzapine last
year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering
me. What can I do about this?” Which response by the nurse would be therapeutic?
“Weight gain can be a side effect of the medication, so you need to watch your diet and exercise.
How much weight have you gained?”
Correct answer
“That medication isn’t any more likely to cause weight gain than the others you’re taking.
Perhaps we could go over your diet and exercise habits.”
“Well, I think you’re overreacting. Today people think they should be skinny-minnies, even
though it’s not healthy.”
“I want you to stop taking this medication immediately, and I’m calling the doctor, because this
is a very serious side effect and you may need dialysis.”
Rationale: Olanzapine is an antipsychotic agent that causes weight gain, a disadvantage of the
medication. Weight gain, especially in a young woman, for whom it may have an especially
serious affect on self-image, may lead to noncompliance with the medication regimen. “That
medication isn’t any more likely to cause weight gain than the others you’re taking” offers
incorrect information. “I think you’re overreacting” minimizes the client’s complaints. “I want
you to stop taking this medication immediately” gives incorrect information and is presented in
an unprofessional style.
Test Taking Strategy: Use therapeutic communication techniques. Eliminate the
option that states the client’s medication does not cause weight gain any more than others do
first, because this medication can cause weight gain. Next eliminate the option in which the
nurse tells the client to stop taking this medication immediately, because it is also inaccurate and
could cause anxiety for the client. To select from the remaining options, eliminate the one in
which the nurse states the client is overreacting, because this minimizes the client’s complaints.
Review: the effects of olanzapine
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Pharmacology
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition, Communication
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 336-338
Question 27
A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which
adverse effect should the nurse monitor the client closely?
Akathisia
Correct answer
Athetoid limbs
Protruding tongue
Pelvic thrusts
Rationale: Approximately 5 to 60 days after starting an antipsychotic medication, the client
may exhibit the adverse 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.
Test Taking Strategy: Focus on the subject, an adverse effect of an antipsychotic
medication. Knowledge regarding the adverse effects of antipsychotic medications is needed to
answer this question. Noting the words “2 months” and recalling the adverse effects of these
medications will assist in directing you to the correct option.
Review: the effects of antipsychotic medications
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts:Psychosis, Safety
HESI Concepts: Cognition, Safety
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A
communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 331,
326). St. Louis: Saunders.
Question 28
A client with schizophrenia who has been taking an antipsychotic medication calls the clinic
nurse and says, “I need to cancel my appointment with the psychiatrist again, because I still have
this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the
client?
“Do you remember when you started this medication? Your psychiatrist told you how important
it is to keep your appointments with him.”
“You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash
every 2 hours or so and drink plenty of water.”
“I wouldn’t be upset. It happens when you aren’t drinking enough water.”
“I think you need to come in for blood work today, because this may be an adverse effect of your
medicine.”
Correct answer
Rationale: Agranulocytosis, an adverse effect of antipsychotic medications, is characterized by
a sore throat with mouth sores, fever, and malaise. Any client taking such a medication who
complains of flulike symptoms should be evaluated carefully. For this reason, the psychiatrist
usually prescribes periodic blood tests while a client is taking antipsychotic medications. The
incorrect options ignore the client’s complaints.
Test-Taking Strategy: Focus on the data in the question and note that the client has an
awful sore throat. Recalling that antipsychotic medications can cause agranulocytosis will direct
you to the correct option. Also note that the correct option is the only one that addresses the
client’s complaint.
Review: the adverse effects of antipsychotic medications
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Infection, Safety
HESI Concepts: Infection, Safety
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A
communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 331). St.
Louis: Saunders.
Question 29
A nurse notes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and
slightly edematous in the area of the insertion site. After taking appropriate steps to care for the
client, the nurse documents in the medical record that the client has experienced which problem?
Infiltration of the IV line
Phlebitis of the vein
Correct answer
An allergic reaction to the IV catheter material
Hypersensitivity to the IV solution
Rationale: Phlebitis at an IV site can be identified by client discomfort at the site, as well as by
redness, warmth, and swelling in the area of the catheter. The IV should be removed and a new
one inserted at a different site. The remaining options are incorrect. Coolness and swelling would
be noted if infiltration had occurred. The symptoms of hypersensitivity and allergic reaction
depend on whether these complications are local or systemic.
Test-Taking Strategy: Remember that comparable or alike options(here,
hypersensitivity and allergic reaction) are not likely to be correct. Choose phlebitis of the vein
over infiltration of the IV line after recalling that warmth is noted at an IV site in which phlebitis
has developed. Coolness would be noted if infiltration had occurred.
Review: the signs of phlebitis
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Intravenous Therapy
Giddens Concepts: Communication, Inflammation
HESI Concepts: Communcation, Inflammation
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 228). St. Louis: Saunders.
Question 30
A nurse has a written prescription to remove an intravenous (IV) line. Which item should the
nurse obtain from the unit supply area for use in applying pressure to the site after removing the
IV catheter?
Alcohol swab
Adhesive bandage
Povidone-iodine (Betadine) swab
Sterile 2 × 2 gauze
Correct answer
Rationale: A dry sterile dressing such as a 2 × 2 is used to apply pressure to the discontinued
IV site. This material is absorbent, sterile, and nonirritating. An adhesive bandage may be used
to cover the site once hemostasis has occurred. A povidone-iodine swab or alcohol swab would
irritate the opened puncture site and would not stop the blood flow.
Test-Taking Strategy: Focus on the subject, the procedure for removing an IV. Visualize
this procedure and think about each of the items identified in the options to answer the question.
Noting the words “applying pressure” in the question will direct you to the correct option.
Review: the procedure for removing an IV
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Caregiving, Clotting
HESI Concepts: Nursing Interventions, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 726). St. Louis: Mosby.
Question 31
A client has just undergone insertion of a central venous catheter by the health care provider at
the bedside. Which result would the nurse be sure to check before initiating infusion of the IV
solution that the health care provider has prescribed?
Intake and output record
Serum osmolality
Serum electrolytes
Portable chest x-ray
Correct answer
Rationale: Before beginning the administration of any volume of IV solution through a central
venous catheter, the nurse should determine whether the results of the chest x-ray reveal that the
catheter is in the proper place. This is necessary to prevent inadvertent infusion of IV fluid into
pulmonary or subcutaneous tissues. The other options are items that are useful for the nurse in
the general care of the client, but they are not related to this procedure.
Test-Taking Strategy: Focus on the subject, care to the client following insertion of a
central venous catheter. Note the words “insertion by the health care provider at the bedside.”
Recalling the complications associated with the insertion of central venous catheters and the
methods used to detect them will assist in answering this question.
Review: nursing responsibilities for the client who underwent insertion of a central venous
catheter
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Intravenous Therapy
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 729). St. Louis: Mosby.
Question 32
A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag
with another nurse. Which parameter should the nurse assess just before hanging the transfusion?
Latest platelet count
Urine output over the last 24 hours
Skin color
Vital signs
Correct answer
Rationale: A change in vital signs may indicate that a transfusion reaction is occurring. This is
why the nurse assesses vital signs before the procedure, every 15 minutes for the first half-hour,
and every half-hour thereafter. The other options do not need to be assessed just before the start
of a transfusion. The nurse should be aware of fluid volume status, as well as weight to help
identify fluid volume overload, but this is not the priority before start of a blood infusion.
Test-Taking Strategy: Note the words “just before,” in the question, which tell you that the
correct option must be assessed for possible comparison during the transfusion. Use the ABCs
(airway, breathing, and circulation) to find the correct option.
Review: the procedure for administering blood
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Blood administration
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 744). St. Louis: Mosby.
Question 33
A nurse has just received a prescription to transfuse a unit of packed red blood cells for an
assigned client. For how long does the nurse plan to stay with the client after the unit of blood is
hung?
60 minutes
5 minutes
15 minutes
Correct answer
45 minutes
Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, the
time frame during which most transfusion reactions occur. This will enable the nurse to quickly
detect a reaction and intervene quickly. Five minutes is too short; the nurse would not be present
during the critical 15 minutes. Staying with the client for 45 or 60 minutes is unnecessary.
Test-Taking Strategy: Focus on the subject, nursing responsibilities after hanging a unit of
blood. Familiarity with blood transfusion procedures is needed to answer this question
accurately. Remember that the client must be directly monitored for the first 15 minutes of the
transfusion.
Review: the procedure for administering blood
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Blood Administration
Giddens Concepts: Caregiving, Safety
HESI Concepts: Assessment, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 748). St. Louis: Mosby.
Question 34
A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should
the nurse obtain to hang with the blood product at the client’s bedside?
5% dextrose in 0.9% sodium chloride
5% dextrose in water in 0.45% sodium chloride
0.9% sodium chloride
Correct answer
Lactated Ringer’s solution (LR)
Rationale: Sodium chloride (normal saline, NS) 0.9% is an isotonic solution that is typically
used both to precede and follow infusion of a blood product. Dextrose is not used because it
could result in clumping and subsequent hemolysis of RBCs. LR is not the solution of choice for
this procedure, even though it is an isotonic solution.
