the healthcare provider prescribes lidocaine lidoject 1 100 mg iv push for ventricular tachycardia for an unconscious client what is the nurses priori
Logo

Nursing Elites

HESI LPN

HESI CAT Exam

1. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?

Correct answer: B

Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.

2. Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?

Correct answer: D

Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.

3. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?

Correct answer: A

Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.

4. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?

Correct answer: B

Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.

5. A client prescribed warfarin is being taught about dietary modifications by a nurse. Which statement by the client indicates understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. Consistency in vitamin K intake is crucial for clients on warfarin to maintain stable anticoagulation levels. Option A is incorrect as vitamin C does not directly interact with warfarin. Option C is incorrect because although leafy greens are high in vitamin K, excessive consumption can affect warfarin's effectiveness. Option D is incorrect as any changes in diet, particularly in vitamin K intake, can impact the efficacy of warfarin.

Similar Questions

In what sequence should the nurse prepare the dose of insulin for a client whose finger stick glucose is 210 mg/dl and is receiving a sliding scale dose of short-acting insulin before breakfast?
Which type of wound would most likely require immediate intervention by the healthcare provider?
A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses