HESI RN
Pharmacology HESI
1. A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals.
- B. Monitor for signs of hypoglycemia.
- C. Avoid alcohol while taking this medication.
- D. Take the medication at bedtime.
Correct answer: C
Rationale: Clients taking metformin (Glucophage) should avoid alcohol as it can increase the risk of lactic acidosis. Metformin should be taken with meals to reduce gastrointestinal upset. While hypoglycemia is less common with metformin compared to other diabetes medications, clients should still be aware of its symptoms.
2. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct answer: B
Rationale: The correct answer is B. In the Jehovah's Witness religion, blood transfusions are forbidden due to their beliefs. Autopsy prohibition is in Judaism, while alcohol and drug use is not allowed in Buddhism. While some sects are vegetarian, the critical concern in nursing care for Jehovah's Witnesses is respecting their prohibition of blood transfusions.
3. The nurse is assessing a client with left-sided heart failure. Which clinical finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct answer: C
Rationale: Corrected Rationale: In a client with left-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention to prevent worsening heart failure symptoms and respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure but are not as critical as crackles in the lungs because they may indicate fluid overload or right-sided heart failure, which are important to address but not as urgently as managing pulmonary congestion.
4. Which of the following is used to differentiate abdominal mass from pelvic mass on clinical examination?
- A. Size
- B. Site
- C. Margins
- D. Lower border
Correct answer: D
Rationale: The lower border is used to differentiate between an abdominal mass and a pelvic mass during clinical examination. The lower border of the mass provides important information about its location and origin. The size (Choice A) alone may not always clearly distinguish between abdominal and pelvic masses. The site (Choice B) and margins (Choice C) are also important factors, but they are not as specific in differentiating between abdominal and pelvic masses as the lower border.
5. A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
- A. Obtain the baseline weight
- B. Check the patient’s blood pressure
- C. Draw blood for serum electrolyte levels
- D. Ask about any extremity numbness or tingling
Correct answer: B
Rationale: The correct answer is to check the patient’s blood pressure. Given the patient's symptoms of frequent, watery stools, there is a concern for fluid volume deficit. Assessing the blood pressure helps determine the patient's perfusion status, which is crucial in managing fluid volume deficits. While obtaining baseline weight, drawing blood for serum electrolyte levels, and asking about extremity numbness or tingling are important assessments, checking the blood pressure takes precedence as it provides immediate information on the patient's circulatory status.