Test-Taking Strategy: Focus on the subject, compatible IV solutions. Familiarity with
blood administration procedures is needed to answer this question. Remember that sodium
chloride is the solution that is compatible with red blood cells.
Review: the procedure for administering blood.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Fluids and Electrolytes, Safety
HESI Concepts: Fluid & Electrolyte, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 747). St. Louis: Mosby.
Question 35
A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion
reaction. Once the incident has been documented appropriately, where does the nurse send the
blood transfusion bag?
Blood bank
Correct answer
Risk management
Microbiology laboratory
Infection-control department
Rationale: The nurse returns the transfusion bag, containing any remaining blood, to the blood
bank. This allows the blood bank to perform any follow-up testing needed in the event of a
documented transfusion reaction. The other options are incorrect because they do not handle post
transfusion reaction procedures or testing.
Test-Taking Strategy: Focus on the subject, post-transfusion reaction procedures. Use your
knowledge of routine transfusion-related procedures to answer this question. Knowing that blood
is issued by the blood bank will help you eliminate each of the incorrect options.
Review: procedures in the event of a blood transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Health Care Quality, Perfusion
HESI Concepts: Perfusion, Quality Improvement/Health Care Quality
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 751). St. Louis: Mosby.
Question 36
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit
values. The nurse takes the client’s temperature orally before hanging the blood transfusion and
notes that it is 100.0° F (37.7 C). What should the nurse do next?
Begin the transfusion as prescribed
Administer an antihistamine and begin the transfusion
Call the health care provider
Correct answer
Administer 2 tablets of acetaminophen and begin the transfusion
Rationale: If the client has a temperature of 100.0° F (37.7 C) or higher, the unit of blood
should not be hung until the health care provider has been notified and had the opportunity to
give further prescriptions. It is likely that the health care provider will prescribe the blood to be
administered despite the temperature, but it is not within the nurse’s scope of practice to make
that determination. Therefore the other options are incorrect. Additionally, medications are not
administered to the client without a prescription.
Test-Taking Strategy: Note the strategic word, next. First eliminate the comparable or
alike options that call for administration of a medication. Choose calling the health care provider
over beginning the transfusion as prescribed, knowing that an increased temperature is
abnormal.
Review: the procedure for blood transfusions
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Clinical Judgment, Collaboration
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking,
Collaboration/Managing Care
References: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 744). St. Louis: Mosby.
Question 37
At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood
bank. The nurse calculates that the transfusion must be started by which time?
1330
Correct answer
1400
1345
1315
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.
Test-Taking Strategy: Focus on the subject, the standard procedures related to blood
administration.Remember that blood must be hung within 30 minutes after obtaining it from the
blood bank.
Review: the procedure for blood administration
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Blood Administration
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 745). St. Louis: Mosby.
Question 38
A client who needs to receive a blood transfusion has experienced a pruritic rash during previous
transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which
medication does the nurse anticipate will most likely be prescribed before the transfusion?
Ibuprofen
Diphenhydramine
Correct answer
Acetaminophen
Acetylsalicylic acid
Rationale: An urticarial reaction is characterized by a rash accompanied by pruritus. This type
of transfusion reaction is prevented by pretreating the client with an antihistamine, such as
diphenhydramine. Acetaminophen and acetylsalicylic acid are analgesics; ibuprofen is a
nonsteroidal antiinflammatory medication.
Test-Taking Strategy: Note the strategic words, most likely. To answer this question
correctly, it is necessary to be familiar with this particular type of reaction and the medication
that may be used in its prevention. Recalling that diphenhydramine is an antihistamine will direct
you to the correct option.
Review: the procedure for administering a blood transfusion
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Blood Administration
Giddens Concepts: Clinical Judgment, Immunity
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Immunity
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 900). St. Louis: Saunders.
Question 39
A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving
morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care
for this client?
Encouraging increased fluids
Monitoring the client’s temperature
Monitoring the client’s respiratory rate
Correct answer
Monitoring urine output
Rationale: Morphine sulfate suppresses respiration, and monitoring respirations is a priority
nursing action. Although the other options may be a component of the plan of care for this client,
monitoring the client’s respiratory rate is the priority nursing action.
Test-Taking Strategy: Note the strategic word “priority” in the question. Use the ABCs
(airway, breathing, and circulation) to identify the correct option.
Review: the effects of morphine sulfate
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Collaboration/Managing Care, Oxygenation-Gas Exchange
Reference: Rosenjack Burchum, Rosenthal (2016) p. 262
Question 40
A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What
should the nurse tell the client?
He probably has an upper respiratory infection
A chest x-ray is required because the cough is a sign of heart failure
This is a side effect of therapy
Correct answer
He needs to have his blood counts checked
Rationale: One common side effect of therapy with any of the angiotensin-converting enzyme
(ACE) inhibitors, such as lisinopril, is a persistent dry cough. The cough generally does not
improve while the client is taking the medication. Clients are advised to notify the health care
provider if the cough becomes troublesome to them. The cough is reversible with discontinuation
of the therapy. The other options are incorrect interpretations of the client’s complaint.
Test-Taking Strategy: Focus on the information in the question and that the client has a
persistent dry cough. Remember, most ACE inhibitor names end with -pril.
Eliminate comparable or alike options upper respiratory infection and checking blood
counts first, because both are measures taken for suspected infection. To select from the
remaining options, note the words “dry cough,” which should direct you to the correct option.
Review: the side effects of ACE inhibitor therapy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Caregiving, Patient Education
HESI Concepts: Nursing Interventions, Teaching and Learning-Patient Education
Reference: Rosenjack Burchum, Rosenthal (2016) p. 476
Question 41
A client has been given a prescription to begin using nitroglycerin transdermal patches for the
management of angina pectoris. What should the nurse tell the client about the medication?
Place the patch in the area of a skin fold to promote adherence
Alternate daily dose times between the morning and the evening to prevent the development of
tolerance to the medication
Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed
Correct answer
If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch.
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.
Test-Taking Strategy: Focus on the subject, correct use of a nitroglycerin transdermal
patch. Specific information on this type of medication administration system is needed to answer
this question correctly. Remember that most nitrate medications contain the letters nitr in their
names and that nitrate medications induce vasodilation. Recalling that medication tolerance can
develop with this type of medication administration will direct you to the correct option.
Review: this type of medication administration
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Perfusion
HESI Concepts: Perfusion, Teaching and Learning/Patient Education
Reference: Rosenjack Burchum, Rosenthal (2016) p. 592
Question 42
A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for
chest pain. The chest pain is relieved, but the client complains of a headache. What should the
nurse tell the client?
This is an indication that the medication should not be used again
Headache indicates medication tolerance, and the dosage must be increased
This is an expected side effect of the nitroglycerin, and the client can relieve it by taking
acetaminophen
Correct answer
This may be an allergic reaction to the nitroglycerin, and the health care provider must be
notified
Rationale: Headache is a frequent side effect of nitroglycerin, a result of the vasodilating action
of the medication. Headaches, which may be treated effectively with the use of acetaminophen,
usually diminish in frequency as the client becomes accustomed to the medication. The other
options are incorrect.
Test-Taking Strategy: Remember that most nitrate medications contain nitr in their names
and that nitrate medications induce vasodilation. Eliminate the comparable or alike
options that imply that the client may no longer use the medication. To select from the
remaining options, recall that the medication induces vasodilation; this will direct you to the
correct option.
Review: the effects of sublingual nitroglyverin
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Patient Education, Perfusion
HESI Concepts: Perfusion, Teaching and Learning-Patient Education
Reference: Rosenjack Burchum, Rosenthal (2016) p. 593
Question 43
A client has been taking metoprolol. Which finding indicates to the nurse that the medication
is effective?
The client’s weight has increased.
The client has wheezes in the lower lobes of the lungs.
The client’s blood pressure has decreased.
Correct answer
The client’s ankles are swollen.
Rationale: Metoprolol is a cardioselective beta-blocking agent used after myocardial infarction,
as well as for hypertension and angina. Side/adverse effects include bradycardia and such
symptoms of heart failure as weight gain and increased edema.
Test-Taking Strategy: Note the strategic word “effective.” Remember that betaadrenergic–blocking agents end with -lol and recall the action and use of these medications.
Eliminate the options that are side/adverse effects, not intended effects, of the medication.
Review: the intended effects of metoprolol
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Perfusion
Reference: Rosenjack Burchum, Rosenthal (2016) p. 164
Question 44
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?
Hypocalcemia
Hypernatremia
Hypermagnesemia
Hypokalemia
Correct answer
Rationale: The client taking a potassium-losing 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.
