Hesi RN Nursing Exam
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Nurses' Notes 0900: Wheezes heard throughout lung fields. Vital Signs: Heart rate 100 beats/minute, Respirations 36 breaths/minute, Blood pressure 116/68 mmHg, Oxygen saturation 83% on room air.
Orders: Give albuterol 2.5 mg via nebulizer every 3 hours PRN for wheezing.
Which 2 drugs would be the most appropriate to give the client now?
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Racemic epinephrine via nebulizer
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Salmeterol via nebulizer
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Fexofenadine orally
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Levalbuterol inhaler
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Budesonide via metered dose inhaler
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Albuterol via nebulizer
Explanation
Correct Answer: (D) Levalbuterol inhaler and (F) Albuterol via nebulizer
This client is in acute bronchospasm with critical oxygen saturation of 83%, wheezing throughout all lung fields, tachycardia, and tachypnea. The standing order for albuterol 2.5 mg via nebulizer PRN for wheezing directly applies and should be administered immediately. Levalbuterol is the R-isomer of albuterol and acts as a short-acting beta-2 agonist that rapidly relieves bronchospasm, making it appropriate for acute asthma management alongside the ordered nebulized albuterol.
Why Other Options are Incorrect:
A. Racemic epinephrine via nebulizer — Racemic epinephrine is used for croup and upper airway edema, not for acute asthma bronchospasm.
B. Salmeterol via nebulizer — Salmeterol is a long-acting beta-2 agonist used for maintenance therapy, not for acute bronchospasm. It has a slow onset and is contraindicated as monotherapy during an acute attack.
C. Fexofenadine orally — Fexofenadine is an antihistamine used for allergic rhinitis. It does not address bronchospasm or acute respiratory distress.
E. Budesonide via metered dose inhaler — Budesonide is an inhaled corticosteroid used for long-term asthma control, not for immediate relief of acute bronchospasm.
Nurses' Notes 1400: Started continuous morphine infusion in the left antecubital vein peripheral intravenous line via patient-controlled pump (PCA). No redness, edema, or bleeding noted at the site. Vital signs: Heart rate 77 beats/minute, Respirations 16 breaths/minute, Blood pressure 118/74 mmHg, Oxygen saturation 97% on room air.
1800 Vital signs: Heart rate 79 beats/minute, Respirations 14 breaths/minute, Blood pressure 114/78 mmHg, Oxygen saturation 93% on room air.
1900: Responded to an alarm in the room. The client is not responsive. Respiratory rate is 5 breaths/minute. Heart rate is 92 beats/minute. Pupils are pinpoint. Oxygen saturation 54% on room air. Pressed the rapid response call button and provided rescue breaths with a manual resuscitation bag. The charge nurse administered naloxone 2 mg IV push.
Orders 1400: Admit to the surgical floor. Clear liquid diet, advance as tolerated. Continuous cardiorespiratory monitoring. Morphine 1 mg/hr continuous IV infusion via patient controlled pump (PCA). Alert surgeon to signs of bleeding or infection in the surgical site.
Orders 1500: Docusate sodium 240 mg PO every morning. Naloxone 2 mg IV push PRN for respiratory depression. Ibuprofen 600 mg PO every 6 hours.
For each statement, click to indicate whether the statements by the student nurse indicate understanding or no understanding of naloxone. Each row must have one option selected.
Student Nurse Statements:
"Naloxone will not affect the client's level of pain."
"When given IV, naloxone starts working immediately and can last several hours."
"If the first dose does not work, you can give as many doses as needed to reverse respiratory depression."
"Naloxone works best on pure agonist opioids."
"You can give naloxone intravenously, intramuscularly, or subcutaneously."
- "Naloxone will not affect the client's level of pain."
- "When given IV, naloxone starts working immediately and can last several hours."
- "If the first dose does not work, you can give as many doses as needed to reverse respiratory depression."
- "Naloxone works best on pure agonist opioids."
- "You can give naloxone intravenously, intramuscularly, or subcutaneously."
Explanation
Correct Answer:
"Naloxone will not affect the client's level of pain." — No Understanding
This statement reflects a misunderstanding. Naloxone is an opioid antagonist that works by competitively blocking and displacing opioids from receptor sites throughout the body. When administered, it reverses not only respiratory depression but also analgesia, meaning the client will experience the return of pain. This is an important clinical consideration, especially for a postoperative amputation client.
