RN HESI Pharmacology Exam
RN HESI Pharmacology Exam ( 31 Questions)
Patient Data
History and Physical
The client is a 75-year-old female who was admitted to the preop area to prepare for pacemaker insertion. She states that she needs this procedure because her heart rate has been very low, she feels tired all the time, and she has fainted once due to low heart rate. She has a history of worsening symptomatic bradycardia and atrial fibrillation controlled by medication. She has been off anticoagulants for four days to prepare for the procedure.
Nurses' Notes
0700: Labs were drawn and completed during a preadmission visit. After changing clothes and settling into bed, she was placed on continuous monitoring. Admission process was completed.
0800: A PIV was started in her right antecubital with a 20-gauge intracath. IVF of NS was started at 50 mL/hr. The cardiac surgeon came to see the client and answer her questions about the procedure.
0830: The client reports no known allergies. Vancomycin 1 gram in 250 mL NS was started at 125 mL/hr as endocarditis prophylaxis.
0840: The client was awaiting transfer to OR. Vancomycin was infusing at 125 mL/hr.
0845: The client says, "I don't feel well." Assessment reveals dizziness, headache, burning sensation on extremities, and red color on face and extremities. Blood pressure is 108/46 mmHg. Vancomycin infusion was stopped. The surgeon was notified.
0850: The client has flushing and redness over her entire body with hives developing. She complains of feeling hot and nauseous. Cool cloths were applied to her face and extremities. She is restless in bed. IVF of NS is running.
Orders:
1140
- Diphenhydramine 25 mg IV now
- Methylprednisolone 100 mg IV now
The nurse is implementing the plan of care.
For each body system, select to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
Body System: Respiratory
The correct choice is A
Choice A: Assess lung sounds This is the correct choice because the client may have developed an allergic reaction to vancomycin, which can cause bronchospasm and wheezing. Assessing lung sounds can help the nurse monitor the client’s respiratory status and intervene if needed.
Choice B: Provide a calm environment This is not the correct choice because providing a calm environment is not specific to the respiratory system. It may help the client feel more comfortable, but it does not address the potential respiratory complications of an allergic reaction.
Choice C: Pain medication This is not the correct choice because pain medication is not related to the respiratory system. The client did not report any pain, and pain medication may have adverse effects on the respiratory system, such as respiratory depression.
Choice D: Chest x-ray This is not the correct choice because a chest x-ray is not indicated for the client at this time. A chest x-ray is a diagnostic test that can show abnormalities in the lungs, such as pneumonia or pleural effusion. However, the client’s symptoms are more likely caused by an allergic reaction, which would not be visible on a chest x-ray.
Body System: Cardiovascular
The correct answer is A, B, and C. Here are the explanations for each choice:
Choice A: Monitor vital signs continuously. This is a correct and appropriate nursing intervention for the cardiovascular system. The client may have hypotension, tachycardia, or arrhythmias due to anaphylaxis or the effects of medications. Continuous monitoring can help detect any changes and guide interventions accordingly .
Choice B: Provide warmth. This is also a correct and appropriate nursing intervention for the cardiovascular system. The client may lose heat due to vasodilation, sweating, or exposure during the procedure. Providing warmth can help prevent hypothermia and shivering, which can increase oxygen demand and worsen cardiac function. Providing warmth can also improve comfort and reduce anxiety .
Choice C: Defibrillator at bedside. This is another correct and appropriate nursing intervention for the cardiovascular system. The client is at risk of cardiac arrest due to anaphylaxis, bradycardia, or pacemaker malfunction. Having a defibrillator at bedside can facilitate prompt resuscitation if needed.
Choice D: ECHO. This is an incorrect and inappropriate nursing intervention for the cardiovascular system. ECHO is a diagnostic test that uses ultrasound waves to create images of the heart and its structures. It can help evaluate the client’s cardiac function, valve function, and presence of any complications such as pericardial effusion or tamponade. However, this is not a priority intervention for the client who is experiencing an anaphylactic reaction and needs immediate treatment to stabilize her condition. ECHO can be done later after the client recovers from the acute episode.
Body System: Immunological
The correct answer is **A and D**.
- Choice A: Administer antihistamine. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Antihistamines, such as diphenhydramine, can block the effects of histamine, which is a major mediator of allergic inflammation and symptoms. Antihistamines can help reduce itching, hives, flushing, and bronchoconstriction¹².
- Choice B: IV fluids. This is an incorrect and inappropriate nursing intervention for the immunological system. IV fluids are not directly related to the immune response or the allergic reaction. IV fluids are mainly used to maintain hydration, electrolyte balance, and blood pressure. However, IV fluids may be indicated for the client as part of the cardiovascular or renal system interventions³.
- Choice C: Assess rash. This is an incorrect and inappropriate nursing intervention for the immunological system. Assessing rash is not a specific intervention for the immune response or the allergic reaction. Assessing rash is part of the general assessment of the client's skin condition, which may reflect other factors such as infection, inflammation, or drug toxicity. However, assessing rash may be helpful to monitor the severity and progression of the allergic reaction and the effectiveness of the treatment⁴.
- Choice D: Administer steroid. This is a correct and appropriate nursing intervention for the immunological system. The client is having an anaphylactic reaction to vancomycin, which is a type of hypersensitivity reaction mediated by IgE antibodies. Steroids, such as methylprednisolone, can suppress the immune system and reduce the production of inflammatory mediators, such as cytokines and prostaglandins. Steroids can help decrease swelling, inflammation, and tissue damage¹².