Test-Taking Strategy: Focus on the subject, side/adverse effect of hydrochlorothiazide.
Recall that most thiazide diuretics names end with -zide. Remembering that hypokalemia is a
concern when a client is taking a potassium-losing diuretic will direct you to the correct option.
Review: the side/adverse effects of hydrochlorothiazide
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Fluid &
Electrolyte
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 452-453
Question 45
A nurse has taught a client who is taking lithium carbonate about the medication. The nurse
determines that the client needs additional teaching if the client makes which comment to
the nurse?
The medication should be taken with meals
The lithium blood levels must be monitored very closely
The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs
It is important to decrease fluid intake while taking the medication to avoid nausea
Correct answer
Rationale: Because the therapeutic and toxic dosage ranges are so close, the blood level of
lithium in a client taking the medication must be monitored closely; assessments are performed
frequently at first and every several months after that. The client should be instructed to stop
taking the medication if excessive diarrhea, vomiting, or diaphoresis occurs and to inform the
health care provider if any of these problems develops. Lithium is irritating to the gastric
mucosa; therefore lithium should be taken with meals. A normal diet and normal salt and fluid
intake (1500 to 3000 mL/day of fluid) should be maintained, because lithium decreases sodium
reabsorption in the renal tubules, which may result in sodium depletion. Low sodium intake
causes an increase in lithium retention and could lead to toxicity.
Test-Taking Strategy: Note the strategic words “needs additional teaching” in the
question, which indicate a negative event query and the need to select the incorrect client
statement. Remember that clients should be taught to maintain adequate fluid intake. This
principle will direct you to the correct option.
Review: client teaching points for the administration of lithium
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Mood and Affect, Safety
HESI Concepts: Mood & Affect, Safety
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
711) St. Louis: Saunders.
Rosenjack Burchum, Rosenthal (2016) pp. 371-372
Question 46
A nurse is developing 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?
Checking the client’s hemoglobin level daily
Placing the client in a right side-lying position
Monitoring intake and output
Correct answer
Monitoring the client’s pupillary response
Rationale: Urine retention is a side effect of benztropine mesylate. 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 and checking the
client’s hemoglobin level daily are not interventions specific to this medication. The client with
heart failure is placed in an upright position to facilitate breathing.
Test-Taking Strategy: Note the strategic word, priority. Focus on the subject, the side
effects specific to benztropine mesylate. Recalling that urine retention is a concern with this
medication and recalling the interventions for the client with heart failure will direct you to the
correct option.
Review: the side effects benztropine mesylate
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Elimination
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Elimination
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
132) St. Louis: Saunders.
Question 47
A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should
teach the client to implement which measure?
To take the medication with meals
That a therapeutic effect will be felt immediately
To rise slowly from a lying to a sitting position
Correct answer
To discontinue the medication if nausea occurs
Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor used
in the treatment of hypertension. The client should be instructed to rise slowly from a lying to a
sitting position and to permit the legs to dangle from the bed momentarily before standing to
reduce the hypotensive effect. The medication does not need to be taken with meals. It may be
given without regard to food. If nausea occurs, the client should be instructed to drink a noncola
carbonated beverage and eat some salted crackers or dry toast. The full therapeutic effect may
take place in 1 to 2 weeks.
Test-Taking Strategy: Focus on the subject, client teaching points for quinapril
hydrochloride. Remember that most ACE inhibitor names end with -pril. Recalling that ACE
inhibitors are used in the treatment of hypertension will direct you to the correct option.
Review: the client teaching points for quinapril hydrochloride
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Perfusion, Safety
HESI Concepts: Perfusion, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
1027) St. Louis: Saunders.
Question 48
Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering
the medication, the nurse explains to the client that the medication will promote which effect?
Maintain a normal blood pressure
Decrease the strength of uterine contractions
Prevent postpartum bleeding
Correct answer
Reduce lochial drainage
Rationale: Methylergonovine, an ergot alkaloid /oxytocic agent, is used to prevent or control
postpartum hemorrhage by inducing uterine contraction and enhancing myometrial tone. The
immediate dose is usually administered intramuscularly, and then, if needed, the medication is
given again by mouth. Methylergonovine increases the strength and frequency of contractions
and may increase blood pressure. One priority before the administration of methylergonovine is
assessment of the client’s blood pressure. There is no relationship between the action of this
medication and lochial drainage.
Test-Taking Strategy: Use the process of elimination and focus on the subject, use of the
medication, methylergonovine. Recalling the classification of the medication and remembering
that this medication is an oxytocic agent will direct you to the correct option.
Review: the effects of methylergonovine
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Perfusion
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
766-767) St. Louis: Saunders.
Question 49
A nurse is assessing 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?
Diabetes mellitus
Dementia
Correct answer
Seizure disorder
Posttraumatic stress disorder
Rationale: 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.
Test-Taking Strategy: Focus on the subject, the indicastions for using donepezil
hydrochloride. Knowledge regarding the use of donepezil hydrochloride is necessary to answer
this question. It is necessary to know that this medication is used in the treatment of mild to
moderate dementia of the Alzheimer type.
Review: donepezil hydrochloride.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Develoment, Cognition
HESI Concepts: Cognition, Developmental
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
387) St. Louis: Saunders.
Question 50
Fluoxetine hydrochloride is prescribed for a client, and the nurse provides instruction regarding
the use of the medication. The nurse tells the client that it is best to take the medication at what
time?
At lunchtime
With the evening meal
Midafternoon, with an antacid
In the morning
Correct answer
Rationale: Fluoxetine hydrochloride is a selective serotonin reuptake inhibitor that elicits an
antidepressant response. It is best administered in the early morning, and there is no need to
coordinate the dose with a meal. (If the medication causes lightheadedness or dizziness, the
healthcare provider may advise the client to take it at bedtime.) The other options are incorrect.
Test-Taking Strategy: Note the strategic word, best. Recall that antacids are not generally
administered with medication. To select from the remaining options, it is necessary to know the
classification of this medication and to recall that it is best to take this medication in the
morning.
Review: the use of fluoxetine and its associated client teaching points
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Mood and Affect
HESI Concepts: Teaching and Learning-Patient Education, Mood & Affect
Reference: Rosenjack Burchum, Rosenthal (2016) p. 360
Question 51
A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse
should provide the client with which information about the insulin?
Remove all of the air from the bottle before mixing the two types
Keep insulin refrigerated at all times
Shake the NPH insulin bottle before mixing the two types
Draw the regular insulin into the syringe first
Correct answer
Rationale: Before different types of insulin are mixed, the NPH bottle should be rotated for at
least one minute between the hands. This resuspends the insulin and helps warm the medication.
The bottles should not be shaken; shaking causes the formation of bubbles, which may trap
particles of insulin and alter the dosage of the medication. Insulin may be maintained at room
temperature. A 25- to 28-gauge 5/8-inch (1.6 cm) needle should be used for subcutaneous
injection of insulin. Bottles of insulin intended for future use should be stored in the refrigerator.
Regular insulin is drawn up before NPH insulin to ensure that there is no contamination of the
rapid-acting insulin by the intermediate-acting insulin. It is not necessary to remove air from the
insulin bottle.
Test-Taking Strategy: Focus on the subject, the procedure for mixing NPH and regular
insulin in the same syringe. Remember “RN” to assist in remembering that the regular insulin is
drawn before the NPH.
Review: the procedure for mixing insulin
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Glucose Regulation
HESI Concepts: Teaching and Learning-Patient Education, Metabolism
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 1161). St. Louis:
Mosby.
Question 52
A nurse provides instructions to a client who will be taking furosemide. Which statement by the
client indicates to the nurse that the client needs additional instruction?
“I should expect to have ringing in my ears.”
Correct answer
“This medication will make me urinate.”
“I need to maintain my fluid intake.”
“I need to sit or stand up slowly.”
Rationale: Furosemide is a loop diuretic. Adverse effects of furosemide therapy include
orthostatic hypotension and ototoxicity. Therefore the client should change positions slowly to
help prevent lightheadedness. The client must also contact the health care provider if signs of
ototoxicity, such as hearing loss or ringing in the ears, occur. Fluid intake should be maintained
to prevent dehydration.
Test-Taking Strategy: Note that the question asks about an adverse effect. Also note
the strategic words “needs additional instruction,” which indicate a negative event
query and the need to select the incorrect client statement. Reading each option carefully will
direct you to the statement that indicates an adverse effect.
Review: client teaching points for furosemide
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Safety
HESI Concepts: Teaching and Learning-Patient Education, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 450-451
Question 53
A client has a prescription for short-term therapy with enoxaparin . The nurse explains to the
client that this medication is being prescribed for which purpose?
Prevent pain
Relieve back spasms
Increase the client’s energy level
Reduce the risk of deep vein thrombosis
Correct answer
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis
and thromboembolism in selected at-risk clients. It is not used to prevent pain, relieve back
spasms, or increase the energy level.
