HESI RN Fundamentals Exam 1 Related

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

• A. Withdraw the medication into a syringe and label with the client’s name.
• B. Ask another nurse to witness the medication being discarded.
• C. Place the vial with the remainder of the medication into a locked drawer.
• D. Throw the vial into the trash in the presence of another nurse.

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

• A. Gives the client a hug and says, 'It’s okay to cry when you are sad.'
• B. While touching the client’s forearm, asks, 'Would you like to talk about it?'
• C. I’m sorry to disturb you at a difficult time. This can wait until later.'
• D. This is a bad time. I can see you are upset. I can come back later.'

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

• A. Assess strength of deep tendon reflexes.
• B. Determine apical pulse rate and rhythm.
• C. Observe color and amount of urine.
• D. Compare muscle strength bilaterally.

A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?

• A. Double check all dosage calculations.
• B. nusually large or small doses.
• C. Compare the medication label to the order.
• D. Use at least 2 client identifiers before administering a dose.
• E. Involve and educate clients in medication administration.
• F. Document all medication in the electronic record as soon as it is given.

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?

• A. Administer PRN oral pain medication.
• B. Ask the client what is causing the grimacing.
• C. Monitor the client’s nonverbal behavior.
• D. Review the pain medications prescribed.