"When given IV, naloxone starts working immediately and can last several hours." — No Understanding
This statement reflects a partial misunderstanding. While naloxone does have a rapid onset of approximately 2 minutes when given intravenously, its duration of action is short, typically 30 to 90 minutes, which is significantly shorter than most opioids. This is why patients must be closely monitored after administration for re-narcotization, as the opioid effect can return once naloxone wears off. Saying it lasts "several hours" is inaccurate and dangerous.
"If the first dose does not work, you can give as many doses as needed to reverse respiratory depression." — No Understanding
This statement reflects a misunderstanding. While repeat doses of naloxone can be given, there is a ceiling to how much should be administered and clinical judgment must guide dosing. Giving unlimited doses without reassessment is unsafe. Additionally, if naloxone in adequate doses does not reverse respiratory depression, another cause must be investigated.
"Naloxone works best on pure agonist opioids." — Understanding
This statement reflects correct understanding. Naloxone is most effective at reversing pure opioid agonists such as morphine, heroin, fentanyl, and oxycodone, which is exactly the drug this client is receiving. It has reduced or variable effectiveness against partial agonists or mixed agonist-antagonist opioids.
"You can give naloxone intravenously, intramuscularly, or subcutaneously." — Understanding
This statement reflects correct understanding. Naloxone is a versatile medication that can be administered via multiple routes including intravenous, intramuscular, subcutaneous, intranasal, and endotracheal routes. The IV route provides the fastest onset, while IM and subcutaneous routes are alternatives when IV access is unavailable.
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Advise the client to go to the nearest emergency department.
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Remind the client to take the medication with plenty of water.
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Suggest use of an antacid two hours after the medication.
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Ask the client to describe how she takes the medication.
Explanation
Correct Answer: (D) Ask the client to describe how she takes the medication.
Risedronate is a bisphosphonate used to treat osteoporosis. Esophageal irritation and heartburn are well-known side effects that are almost always related to improper administration technique rather than the drug itself. Before making any recommendations, the nurse should first assess how the client is taking the medication, as the most common errors include not taking it with a full glass of water, lying down after taking it, or taking it with food or other beverages. Gathering this information guides the most appropriate nursing response.
Why Other Options Are Incorrect:
A. Heartburn from risedronate, while uncomfortable, is typically not an emergency. Directing the client to the emergency department is an unnecessary escalation unless there are signs of severe esophageal injury such as difficulty swallowing or chest pain that does not resolve.
B. While reminding the client to take the medication with plenty of water is good advice, doing so without first assessing how she is currently taking it assumes the problem without a thorough assessment, which is not the best initial nursing action.
C. Antacids should not be taken within two hours of risedronate because they contain calcium and other minerals that interfere with the drug's absorption. Suggesting an antacid without fully understanding the client's current medication routine could worsen the absorption problem.
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Sleeps soundly through the night.
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Improved ability to concentrate.
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Decreased episodes of incontinence.
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Exhibits fewer emotional outbursts.
Explanation
Correct Answer: (A) Sleeps soundly through the night.
Zolpidem is a sedative-hypnotic agent prescribed specifically for the treatment of insomnia. The primary therapeutic goal of zolpidem is to help the client initiate and maintain sleep. Documentation that the client sleeps soundly through the night directly reflects achievement of the intended therapeutic outcome and confirms the medication is working as prescribed.
Why Other Options Are Incorrect:
B. Improved ability to concentrate is not a therapeutic goal of zolpidem. Cognitive enhancement is associated with medications such as cholinesterase inhibitors used in dementia management, not sedative-hypnotics.
C. Decreased episodes of incontinence is unrelated to zolpidem's mechanism of action. Urinary incontinence management involves entirely different pharmacological agents and interventions.
D. Fewer emotional outbursts are outcomes associated with mood-stabilizing or antipsychotic medications. Zolpidem acts on GABA receptors to induce sleep and has no direct effect on emotional regulation or behavioral disturbances.
