HESI Registered Nurse EXIT Practice Exam

For a client presenting with nausea, vomiting, yellow vision, and palpitations, what is the most important assessment for the nurse?

1. Assess for dehydration

2. Evaluate cardiac rhythm

3. Obtain a list of medications taken for cardiac history

4. Check vital signs

The correct answer is: Obtain a list of medications taken for cardiac history

In a scenario where a client is experiencing nausea, vomiting, yellow vision, and palpitations, assessing the list of medications taken for cardiac history is crucial. This assessment can help identify any potential drug-related causes for the client's symptoms, particularly if they are taking medications that might contribute to cardiac issues or toxicity. Nausea and vomiting can occur as side effects of certain medications, and yellow vision, or "xanthopsia," can be indicative of toxicity to specific cardiac medications, such as digoxin. Palpitations may suggest an underlying arrhythmia, which can also be linked to drug interactions, doses that are too high, or the effects of multiple medications on heart function. Understanding the client's medication history provides valuable insight into possible pharmacological explanations for their presenting symptoms, guiding the nurse in making informed clinical decisions. It sets the foundation for further assessments, including vital signs and cardiac rhythm evaluation, while considering the overall context of the client's medication use.