Test-Taking Strategy: Focus on the subject, the purpose of enoxaparin. To answer this
question accurately, it is necessary to be familiar with this medication and its intended effects.
Recalling that this medication is an anticoagulant will direct you to the correct option.
Review: the action of enoxaparin
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Patient Education, Clotting
HESI Concepts: Teaching and Learning-Patient Education, Perfusion
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
419-420) St. Louis: Saunders.
Question 54
A client with HIV infection has been started on therapy with zidovudine. The nurse tells the
client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy.
Which laboratory test is most important to monitor for this client?
Serum potassium
Creatinine
Blood urea nitrogen (BUN)
Complete blood count (CBC)
Correct answer
Rationale: Zidovudine can cause serious adverse effects such as lactic acidosis, liver disorders,
and blood disorders such as severe anemia and neutropenia. Liver enzymes should be monitored;
creatinine and bood urea nitrogen levels monitor kidney disorders. Potassium can be elevated in
kidney disorders, but is not affected by zidovudine.
Test-Taking Strategy: Eliminate comparable or alike options such as creatinine and blood
urea nitrogen, because both tests monitor kidney function.
Review: adverse effects of zidovudine.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Immunity, Infection
HESI Concepts: Immunity, Infection
Question 55
A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the
health care provider has documented that the client is experiencing signs of akathisia. On the
basis of the health care provider’s note, which clinical manifestation would the nurse expect to
find during assessment of the client?
Puffing of the cheeks
Puckering of the mouth
Motor restlessness
Correct answer
Protrusion of the tongue
Rationale: Akathisia —motor restlessness, or the desire to keep moving —may appear within 6
hours of administration of the first dose of haloperidol. It may be difficult to distinguish from
psychotic agitation. Tardive dyskinesia is uncontrolled rhythmic movements of the mouth, face,
and extremities, including lip smacking or puckering, puffing of the cheeks, uncontrolled
chewing, and rapid or wormlike movements of the tongue. The health care provider should be
notified if any of these symptoms occurs.
Test-Taking Strategy: Focus on the subject, akathisia. Eliminate the comparable or alike
options that are manifestations involving the face.
Review: the signs of akathisia
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clincial Judgment, Psychosis
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Cognition
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
567) St. Louis: Saunders.
Question 56
Phenelzine sulfate is being administered to a client with depression. The client suddenly
complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and
vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which
medication should the nurse prepare to administer, anticipating that it will be prescribed as the
antidote to treat phenelzine-induced hypertensive crisis?
Phentolamine
Correct answer
Protamine sulfate
Calcium gluconate
Acetylcysteine
Rationale: The antidote to treat phenelzine-induced hypertensive crisis is phentolamine.
Hypertensive crisis may manifest as hypertension, frontally radiating occipital headache, neck
stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils,
and palpitations. Tachycardia or bradycardia and constricting chest pain may also be present.
Test-Taking Strategy: Focus on the subject, the antidote to treat phenelzine-induced
hypertensive crisis. Protamine sulfate and calcium gluconate may be easily eliminated, because
protamine sulfate is the antidote to heparin and calcium gluconate is used in cases of magnesium
overdose. To select from the remaining options, it is necessary to recall that acetylcysteine is the
antidote to acetaminophen.
Review: the antidote to treat phenelzine-induced hypertensive crisis
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Mood and Affect, Safety
HESI Concepts: Mood & Affect, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
952) St. Louis: Saunders.
Question 57
Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study
does the nurse expect to see among the health care provider’s prescriptions?
Creatinine level
Correct answer
Sedimentation rate
Red blood cell count
Platelet count
Your answer is incorrect
Rationale: Baseline assessment includes renal and liver function parameters. Risperidone is
used with caution — often at a reduced dosage — in clients with renal or hepatic impairment,
clients with underlying cardiovascular disorders, and in older or debilitated clients. The
laboratory tests identified in the other options are not necessary.
Test-Taking Strategy: Focus on the subject, the laboratory test to monitor for the client
receiving risperidone. Recalling that this medication is used with caution in clients with renal or
hepatic failure will direct you to the correct option.
Review: risperidone
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Psychosis, Safety
HESI Concepts: Cognition, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 336-337
Question 58
Betaxolol eye drops have been prescribed for the treatment of a client’s glaucoma. The nurse
tells the client to return to the clinic for follow-up for which purpose?
To give a sample for urinalysis
To have weight checked
To have the blood glucose level checked
For measurement of blood pressure and apical pulse
Correct answer
Rationale: Betaxolol is an antiglaucoma medication and a beta-adrenergic blocker.
Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, constipation, and
diarrhea are side/adverse effects of the medication. Nursing interventions include blood pressure
monitoring to detect hypotension and assessment of the pulse for strength, weakness,
irregularity, and bradycardia. Blood glucose testing is not a part of follow-up with this
medication; neither are weighing and urinalysis.
Test-Taking Strategy: Remember that beta-blocker medication names end with -lol. Also, use
the ABCs (airway, breathing, and circulation) to find the correct option.
Review: the side/adverse effects of betaxolol
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Safety, Sensory Perception
HESI Concepts: Safety, Sensory/Perception
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 1066). St. Louis: Saunders.
Question 59
Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For
which of the following symptoms, indicative of an adverse effect, does the nurse monitor the
client?
Hypotension
Nausea
Vomiting
Vertigo
Correct answer
Rationale: Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of
the eighth cranial nerve. Ototoxicity, a common adverse effect of therapy with the
aminoglycosides, may result in permanent hearing loss. If signs of ototoxicity occur, the nurse
should hold the next dose of the medication and notify the health care provider. Nausea,
vomiting, and hypotension are rare side effects of the medication.
Test-Taking Strategy: Focus on the subject, an adverse effect. Answer this question by
recalling that tobramycin is an aminoglycoside and that ototoxicity is a common adverse effect
of aminoglycoside therapy.
Review: the adverse effects of aminoglycoside therapy
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Safety, Sensory Perception
HESI Concepts: Safety, Sensory/Perception
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p.
1177). St. Louis: Mosby.
Question 60
A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been
doubling the daily dose to make it easier to resist smoking. The nurse warns the client that
doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse
warn the client?
Orthostatic hypotension
Seizures
Correct answer
Weight gain
Insomnia
Rationale: Bupropion is an antidepressant. Seizure activity is common with dosages greater
than 450 mg/day. It does not cause significant orthostatic blood pressure changes. Bupropion
frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity is more
dangerous to the client.
Test-Taking Strategy: Focus on the subject, adverse effects of bupropion. Specific
knowledge regarding this medication and its adverse effects is necessary to answer the question.
Remember that bupropion is associated with a risk of seizures to answer questions similar to this
one.
Review: bupropion.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Intracranial Regulation, Safety
HESI Concepts: Intracranial Regulation, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) p. 356
Question 61
A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B .
Which is the most critical observation for the nurse to make while the medication is being
administered?
Monitor the client’s urine output
Correct answer
Monitor the client for hypothermia
Check the client’s blood glucose level
Check the client’s neurological status
Rationale: Amphotericin B can produce medication toxicity during administration and exhibit
symptoms such as chills, fever, headache, vomiting, and impairment of renal function. The
medication is also irritating to the IV site, commonly causing thrombophlebitis. The nurse
administering this medication watches for all of these problems. The other options are not
specifically related to the administration of this medication.
Test-Taking Strategy: Focus on the subject, nursing responsibilities related to the
administration of Amphotericin B. Use your knowledge of this potent medication to answer this
question. Recalling that fever and chills may occur will help you eliminate monitoring of the
client for hypothermia. To select from the remaining options, recall that the medication can be
toxic to the kidneys, which should direct you to the correct option.
Review: nursing care in regard to the administration of amphotericin B.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., pp.
89-90). St. Louis: Mosby.
Question 62
A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the
client for aspirin toxicity, which question should the nurse ask the client?
“Are you constipated?”
“Are you having any diarrhea?”
“Do you have any double vision?”
“Do you have any ringing in the ears?”
Correct answer
Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, is common when the
daily dose is more than 4 g. Tinnitus (ringing in the ears) is the effect most frequently noted with
intoxication. Hyperventilation may also occur, because salicylate stimulates the respiratory
center. The client may have a fever, because salicylate interferes with oxygen consumption and
heat production.
Test-Taking Strategy: Focus on the subject, aspirin toxicity. Recalling that this medication
is ototoxic will direct you to the correct option.
Review: the signs of aspirin toxicity.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Safety, Sensory Perception
HESI Concepts: Safety, Sensory Perception
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 866-867
Question 63
A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy.
Which laboratory finding prompts the nurse to initiate neutropenic precautions?
A clotting time of 10 minutes
An ammonia level of 20 mcg N/dL (14.6 μmol N/L)
A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).
Correct answer
A platelet count of 100 × 103/μL (100× 109/L).
