HESI RN
HESI Bsn 225 RN Pharmacology Questions
Extract:
History and physical
The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses notes
0700
Laboratory specimens have been drawn and completed during a preadmission visit. After changing clothes and settling into bed, client was placed on continuous monitoring. Admission process completed.
0800
Peripheral IV (PIV) started in right antecubital with 20 gauge catheter. IV fluids of 0.9% sodium chloride started at 50 mL/hr. Cardiac surgeon in to see client and answers questions about the procedure.
0830
Client reports no known allergies. Vancomycin 1 gram in 250 ml 0.9% sodium chloride started at 125 mL/hr as endocarditis prophylaxis.
0840
Awaiting transfer to operating room (OR).
Vancomycin infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
0900
Heart rate 90 beats/minute, blood pressure 110/60 mm Hg. Surgeon remains at bedside.
0915
Heart rate 60 beats/minute, blood pressure 120/70 mm Hg. Appears more relaxed - not thrashing about bed. Skin color remains red: reports itching
resulting in symptoms of skin color0945
Heart rate 52 beats/minute, blood pressure 128/72 mm Hg. To OR for pacemaker placement.
1100
Returned from OR. Heart rate 64 beats/minute, blood pressure 118/68 mm Hg, temperature 97.4° F(36.3° C) orally. Verbalizes not being able to stop shaking and pounding chest pain. Short of breath. Skin color is dark pink. Headache increasing and has nausea. Surgeon at bedside. Chest x-ray done. Echocardiogram performed.
Orders
0800
Start peripheral IV
Vancomycin 1 gram in 250 mL 0.9% sodium chloride
0845
• Stop vancomycin
The nurse is implementing solutions to provide care.
0855
IV diphenhydramine
Question 1 of 5
The nurse is assessing the client to update the plan of care.Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. "The nurse determines that the client's is experiencing -----------, and the blood pressure changes are the result of-------------------.
Correct Answer: A,B
Rationale: The client’s symptoms (dizziness, hives, etc.) indicate an adverse reaction (Red Man Syndrome) to vancomycin, causing hypotension. Both blanks are correctly filled by 'Adverse drug reaction' and 'Antibiotic' (vancomycin).
Extract:
Question 2 of 5
A client with heart failure (HF) develops hyperaldosteronism and spironolactone is prescribed. Which instruction should the nurse include in the client's plan of care?
Correct Answer: A
Rationale: Spironolactone is potassium-sparing, so limiting potassium-rich foods prevents hyperkalemia. Sun protection, bruising, and salt substitutes (often potassium-based) are not primary concerns.
Question 3 of 5
Prior to administering an oral dose of methylprednisolone, the nurse determines the client's serum total calcium level is 5.5 mg/dL (1.375 mmol/L). What action is most important for the nurse to take?
Correct Answer: C
Rationale: A calcium level of 5.5 mg/dL is critically low, requiring immediate provider notification for evaluation. Milk administration, tapering, or dietary teaching are not immediate priorities.
Question 4 of 5
Based on a client's serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?
Correct Answer: D
Rationale: Checking acid-base and electrolyte values is critical to manage digoxin toxicity, as imbalances like hypokalemia exacerbate toxicity. Changing routes, cardioversion, or potassium administration are not immediate actions without further assessment.
Extract:
History and physical
The client is a 24-year-old female who was hit by a car while riding her bicycle. She was wearing a helmet, but her head struck the windshield of the vehicle at approximately 40 miles per hour (mph).
Nurses notes
1800
Client is intubated and on a ventilator. Breath sounds clear and equal. Pupils are 3 mm and sluggish. Responds to painful stimuli. Intracranial pressure 12 mm Hg. Pulses 2+ in all extremities. Capillary refill 2 seconds.
1900
Pupils are 3 mm and sluggish. Client is unresponsive to painful stimuli. Intracranial pressure 24 mm Hg. Healthcare provider (HCP) notified of status. Mannitol given as prescribed.
2000
Breath sounds clear and equal. Pupils are 4 mm and sluggish. Now responds to painful stimuli. Intracranial pressure 11 mm Hg. Has some dependent peripheral edema noted.
Flowsheet
Heart rate 79 beats/minute • Respiratory rate 18 breaths/minute
Blood pressure 111/79 mm Hg
Oxygen saturation 99% on ventilator
Orders
Admit to the surgical intensive care unit
Monitor intracranial pressure every hour
Lactated Ringer's 100 mL/hr IV infusion
Vital signs every hour
Neurological check every hour
Complete blood count, blood gas, and chemistry every 4 hours
Imaging
Head CT scan: cerebral edema
Question 5 of 5
Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions.Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
| Options | Therapeutic result | Non therapeutic side effect | Unrelated finding |
|---|---|---|---|
| Peripheral edema: Non-therapeutic side effect | |||
| Potassium 2.9: Non-therapeutic side effect | |||
| Urine output 280 ml: Therapeutic result | |||
| Heart rate 79: Unrelated finding | |||
| Intracranial pressure 11mmHg: Therapeutic result | |||
| Oxygen saturation: Unrelated finding |
Correct Answer:
Rationale: A: Edema is a mannitol side effect. B: Hypokalemia is a side effect. C: Increased urine output is therapeutic. D: Normal heart rate is unrelated. E: Reduced intracranial pressure is therapeutic. F: Normal oxygen saturation is unrelated.