the nurse is preparing to administer doses of hydrochlorothiazide hydrodiuril and digoxin lanoxin to a patient who has heart failure the patient repor
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Quiz

1. The nurse is preparing to administer doses of hydrochlorothiazide (HydroDIURIL) and digoxin (Lanoxin) to a patient who has heart failure. The patient reports having blurred vision. The nurse notes a heart rate of 60 beats per minute and a blood pressure of 140/78 mm Hg. Which action will the nurse take?

Correct answer: C

Rationale: In this scenario, the patient is experiencing symptoms of digoxin toxicity, such as blurred vision and bradycardia. When thiazide diuretics like hydrochlorothiazide are taken with digoxin, the patient is at risk of digoxin toxicity due to the potential for thiazides to cause hypokalemia. Therefore, the correct action for the nurse to take is to hold the digoxin and notify the provider. Administering the medications without addressing the potential toxicity could worsen the patient's condition. Requesting serum electrolytes (Choice A) may be necessary but holding the digoxin takes priority. Evaluating serum blood glucose (Choice B) is not relevant to the current situation. Holding hydrochlorothiazide (Choice D) is not the best option as the primary concern is the digoxin toxicity that needs to be addressed promptly.

2. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action?

Correct answer: D

Rationale: The nurse should recognize that the client may be developing fluid overload and respiratory distress due to the rapid normal saline infusion. The priority action is to slow down the infusion to prevent worsening respiratory distress and potential fluid overload. While calculating the mean arterial pressure (MAP) is important to assess perfusion, addressing the immediate respiratory distress takes precedence. Inserting a pulmonary artery catheter would provide detailed hemodynamic information but is not the initial step in managing acute respiratory distress. Monitoring vital signs, including the client's pulse, is crucial after adjusting the intravenous infusion to ensure a safe response to the intervention.

3. In a patient with chronic kidney disease, which of the following is a common complication?

Correct answer: A

Rationale: Hyperkalemia is a common complication in chronic kidney disease due to the kidneys' reduced ability to excrete potassium. As kidney function declines, potassium levels may increase, leading to hyperkalemia. Hypernatremia (increased sodium levels), hypocalcemia (low calcium levels), and hyperphosphatemia (elevated phosphate levels) are not typically associated with chronic kidney disease. Therefore, the correct answer is hyperkalemia.

4. A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

Correct answer: A

Rationale: The correct answer is A. For an EEG, it is essential that the client's hair is clean, without any products like hairspray or gel, to ensure good electrode contact with the scalp. Choice B is not a concern as having breakfast is allowed before the test. Choice C, not taking an anticonvulsant, might be required for certain types of EEGs to capture accurate brain activity. Choice D, not drinking coffee, is not a specific requirement for an EEG preparation.

5. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

Correct answer: D

Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.

Similar Questions

When obtaining the health history of a client suspected of having bladder cancer, which question should the nurse ask to determine the client's risk factors?
Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contraindications to administering the drug?
A client has lost a significant amount of blood due to complications during surgery. What parameter does the nurse recognize as the earliest indication of new decreases in fluid volume?
A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?
The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?

Access More Features

HESI RN Basic
$69.99/ 30 days

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

HESI RN Premium
$149.99/ 90 days

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

Other Courses