Rationale: The normal WBC count is 4.0 to 11.0 × 103/μL (4.0 to 11.0 × 109/L).. When the
WBC count drops, neutropenic precautions — including protective isolation to protect the client
from infection — must be implemented. Bleeding precautions must be initiated when the platelet
count drops. With bleeding precautions, traumatic procedures such as injections and rectal
temperatures are avoided. The normal platelet count is 150 to 400 × 103/μL (150 to 400 ×
109/L).. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg
N/dL (11-32 μmol N/L).
Test-Taking Strategy: Focus on the subject, the need to initiate neutropenic precutions.
Eliminate the options that identify normal laboratory values first. To select from the last two
options, correlate a low WBC count with the need for neutropenic precautions and a low platelet
count with the need for bleeding precautions.
Review: the interventions associated with caring for the client undergoing chemotherapy.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Infection
HESI Concepts: Cellular Regulation, , Infection
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 265-266). St.
Louis: Mosby.
Question 64
Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the
nurse is providing instructions to the client. The nurse realizes the instructions have been
effective if the client makes the statement she will change which aspect of care?
To drink at least 2 glasses of orange juice every day
That it is best to take the medication with food
To increase fluid intake to 2000 mL to 3000 mL/day
Correct answer
To avoid salt while taking this medication
Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client must be
instructed to drink copious amounts of fluid during administration of this medication. The client
should also monitor her urine for hematuria. The medication should be taken on an empty
stomach, unless gastrointestinal upset occurs. Hyperkalemia may also result from the use of the
medication; therefore the client would not be encouraged to increase potassium intake (i.e.,
bananas and orange juice). The client also would not be instructed to alter her sodium intake.
Test-Taking Strategy: Focus on the subject, the toxic effects of cyclophosphamide.
Correlate cyclophosphamide with hemorrhagic cystitis to direct you to the correct option and to
answer questions similar to this one.
Review: the toxic effects associated with this cyclophosphamide.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Safety
HESI Concepts: Cellular Regulation, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
299) St. Louis: Saunders.
Question 65
A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy,
nursing assessment is the priority?
Lung sounds
Correct answer
Heart rate
Peripheral pulses
Level of consciousness
Rationale: Bleomycin sulfate, an antineoplastic medication, can cause interstitial pneumonitis
that may progress to pulmonary fibrosis. Pulmonary function parameters, along with
hematologic, hepatic, and renal function tests, must be monitored. The nurse should monitor lung
sounds for dyspnea and wheezes, indicative of pulmonary toxicity. The medication must be
discontinued immediately if pulmonary toxicity occurs.
Test-Taking Strategy: Note the strategic word, priority. Eliminate the comparable or
alike options that address circulatory status. From this point, prioritize and select lung sounds,
an indicator of airway status.
Review: the toxic effects of bleomycin sulfate.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Gas Exchange
HESI Concepts: Cellular Regulation, Oxygenation-Gas Exchange
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p.
178). St. Louis: Mosby.
Question 66
The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL.
On the basis of this result, the nurse should take which action initially?
Call the health care provider immediately
Call the rapid response team to help with the emergency
Document the normal value on the chart
Correct answer
Call the pharmacy to alert the pharmacist regarding the client’s theophylline level
Rationale: The normal therapeutic range for theophylline is 10 to 20 mcg/mL. A level above 20
mcg/mL is considered toxic. A value of 16 mcg/mL is within the therapeutic range.
Test-Taking Strategy: Focus on the information in the question, and note that the
theophylline level is 16 mcg/mL. Specific knowledge regarding the therapeutic range for this
medication is necessary to answer this question. Recalling that the normal therapeutic range for
theophylline levels is 10 to 20 mcg/mL will direct you to the correct option. Eliminate
the comparable or alike options that indicate reporting an abnormal level is necessary.
Review: the nursing considerations related to theophylline.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation-Gas Exchange, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
1180) St. Louis: Saunders.
Question 67
A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of
returning to the clinic for follow-up blood testing. The nurse realizes the client understands the
instructions if the client verbalizes the need to return to the clinic for which blood test?
Blood urea nitrogen
Liver enzymes
Correct answer
Red blood cell count
Serum creatinine
Rationale: Isoniazid therapy can increase hepatic enzymes and cause hepatitis. Therefore the
client’s liver enzymes are assessed when therapy is initiated and during the first 3 months of
therapy. Monitoring may be continued further in the client who is older than 50 or abuses
alcohol. The other options are not specifically related to the use of this medication.
Test-Taking Strategy: Eliminate blood urea nitrogen and serum creatinine because they
are comparable or alike options that are indicators of renal function. To select from the
remaining options, it is necessary to know that this medication can be toxic to the liver.
Review: the adverse effects of isoniazid .
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation-Gas Exchange, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) p. 1084
Question 68
Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms.
While providing instructions to the client, which side effect does the nurse tell the client is
possible?
Increased appetite
Increased salivation
Nasal congestion
Correct answer
Photosensitivity
Rationale: Common side effects of baclofen include drowsiness, dizziness, weakness, and
nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation
or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous
system excitement and restlessness may occur, along with slurred speech, tremor, dry mouth,
nocturia, and erectile dysfunction. Photosensitivity is not a side effect of this medication.
Test-Taking Strategy: Eliminate increased appetite and increased salivation because they
are comparable or alike options. To select from the remaining options it is necessary to
know that nasal congestion can occur.
Review: the side effects of baclofen
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Safety
HESI Concepts: Teaching and Learning-Patient Education, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
116-117) St. Louis: Saunders.
Question 69
A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis.
Which medication does the nurse ensure is available to treat this crisis?
Protamine sulfate
Pyridostigmine bromide
Acetylcysteine
Atropine sulfate
Correct answer
Rationale: The treatment for cholinergic crisis is atropine sulfate. Protamine sulfate is the
antidote for heparin, and acetylcysteine is the antidote for acetaminophen. Pyridostigmine
bromide is an anticholinesterase agent used in the treatment of myasthenia gravis to improve
muscle strength. An overdose of this medication can cause cholinergic crisis.
Test-Taking Strategy: Focus on the information in the question and note the words
“cholinergic crisis.” Recall that atropine sulfate is an anticholinergic to find the correct option.
Review: the antidote for cholinergic crisis
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 126, 132-133
Question 70
A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain.
Which instruction should the nurse provide to the client?
Avoid all exercise to help prevent lightheadedness
Maintain a high-fiber diet
Correct answer
Decrease fluid intake
Avoid the use of stool softeners to help prevent diarrhea
Rationale: Codeine sulfate can cause constipation. The client is instructed to increase fluid
intake and maintain a high-fiber diet to help prevent constipation. The other options are incorrect
because they do not address the side effects associated with the use of this medication. Although
lightheadedness may occur with the use of this medication, all exercise is not avoided; in fact,
the client should ambulate frequently.
Test-Taking Strategy: Focus on the information in the question and recall that codeine
sulfate is an opioid analgesic. Recalling that codeine sulfate can cause constipation will direct
you to the correct option. The option with the closed-ended term “all” can be eliminated.
Review: nursing measures related to the administration of codeine sulfate.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Elimination, Pain
HESI Concepts: Comfort, Elimination
Reference: Rosenjack Burchum, Rosenthal (2016) p. 284
Question 71
A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce
labor. Which occurrence does the nurse include in the plan of care as a reason for immediate
discontinuation of the oxytocin infusion?
Severe drowsiness
Uterine hyperstimulation
Correct answer
Early decelerations of the fetal heart rate
Uterine atony
Rationale: Oxytocin, a synthetic hormone that stimulates uterine contractions, is a commonly
used pharmacological means of inducing labor. One major concern associated with oxytocin is
hyperstimulation of uterine contractions. Hyperstimulation of the uterus, which may result in
diminished placental perfusion, may cause fetal distress. Therefore an oxytocin infusion must be
stopped if there are any signs of uterine hyperstimulation. Early decelerations of the fetal heart
rate are a reassuring sign and do not indicate fetal distress. Uterine atony and severe drowsiness
are not indications of the need to discontinue the infusion.
Test-Taking Strategy: Focus on the subject, the need to immediately discontinue oxytocin.
Knowing that induction of labor involves the stimulation of uterine contractions will help you
answer this question. Using your knowledge of the effect of uterine contractions on
uteroplacental circulation should help you recognize that hyperstimulation of contractions would
compromise fetal oxygenation, a primary physiological need.
Review: the nursing implications associated with the administration of oxytocin
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Perfusion, Safety
HESI Concepts: Perfusion, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 786-787
Question 72
A home health nurse provides instructions to a client who is taking allopurinol for the treatment
of gout. The nurse realizes the instructions have been effective if the client verbalizes the
importance of which teaching point?
Place an ice pack on the lips if they swell
Drink at least 8 glasses of fluid every day
Correct answer
Take the medication on an empty stomach 2 hours before meals
Use an over-the-counter (OTC) antihistamine lotion if a rash develops
Rationale: Clients taking allopurinol are encouraged to drink 3000 mL/day of fluid.
