HESI PN COMPREHENSIVE EXIT EXM 2023\\2024 1. The N
HESI PN COMPREHENSIVE EXIT EXM 2023\\2024 1. The n
Exam (elaborations)
HESI PN COMPREHENSIVE EXIT EXAM
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HESI PN COMPREHENSIVE EXIT EXM 2023\\2024 1. The n
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HESI PN COMPREHENSIVE EXIT EXM 2023\\2024 1. The N
HESI PN COMPREHENSIVE
EXIT EXAM
1. The nurse is administering pain medication for several patients. Which patient
does the nurse administer medication to first?
a. The patient who needs to be premedicated before walking
b. The patient who has a PCA running that
needs the syringe replaced The...
HESI PN COMPREHENSIVE
EXIT EXAM 2023\2024
1. The nurse is administering pain medication for several patients. Which patient
does the nurse administer medication to first?
a. The patient who needs to be premedicated before walking
b. The patient who has a PCA running that
needs the syringe replaced The patient who
needs to take a scheduled dose of
maintenance pain
c. medication
The patient who is experiencing 8/10 pain and has an immediate order
d. for pain medication
ANS: D
Immediate (STAT) medications need to be given as soon as possible. In
addition, this patient is the priority because of the report of severe pain. The
other patients need pain medication, but their situations are not as high a
priority as that of the patient with the STAT medication order.
2. The nurse is assessing a patient for opioid tolerance. Which finding supports the
nurse’s assessment?
a. The patient needed a substantial dose of naloxone (Narcan).
b. The patient needs increasingly higher doses
of opioid to control pain. The patient no
longer experiences sedation from the usual
dose of
c. opioid.
The patient asks for pain medication close to the time it is due around
d. the clock.
ANS: B
Opioid tolerance occurs when a patient needs higher doses of an opioid to control
pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects
of opioid overdose. Taking pain medications regularly around the clock is an
effective way to control pain. The pain medication for this patient is most likely
effectively managing the patient’s pain because the patient is not asking for the
medication before it is due. A patient no longer experiencing a side effect
(sedation) of an opioid does not indicate opioid tolerance.
29.A nurse is caring for a patient with rheumatoid arthritis who is now going to
1
, `
be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain.
Which part of the patient’s social history is the
nurse most concerned about?
a. Patient drinks 1 to 2 glasses of wine every night.
b. Patient smokes 2 packs of cigarettes a day.
c. Patient occasionally uses marijuana.
d. Patient takes antianxiety medications.
ANS: A
The major adverse effect of acetaminophen is hepatotoxicity (liver toxicity).
Because both alcohol and acetaminophen are metabolized by the liver, when taken
together, they can cause liver damage. Smoking cigarettes and smoking marijuana
are not healthy behaviors, but their effects on health are not affected by
acetaminophen. Antianxiety medications can be taken with acetaminophen.
30. The nurse is caring for a patient who suddenly experiences chest pain. What is
the nurse’s first priority?
a. Call the rapid response team.
b. Start an intravenous (IV) line.
c. Administer pain-relief medications.
d. Ask the patient to rate and describe the pain.
ANS: D
The nurse’s ability to establish a nursing diagnosis, plan and implement care, and
evaluate the effectiveness of care depends on an accurate and timely assessment.
The other responses are all interventions; the nurse cannot know which
intervention is appropriate until the nurse completes the assessment.
31. The nurse is caring for a group of patients. Which task may the nurse
delegate to the nursing assistive personnel (NAP)?
a. Administer a back massage to a patient with pain.
b. Assessment of pain for a patient reporting abdominal pain.
c. Administer patient-controlled analgesia for a postoperative patient.
d. Assessment of vital signs in a patient receiving epidural analgesia.
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