Explanation
Correct Answer: 0.8
Using the standard dosage calculation formula: Desired dose divided by the dose on hand, multiplied by the volume on hand. The desired dose is 80 mg, the dose on hand is 60 mg, and the volume on hand is 0.6 mL. Calculating: 80 divided by 60, multiplied by 0.6 equals 0.8 mL. The nurse should administer 0.8 mL of enoxaparin sodium subcutaneously.
Nurses' Notes 1400: Started continuous morphine infusion in the left antecubital vein peripheral intravenous line via patient-controlled pump (PCA). No redness, edema, or bleeding noted at the site. Vital signs: Heart rate 77 beats/minute, Respirations 16 breaths/minute, Blood pressure 118/74 mmHg, Oxygen saturation 97% on room air.
Orders 1400: Admit to the surgical floor. Clear liquid diet, advance as tolerated. Continuous cardiorespiratory monitoring. Morphine 1 mg/hr continuous IV infusion via patient controlled pump (PCA). Alert surgeon to signs of bleeding or infection in the surgical site.
Orders 1500: Docusate sodium 240 mg PO every morning. Naloxone 2 mg IV push PRN for respiratory depression.
Which side effects of morphine could contribute to this client's fall risk? Select all that apply.
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Sedation
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Nausea
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Itching
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Seizures
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Orthostatic hypotension
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Euphoria
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Urinary retention
Explanation
Correct Answer: (A) Sedation, (B) Nausea, (E) Orthostatic hypotension, and (F) Euphoria
This client has already had a right above-the-knee amputation, which significantly increases her baseline fall risk due to altered mobility and balance. Morphine compounds this risk through several mechanisms. Sedation impairs alertness, reaction time, and coordination, making safe ambulation dangerous. Nausea can cause sudden dizziness and loss of balance, increasing the likelihood of a fall. Orthostatic hypotension from morphine-induced vasodilation causes blood pressure to drop when the client changes position, leading to lightheadedness and falls. Euphoria from opioid use impairs judgment and alters the client's perception of her own limitations, making her more likely to attempt unsafe movements without assistance.
Why the other options are incorrect:
C. Itching — Opioid-induced pruritus is an uncomfortable side effect caused by histamine release, but itching does not directly impair balance, coordination, or judgment in a way that contributes to fall risk.
D. Seizures — Seizures are not a typical or well-documented side effect of morphine at standard therapeutic doses. While opioid toxicity can cause neurological effects, seizures are not a primary concern at this client's prescribed dose of 1 mg/hr and are not a direct contributor to fall risk in this context.
G. Urinary retention — Morphine can cause urinary retention by relaxing the detrusor muscle and increasing urethral sphincter tone. While urinary retention is uncomfortable and requires monitoring, it does not directly contribute to fall risk unless the client is attempting to get up unassisted to use the bathroom, which would be addressed through fall prevention protocols rather than being attributed to the medication effect itself.
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Prednisone.
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Captopril.
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Acetaminophen.
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Omeprazole.
Explanation
Correct Answer: (C) Acetaminophen
Jaundice is a clinical sign of liver dysfunction, indicated by yellowing of the skin and sclera due to elevated bilirubin levels. Acetaminophen is hepatotoxic in excessive doses or in clients with compromised liver function, and its continued use in a jaundiced client poses a serious risk of worsening liver damage. The nurse must notify the provider so the medication can be reviewed, adjusted, or discontinued.
Why Other Options are Incorrect:
A. Prednisone — While prednisone has several side effects, it is not primarily associated with causing or worsening jaundice and is not the priority medication to flag in this scenario.
B. Captopril — Captopril is an ACE inhibitor used for hypertension. Although rare hepatic side effects exist, it is not the most clinically urgent concern when jaundice is present compared to acetaminophen.
D. Omeprazole — Omeprazole is a proton pump inhibitor used for gastroesophageal reflux and does not carry the same degree of hepatotoxic risk that warrants priority notification in the presence of jaundice.
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Demonstrate how to select dose based on before meal blood sugar readings.
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Teach the client self-injection skills for daily subcutaneous administration.
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Provide information on increasing medication dosage if ketoacidosis occurs.
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Explain to the family how to inject this medication for severe hypoglycemia.
Explanation
Correct Answer: (B) Teach the client self-injection skills for daily subcutaneous administration.
Insulin glargine is a long-acting basal insulin administered once daily via subcutaneous injection. Teaching the client how to self-administer is the most essential and practical component of discharge education, as proper injection technique directly affects therapeutic outcomes and safety.
Why the other options are incorrect:
A. Insulin glargine is a basal insulin that provides steady background coverage and is not adjusted based on premeal blood glucose readings. That approach applies to rapid-acting or short-acting insulins used for mealtime coverage.
C. Diabetic ketoacidosis is a life-threatening emergency that requires immediate hospitalization and medical intervention, not independent dosage adjustments by the client at home.
D. Insulin glargine is not used to treat severe hypoglycemia. The appropriate interventions for severe hypoglycemia include glucagon administration or intravenous dextrose, not additional insulin.
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Observe bowel movement pattern and take a stool softener.
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Do not drink grapefruit juice after taking morphine.
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Take the benzodiazepine at the same time as taking the morphine.
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Watch for signs of agitation and record any insomnia.
Explanation
Correct Answer: (A) Observe bowel movement pattern and take a stool softener.
Constipation is the most common and predictable side effect of opioid analgesics such as morphine, occurring because opioids bind to receptors in the gastrointestinal tract and slow intestinal motility. Unlike many other opioid side effects, constipation does not diminish with continued use. The client demonstrating awareness of the need to monitor bowel patterns and use a stool softener proactively shows a clear and accurate understanding of morphine's expected effects and how to manage them safely at home.
Why the other options are incorrect:
B. Grapefruit juice interactions are primarily associated with medications metabolized by the CYP3A4 enzyme system, such as certain statins, calcium channel blockers, and immunosuppressants. Morphine is not significantly metabolized through this pathway, making this instruction clinically inaccurate for morphine therapy.
C. Taking a benzodiazepine concurrently with morphine is a dangerous combination. Both are central nervous system depressants, and combining them significantly increases the risk of respiratory depression, sedation, and death. This statement indicates a dangerous misunderstanding rather than correct medication knowledge.
D. Agitation and insomnia are not the primary side effects the client should be monitoring for with morphine. The more clinically significant concerns include constipation, respiratory depression, sedation, nausea, and urinary retention, making this response an inaccurate reflection of medication understanding.
Nurses' Notes 1400: Started continuous morphine infusion in the left antecubital vein peripheral intravenous line via patient-controlled pump (PCA). No redness, edema, or bleeding noted at the site.
Orders 1400: Admit to the surgical floor. Clear liquid diet, advance as tolerated. Continuous cardiorespiratory monitoring. Morphine 1 mg/hr continuous IV infusion via patient controlled pump (PCA). Alert surgeon to signs of bleeding or infection in the surgical site.
Which actions should the nurse take to assure safety during morphine administration? Select all that apply.
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Take an initial respiratory rate
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Perform a 12-lead electrocardiogram
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Suction the client to clear the airway
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Have a manual resuscitation bag at the bedside
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Restrain the client with soft restraints
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Ask the client about other medications she takes
Explanation
Morphine is an opioid analgesic with the most serious risk being respiratory depression. Taking a baseline respiratory rate before and during administration allows the nurse to detect early signs of respiratory compromise. Having a manual resuscitation bag at the bedside ensures immediate intervention capability if respiratory depression or arrest occurs. Asking about other medications is critical because concurrent use of CNS depressants such as benzodiazepines, sedatives, or other opioids significantly increases the risk of life-threatening respiratory depression and sedation.
Why the other options are incorrect:
B. Perform a 12-lead electrocardiogram — A 12-lead ECG is not a standard safety measure required before or during morphine administration. While continuous cardiorespiratory monitoring is ordered, a 12-lead ECG is not indicated specifically for morphine safety.
C. Suction the client to clear the airway — Suctioning is performed when there is an active airway obstruction or excessive secretions. There is no indication of airway compromise at this time, and suctioning is not a prophylactic safety measure for opioid administration.
E. Restrain the client with soft restraints — Restraints are not appropriate or indicated simply because a client is receiving morphine. Applying restraints without clinical justification violates the client's rights and is not a recognized safety measure for opioid administration.
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