Allopurinol is to be given with or immediately after meals or milk. If a rash, irritation of the
eyes, or swelling of the lips or mouth develops, the client should contact the health care provider
because this development may indicate hypersensitivity.
Test-Taking Strategy: Focus on the subject, client instructions for allopurinol. The options
that indicate hypersensitivity may be eliminated first, because they are not normal, expected
responses. To select from the remaining options, recall that the medication should be taken with
food or milk; this will direct you to the correct option.
Review: client instructions for allopurinol.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Mobility, Pain
HESI Concepts: Comfort, Mobility
Reference: Rosenjack Burchum, Rosenthal (2016) p. 893
Question 73
A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse
to express concern because her urine has turned dark in color. The nurse should provide which
information to the client?
That darkening of the urine is a harmless side effect
Correct answer
To discontinue the medication
To report to the clinic to see the health care provider
To increase her fluid intake
Rationale: Metronidazole can produce a variety of untoward effects, but they rarely require
termination of treatment. Harmless darkening of the urine may occur, and the client should be
forewarned of this effect. The nurse would not instruct the client to discontinue the medication. It
is not necessary that the client see the health care provider. Increasing fluid intake is a good
health measure but will not prevent this expected side effect.
Test-Taking Strategy: Focus on the information in the question, that the client’s urine
has turned to a dark color. Knowledge regarding the expected effect of this medication will direct
you to the correct option. Remember that darkening of the urine is a harmless side effect of
metronidazole.
Review: the effects of metronidazole
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
Reference: Rosenjack Burchum, Rosenthal (2016) p. 1197
Question 74
Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides
instructions to the client regarding the administration of the oral medication and tells the client
that it is best to take the medication in which way?
With a meal
At bedtime, with a snack
With juice
On an empty stomach
Correct answer
Rationale: Oral erythromycin should be taken on an empty stomach with a full glass of water.
Some preparations may be administered with food if gastrointestinal upset occurs, but it is best to
administer the drug on an empty stomach.
Test-Taking Strategy: Note the strategic word, best. The comparable or alike
options are incorrect in that they all identify administering the medication with a food or fluid
product.
Review: the administration of erythromycin
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Infection
HESI Concepts: Teaching and Learning-Patient Education, Infection
Reference: Rosenjack Burchum, Rosenthal (2016) p. 1048
Question 75
A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine
sulfate. Which finding should cause the nurse to contact the health care provider?
Respiratory rate of 10 breaths/min
Correct answer
Urine output of 30 mL/hr
Blood pressure of 100/60 mm Hg
Temperature of 97.6° F (36.4°C)
Rationale: Before an opioid is administered, respiratory rate, blood pressure, and pulse rate
should be measured. The medication should be withheld and the health care provider notified if
the respiratory rate is 12 breaths/min or slower, if the blood pressure is significantly below the
pretreatment value, or if the pulse rate is significantly above or below the pretreatment value. A
urine output of 30 mL/hr is normal. A temperature of 97.6° F (36.4°C) is below normal, but it is
not necessary to notify the health care provider of this reading.
Test-Taking Strategy: use the ABCs, Airway, Breathing, and Circulation. Recalling
that morphine sulfate primarily affects respiration will help direct you to the correct option.
Review: the adverse effects of morphine sulfate
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation-Gas Exchange, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) p. 262
Question 76
A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis.
Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing
the medication from a single-use vial. What should the nurse do to prepare the medication?
Shake the vial before drawing up the medication
Draw up the medication and discard the unused portion
Correct answer
Mix the medication with 0.1 mL of heparin before administration to prevent clotting
Obtain the medication from the medication freezer and allow it to thaw
Rationale: Epoetin alfa is dispensed in a 1-mL vial for subcutaneous or IV injection. The vial
should not be shaken, because epoetin alfa is a protein that can be denatured with agitation. The
nurse should use only one dose per single-dose vial and discard the unused portion. Epoetin alfa
is not to be mixed with other medications. The medication should be stored at 2° to 8 °C (35° to
46° F) and should not be frozen.
Test-Taking Strategy: Focus on the information in the question. Noting the words
“single-use vial” in the question will direct you to the correct option.
Review: the procedure for administering Epoetin alfa
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 663-664
Question 77
Zidovudine is prescribed for an adult client with HIV infection. The nurse should provide which
instruction to the client about the medication?
To space the doses evenly around the clock
Correct answer
That aspirin can be taken to treat headache
To discontinue the medication if nausea occurs
That the medication must be taken with milk
Rationale: The adult dosage of zidovudine is usually 200 mg every 8 hours or 300 mg every 12
hours. The client is instructed to space doses of the medication evenly around the clock. Food or
milk does not affect the gastrointestinal absorption of the medication. The client is instructed to
continue therapy for the full prescribed duration of treatment. The client is also instructed not to
take any medication, including aspirin, without the health care provider’s approval.
Test-Taking Strategy: Focus on the subject, client instructions for taking zidovudine.
Knowledge of the basic principles of medication administration will assist you in eliminating the
option referring to discontinuation of the medication. To select from the remaining options,
recall that this medication is an antiviral, which will direct you to the correct option. Remember
that evenly spaced doses are necessary to maintain virustatic concentrations of the medication.
Review: client teaching points for zidovidine
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts:Immunity, Safety
HESI Concepts: Immunity, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
1294-1295) St. Louis: Saunders.
Question 78
A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the
client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the
administration of the dose?
Should be withheld and the health care provider notified
Should be administered as prescribed
Correct answer
Should be preceded with a dose of potassium
Should be withheld that day
Rationale: Hypokalemia can make the client more susceptible to digoxin toxicity, so the nurse
monitors the client’s potassium level. The normal reference range of potassium for an adult is 3.5
to 5.0 mEq/L (3.5 to 5.0 mmol/L). If the potassium level is low, the dose is withheld and the
health care provider is notified. In this situation, the dose should be administered as prescribed,
because the potassium level is within the normal range.
Test-Taking Strategy: Focus on the information in the question and note the client’s
potassium level. To answer this question correctly, you must know that hypokalemia increases
the likelihood of digoxin toxicity and know the normal range of values for potassium. Noting
that the client’s potassium level is within the normal limits will direct you to the correct option.
Review: the normal potassium level and the nursing considerations related to the administration
of digoxin
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Pharmacology
Giddens Concepts: Fluids and Electrolytes, Perfusion
HESI Concepts: Fluid & Electrolyte, Perfusion
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 296). St. Louis:
Mosby.
Rosenjack Burchum, Rosenthal (2016) pp. 532-533
Question 79
A client with heart failure being discharged home will be taking furosemide. Which statement by
the client indicates to the nurse that the teaching has been effective?
“I’ll check my ankles every day for swelling.”
“I’ll weigh myself every day.”
Correct answer
“I’ll measure my urine output.”
“I’ll take my pulse every day.”
Rationale: A client taking furosemide must be able to monitor fluid status throughout therapy.
Weighing oneself each day is the easiest and most accurate way to accomplish this. Checking the
ankles for swelling and measuring urine output are incorrect because of the difficulty of
assessing fluid status accurately in these ways. Taking daily pulse is not necessary and unrelated
to the administration of furosemide.
Test-Taking Strategy: Note the strategic word, effective. In client teaching questions, try
to select the option that would be the easiest and most effective for a nurse to teach and for the
client to understand. Remember, if you teach a client to do something that is too complicated,
compliance will be poor. Having the client weigh himself every day is the easiest and most
accurate way to measure fluid status.
Review: the measures with which to effectively identify a therapeutic response to furosemide.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Patient Education, Fluids and Electrolytes
HESI Concepts: Teaching and Learning-Patient Education, Fluid& Electrolyte
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 450-451
Question 80
A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates
that the client is experiencing an adverse effect of the medication?
Dry mouth
Tarry stools
Correct answer
Hypotension
Hypoglycemia
Rationale: Corticosteroids increase gastric secretion, which may result in the development of
peptic ulcers and gastrointestinal bleeding. Corticosteroids increase blood glucose. Dry mouth
and hypotension are not side effects of corticosteroid therapy.
Test-Taking Strategy: Focus on the subject, and adverse effect of prednidone. Knowledge
regarding the adverse effects of corticosteroid therapy is necessary to answer this question.
Recalling that corticosteroids increase gastric secretion, resulting in gastrointestinal irritation,
will assist you in finding the correct option.
Review: the adverse effects associated with corticosteroids
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Tissue Integrity
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Tissue
Integrity
Reference: Rosenjack Burchum, Rosenthal (2016) p. 878
Question 81
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which
assessment finding indicates to the nurse that the client is experiencing magnesium toxicity?
