a client with a diagnosis of coronary artery disease is receiving atorvastatin lipitor which laboratory test should the nurse monitor to evaluate the

HESI RN

HESI Fundamentals

1. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

A. Complete blood count (CBC)
B. Serum potassium level
C. Liver function tests (LFTs)
D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.

2. Which client is most likely to be at risk for spiritual distress?

A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-day Adventist in need of a blood transfusion
D. Muslim man in need of a total knee replacement

Correct answer: A

Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.

3. During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?

A. Stop advancing the tube and allow the client to rest
B. Remove the tube and try again after a few minutes
C. Continue inserting the tube while the client sips water
D. Withdraw the tube slightly and pause before continuing

Correct answer: D

Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.

4. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

A. Blood glucose level of 150 mg/dL.
B. Blood pressure of 110/70 mm Hg.
C. Serum albumin level of 3.5 g/dL.
D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

5. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

A. 0.8 mL
B. 0.75 mL
C. 0.7 mL
D. 0.9 mL

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg ÷ 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.