the nurse is preparing to administer 10 ml of liquid potassium chloride through a feeding tube followed by 10 ml of liquid acetaminophen which action
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?

Correct answer: C

Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.

2. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?

Correct answer: D

Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.

3. During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

Correct answer: D

Rationale: The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve), responsible for vision. Hearing a whisper (A) is associated with cranial nerve VIII (vestibulocochlear nerve), identifying an object by touch (B) is related to cranial nerves V (trigeminal nerve) and VII (facial nerve), and shoulder shrugging against resistance (C) is a test for cranial nerve XI (accessory nerve). Thus, the correct answer is D as it specifically tests the function of cranial nerve II.

4. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

Correct answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

5. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

Correct answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care. Notifying the charge nurse or submitting a medication variance report may not be necessary as the situation was managed appropriately, and discarding the original medication administration record is not recommended as it is part of the client's medical record and should be kept for documentation purposes.

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