Proteinuria of +3
Sudden drop in fetal heart rate
Correct answer
Serum magnesium level of 2.5 mEq/L (1.25 mmol/L)
Presence of deep tendon reflexes
Rationale: Magnesium toxicity may result from magnesium sulfate therapy. Signs of
magnesium sulfate toxicity, related to the central nervous system–depressant effects of the
medication, include respiratory depression, loss of deep tendon reflexes, sudden drop in fetal or
maternal heart rate, and decreased blood pressure. The normal serum range for magnesium is
1.5-2.5 mEq/L 0.75-1.25 mmol/L)Proteinuria of 3+ is likely to be noted in a client with
preeclampsia.
Test-Taking Strategy: Focus on the subject, adverse effects. Eliminate the presence of deep
tendon reflexes first, because it is a normal finding. Next eliminate the serum magnesium level
of 2.5 mEq/L (1.25 mmol/L), knowing that the normal serum range for magnesium is 1.5-2.5
mEq/L 0.75-1.25 mmol/L). To select from the remaining options, recall that proteinuria of 3+
would be noted in a client with preeclampsia; this should direct you to the correct option.
Review: the adverse effects of magnesium sulfate
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Assessment, Perfusion
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternalchild nursing (4th ed., pp. 594-595). St. Louis: Elsevier.
Question 82
A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by
the client indicates to the nurse that the client is experiencing an adverse effect of the
medication?
“I’m feeling really drowsy.”
Correct answer
“I can’t seem to get enough to eat.”
“I urinate about the same amount as I always did.”
“My legs are very relaxed.”
Rationale: Drowsiness, diarrhea, and hepatotoxicity are the adverse effects of this muscle
relaxant, which is used to treat the chronic spasticity seen with spinal cord injury. The
drowsiness may interfere with the client’s rehabilitation. Relaxed legs are a desired effect. Some
clients experience anorexia and urinary frequency.
Test-Taking Strategy: Focus on the subject, an adverse effect of a medication. Relaxed legs
are a desired effect, so eliminate this option. To select from the remaining options, recall that this
medication is a muscle relaxant. This will direct you to the correct option.
Review: the adverse effects of dantrolene sodium
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Intracranial Regulation
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Intracranial
Regulation
Reference: Rosenjack Burchum, Rosenthal (2016) p. 244
Question 83
The emergency department staff prepares for the arrival of a child who has ingested a bottle of
acetaminophen. Which medication does the nurse ensure is available?
Phytonadione
Pancreatin
Acetylcysteine
Correct answer
Protamine sulfate
Rationale: Acetylcysteine is the antidote to acetaminophen. Pancreatin is a pancreatic enzyme
replacement or supplement. Phytonadione is the antidote to warfarin sodium. Protamine sulfate is
the antidote to heparin.
Test-Taking Strategy: Focus on the information in the question and note that the child
ingested a bottle of acetaminophen. Knowledge regarding the appropriate antidote to
acetaminophen is necessary to answer the question. Remember that acetylcysteine is the antidote
to acetaminophen.
Review: the antidote for acetaminophen
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) p. 868
Question 84
A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if
documented in the assessment data, indicates to the nurse that the client may be experiencing an
adverse effect of the medication?
No change in peripheral vision
Tinnitus
Jaundice
Correct answer
Pupillary constriction in response to light
Rationale: Acetazolamide is a carbonic anhydrase inhibitor used in the treatment of glaucoma
to reduce the rate of aqueous humor formation and to lower intraocular pressure. Adverse effects
include nephrotoxicity, hepatotoxicity, and bone marrow depression. Jaundice is a sign of
hepatotoxicity. Tinnitus is not related to this medication. Pupillary constriction in response to
light is a normal response. Diminished peripheral vision would signal a complication of
glaucoma.
Test-Taking Strategy: Focus on the subject, an adverse effect of the medication. Eliminate a
lack of change in the client’s peripheral vision and pupillary constriction in response to light,
both of which are normal responses. To select from the remaining options, remember that
nephrotoxicity, hepatotoxicity, and bone marrow depression are adverse effects; this will direct
you to the correct option.
Review: acetazolamide
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Safety, Sensory Perception
HESI Concepts: Safety, Sensory/Perception
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 1271-1272
Question 85
A nurse instructs a client with hypothyroidism about the dosage, method of administration, and
side effects of levothyroxine sodium. Which statement by the client indicates an understanding
of the nurse’s instructions?
“I should take the medication in the evening.”
“I can expect diarrhea, insomnia, and excessive sweating.”
“If I feel nervous or have tremors, I should only take half the dose.”
“I need to report any episodes of palpitations, chest pain, or dyspnea.”
Correct answer
Rationale: One major concern when initiating thyroid hormone–replacement therapy is that the
dose is too high, which can lead to cardiovascular problems. For this reason, clients need to be
made aware of the early signs and symptoms of toxicity and urged to report these findings
immediately to the health care provider. Diarrhea, insomnia, and excessive sweating are signs
and symptoms of hyperthyroidism; though they may occur with thyroid-replacement therapy,
they are not expected and should be reported. Tremors and nervousness are also signs of toxicity,
which should be reported. Clients should never take it upon themselves to adjust hormone
dosage. Levothyroxine sodium is administered in the morning.
Test-Taking Strategy: Think about the purpose and use of levothyroxine (Synthroid). Use
the ABCs,airway, breathing, and circulation to find the correct option.
Review: levothyroxine sodium
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Patient Education, Safety
HESI Concepts: Metabolism, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) p. 713
Question 86
Warfarin sodium has been prescribed, and the nurse teaches the client about the medication.
Which statement by the client indicates that further teaching is necessary?
“I’ll buy one of those medication alert tags that tells people I’m taking an anticoagulant.”
“I’ll use an electric shaver until the doctor stops the Coumadin prescription.”
“I won’t play football anymore.”
“I won’t take any over-the-counter medications except aspirin.”
Correct answer
Rationale: No over-the-counter medications of any kind should be ingested by a client taking
an anticoagulant. This is especially true of aspirin and aspirin-containing products (because of
the potential for bleeding). The other options are correct statements. Strenuous games (e.g.,
contact sports) that may result in bruising and skin breakdown should be avoided. Electric
shavers are less irritating to the skin than razors and less likely to cause skin breakdown.
Medication alert tags are recommended in case of emergency. The client should also be taught to
carry an identification card listing all medications currently being taken.
Test-Taking Strategy: Note the strategic words “further teaching is necessary,” which
indicate a negative event query and the need to select the incorrect client statement.
Recalling that warfarin sodium is an anticoagulant and that anticoagulants can cause bleeding
will direct you to the correct option.
Review: the teaching points for clients on anticoagulants.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Clotting, Safety
HESI Concepts: Perfusion, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 622-623
Question 87
A home care nurse has been assigned a client who has been discharged home with a prescription
for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit
as a means of identifying complications of the TPN therapy? Select all that apply.
Weight
Correct answer
Glucose test
Correct answer
Temperature
Correct answer
Hemoglobin and hematocrit
Peripheral pulses
Rationale: When a client is receiving TPN 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 TPN 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 TPN therapy.
Test-Taking Strategy: Focus on the subject, complications associated with TPN therapy.
Think about the procedures involved with the administration of TPN and the associated
complications to answer correctly.
Review: the priority assessments in the client receiving TPN
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Total Parenteral Nutrition
Giddens Concepts: Fluids and Electrolytes, Nutrition
HESI Concepts: Fluid & Electrolyte, Metabolism
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 800). St. Louis: Mosby.
Question 88
A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does
the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select
all that apply.
A client with severe sepsis
Correct answer
A client with a severe exacerbation of ulcerative colitis
Correct answer
A client with renal calculi
A client who has undergone repair of a hiatal hernia
A client with pancreatitis
Correct answer
Rationale: TPN is indicated in the client whose gastrointestinal tract is not functional or who
cannot tolerate an enteral diet for extended periods. The client with sepsis is very ill and may
require TPN. Other candidates include clients who have undergone extensive surgery, sustained
multiple fractures, or have advanced cancer or AIDS. The client who has undergone hiatal hernia
repair is not a candidate, because this client would resume a normal diet within a relatively short
period after the hernia repair. The client with renal calculi also is not a candidate because the
client would be able to eat.
Test-Taking Strategy: Note that the question contains the strategic words “most likely,”
telling you that the correct options are the clients who require this type of nutritional support.
Focus on the needs of the clients identified in the options and use your knowledge of the
purposes of TPN to direct you to the correct option.
Review: the purposes and uses for TPN
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Total Parenteral Nutrition
Giddens Concepts: Fluids and Electrolytes, Nutrition
HESI Concepts: Fluid & Electrolyte, Metabolism
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 797). St. Louis: Mosby.
Question 89
A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to
the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse
monitor the client? Select all that apply.
