HESI LPN
Pharmacology HESI 2023
1. A client with pulmonary tuberculosis has been taking rifampin for 3 weeks. The client reports orange urine. What should be the nurse's next action?
- A. Notify the client's health care provider.
- B. Inform the client that this is not harmful.
- C. Assess the client for other signs of nephrotoxicity.
- D. Monitor the client's most recent creatinine level.
Correct answer: B
Rationale: The correct action for the nurse to take when a client reports orange urine after taking rifampin is to inform the client that this change is not harmful. Rifampin is known to cause orange discoloration of urine, which is a harmless side effect. There is no need to notify the health care provider as this is an expected outcome. Monitoring creatinine levels or assessing for nephrotoxicity is unnecessary in this situation, as rifampin does not typically cause kidney damage.
2. When a nurse teaches a community about the importance of hand hygiene, the nurse is engaging in:
- A. Primary prevention
- B. Secondary prevention
- C. Tertiary prevention
- D. Quaternary prevention
Correct answer: A
Rationale: The correct answer is A: Primary prevention. Primary prevention aims to prevent the occurrence of a disease or injury before it happens. Teaching about hand hygiene to the community helps in preventing infections from occurring in the first place. Choice B, Secondary prevention, involves early detection and treatment to halt or slow the progress of a condition. This would involve screening or early intervention after exposure. Choice C, Tertiary prevention, focuses on managing the disease to prevent complications, recurrence, or deterioration. This would include rehabilitation and monitoring to prevent further complications. Choice D, Quaternary prevention, relates to actions taken to avoid unnecessary interventions or over-medicalization. This usually involves questioning the necessity of certain medical procedures or treatments to prevent harm to patients.
3. A client with a history of heart failure is prescribed digoxin. The nurse should monitor for which potential side effect?
- A. Bradycardia
- B. Tachycardia
- C. Hypertension
- D. Hypotension
Correct answer: A
Rationale: Digoxin, a medication commonly prescribed for heart failure, can lead to bradycardia, characterized by a slow heart rate. Monitoring for bradycardia is crucial to detect and manage this potential side effect early on to prevent complications such as arrhythmias or decreased cardiac output. Tachycardia (choice B) is not typically associated with digoxin use. Hypertension (choice C) and hypotension (choice D) are also not common side effects of digoxin.
4. The nurse is assessing a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical finding is characteristic of this condition?
- A. Pursed-lip breathing
- B. Hyperresonance on percussion
- C. Bradycardia
- D. High-pitched inspiratory crackles
Correct answer: A
Rationale: Pursed-lip breathing is a characteristic finding in clients with COPD. It helps keep the airways open during exhalation, acting as a compensatory mechanism to prevent airway collapse, which is common in COPD. Hyperresonance on percussion is typically found in conditions like emphysema, which is a component of COPD but not characteristic of the overall disease. Bradycardia is not typical in COPD; instead, clients often exhibit tachycardia due to chronic hypoxemia. High-pitched inspiratory crackles are more commonly associated with conditions like pneumonia, not COPD.
5. A client with a fractured femur is in Buck's traction. The nurse should assess for which of the following complications?
- A. Foot drop
- B. Urinary retention
- C. Constipation
- D. Muscle spasms
Correct answer: A
Rationale: Corrected Rationale: Foot drop is a potential complication of prolonged immobility and improper positioning in traction. In Buck's traction, the lower extremity is suspended to immobilize and align the fractured femur. Prolonged suspension of the leg in traction can lead to nerve damage, specifically to the common peroneal nerve, resulting in foot drop. Urinary retention, constipation, and muscle spasms are not directly associated with Buck's traction and a fractured femur.