the nurse retrieves hydromorphone 4mgml from the pyxis medstation an automated dispensing system for a client who is receiving hydromorphone 3 mg im 6

HESI RN

HESI Fundamentals

1. 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.

2. A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Correct answer: D

Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.

3. 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.

4. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?

A. Is voiding normally.
B. Has urinary retention.
C. Has developed renal failure.
D. Needs an indwelling catheter.

Correct answer: B

Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.

5. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

A. Release the suction by opening the vent.
B. Continue suctioning to remove obstruction.
C. Increase the pressure.
D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.