Nausea and vomiting
Correct answer
Pallor
Subnormal temperature
Chills
Correct answer
Headache
Correct answer
Chest and back pain
Correct answer
Rationale: Signs of an adverse reaction to fat emulsion include chest and back pain, chills,
fever, dyspnea, cyanosis, diaphoresis, flushing, headache, nausea and vomiting, pressure over the
eyes, vertigo, and thrombophlebitis at the infusion site.
Test-Taking Strategy: Focus on the subject, adverse effects of fat emulsion. Recalling that
fever and flushing occur will assist you in answering correctly. Specific knowledge about these
adverse effects is needed to select the remaining correct options.
Review: the signs of an adverse reaction to fat emulsion
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Total Parenteral Nutrition
Giddens Concepts: Clinical Judgment, Immunity
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Immunity
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p.
528). St. Louis: Mosby.
Question 90
The client rings the call bell and complains of pain at the site of an IV infusion. The nurse
assesses the site and determines that phlebitis has developed. Which actions should the nurse
take? Select all that apply.
Removing the IV catheter at that site
Correct answer
Applying warm, moist compresses to the IV site
Correct answer
Notifying the health care provider about the finding
Correct answer
Starting a new IV line in a proximal portion of the same vein
Encouraging the client to scrub the site while in the shower
Rationale: The nurse should remove the IV from the phlebitic site and apply warm, moist
compresses to the area to speed resolution of the inflammation and absorb the fluid from the
tissue. The nurse also notifies the primary health care provider of this complication. The nurse
should restart the IV line in a vein other than the one in which phlebitis has developed. The nurse
should discourage the client from rubbing the site while in the shower, because this could cause
sloughing of the tissue.
Test-Taking Strategy: Focus on the information in the question and the client’s problem,
phlebitis. Think about the pathophysiology of phlebitis to find the correct interventions.
Review: nursing interventions for phlebitis
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Intravenous Therapy
Giddens Concepts: Inflammation, Perfusion
HESI Concepts: Inflammation, Perfusion
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 228). St. Louis: Saunders.
Question 91
A nurse has just hung a transfusion of packed red blood cells 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 if it occurs? Select all that apply.
Rash
Correct answer
Backache
Correct answer
Tiredness
Chills
Correct answer
Fatigue
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 and tiredness are not specifically related to a
transfusion reaction.
Test-Taking Strategy: Note the strategic words “most important” and “immediately.”
Eliminate the comparable or alike options (fatigue and tiredness).
Review: the signs of a transfusion reaction
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Blood Administration
Giddens Concepts: Immunity, Perfusion
HESI Concepts: Immunity, Perfusion
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills &
techniques (8th ed., p. 749). St. Louis: Mosby.
Question 92
A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride.
Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of
care? Select all that apply.
Hypotension
Correct answer
Bradycardia
Urine retention
Correct answer
Constipation
Correct answer
Respiratory depression
Correct answer
Rationale: Side/adverse effects of meperidine hydrochloride respiratory depression, orthostatic
hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine retention.
Test-Taking Strategy: Focus on information in the question and note the classification
of the medication. Recalling that meperidine hydrochloride is an opioid analgesic will assist you
in answering correctly.
Review: the side/adverse effects of meperidine hydrochloride
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 270, 432
Question 93
A nurse has taught a client taking a methylxanthine bronchodilator, theophylline, about
beverages that must be avoided. Which beverage choices by the client indicate to the nurse that
the client needs further education? Select all that apply.
Chocolate milk
Correct answer
Orange juice
Lemonade
Coffee
Correct answer
Cocoa
Correct answer
Rationale: Cola, coffee, and chocolate contain xanthine and should therefore be avoided by the
client taking a methylxanthine bronchodilator theophylline, because they will enhance the effects
of the medication, increasing the likelihood of cardiovascular and central nervous system
side/adverse effects. Lemonade and orange juice are acceptable choices.
Test-Taking Strategy: Note the strategic words “needs further education,” which indicate
a negative event query and the need to select the incorrect items. Note that the correct
answers to this question are comparable or alike in that they all contain caffeine.
Review: foods to be avoided by a client taking a methylxanthine bronchodilator
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Safety
HESI Concepts: Teaching and Learning-Patient Education, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 398-399
Question 94
Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects
does the nurse instruct the client to report to the health care provider? Select all that apply.
Sore throat
Correct answer
Fever
Correct answer
Mouth sores
Correct answer
Headache
Nausea
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.
Test-Taking Strategy: Focus on the subject, the need to contact the health care provider.
Recall that blood dyscrasias may occur with the use of carbamazepine. This will direct you to the
correct options.
Review: the side/adverse effects of carbamazepine
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Intracranial Regulation, Safety
HESI Concepts: Intracranial Regulation, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
190-191) St. Louis: Saunders.
Question 95
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.
“Do you have a history of thyroid problems?”
Correct answer
“Do you have a history of cancer in your family?”
“When was your last drink of alcohol?”
Correct answer
“Do you have a history of diabetes insipidus?”
“When did you have your last full meal?”
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.
Test-Taking Strategy: Note the strategic word, priority. Recalling that the medication is
used as an adjunct treatment for selected clients with alcoholism will help direct you to the
option in which the client is asked when he consumed his last alcoholic drink. To find the other
correct options, it is necessary to know the contraindications to the use of disulfiram.
Review: the effects of disulfiram.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts:Addiction, Safety
HESI Concepts: Behaviors, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 421-422
Question 96
A client is receiving heparin sodium by way of continuous IV infusion. For which adverse
effects of the therapy does the nurse assess the client? Select all that apply.
Bleeding from the gums
Correct answer
Slowed pulse
Tinnitus
Increased blood pressure
Tarry stools
Correct answer
Rationale: Heparin is an anticoagulant, and the client who receives continuous IV heparin is at
risk for bleeding. The nurse must be alert for signs of bleeding: bleeding from the gums,
ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test
positive for occult blood.
Test-Taking Strategy: Focus on the subject, the adverse effects of heparin sodium.
Recalling that this medication is an anticoagulant will direct you to the correct options.
Review: the adverse effects of heparin sodium.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clotting, Safety Perfusion, Safety
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p.
626). St. Louis: Mosby.
Question 97
Metoprolol has been prescribed for a client with hypertension. For which common side effects of
the medication does the nurse monitor the client? Select all that apply.
Nightmares
Weakness
Correct answer
Dry eyes
Fatigue
Correct answer
Erectile dysfunction
Correct answer
Rationale: One common side effect of beta-adrenergic–blocking agents, such as metoprolol, is
erectile dysfunction. Fatigue and weakness are also common. Rarer central nervous system side
effects include mental status changes, nervousness, depression, and insomnia. Altered taste, dry
eyes, and nightmares are rare side effects.
Test-Taking Strategy: Focus on the subject, “common side effects” and recall that
medications whose names that end with -lol are beta-blockers. Knowledge of the common side
effects of these medications is needed to answer correctly.
Review: the common side effects of beta-blockers.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Assessment, Perfusion
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
779) St. Louis: Saunders.
Rosenjack Burchum, Rosenthal (2016) pp. 166-167
Question 98
A nurse is providing dietary instructions to a client taking spironolactone. The nurse realizes the
teaching has been effective if the client selects which food items from the menu? Select all
that apply.
Cereal
Correct answer
Bananas
Your answer is incorrect
Citrus fruits
Your answer is incorrect
Rice
Correct answer
Carrots
Correct answer
Rationale: Spironolactone is a potassium-retaining diuretic. Hyperkalemia is the principal
adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as
citrus fruits and bananas. Rice, cereal, and carrots are appropriate foods for the daily diet.
Test-Taking Strategy: Focus on the information in the question and the
medication,spironolactone. Recalling that spironolactone is a potassium-retaining diuretic and
using your knowledge of foods that are high in potassium will direct you to the correct options.
Review: the adverse effects of spironolactone.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Client Education, Fluid and Electrolytes
HESI Concepts: Teaching and Learning-Patient Education, Fluid & Electrolyte
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p.
1127) St. Louis: Saunders.
Question 99
A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to
evaluate the effectiveness of this therapy? Select all that apply.
Magnesium
Blood glucose
Alkaline phosphatase
Hemoglobin
Correct answer
Hematocrit
Correct answer
Rationale: Folic acid, necessary for red blood cell production, is classified as a vitamin and as
an antianemic agent. Both hematocrit and hemoglobin are appropriate parameters by which to
assess the blood count. The nurse can gauge the effectiveness of therapy by monitoring the
results of periodic complete blood counts, in particular the hematocrit.
Test-Taking Strategy: Note the strategic word, effectiveness. To answer this question
accurately, it is necessary to know that folic acid is a vitamin that may be prescribed as a
supplement to treat anemia. From this point, you should be able to eliminate the incorrect
options.
Review: the effects of folic acid on the body
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Nutrition
HESI Concepts: Cellular Regulation, Metabolism
Reference: Rosenjack Burchum, Rosenthal (2016) p. 994