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HESI COMPLETE BUNDLE SOLUTION LATEST UPDATE 2022, A GRADED
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OB HESI Study Questions (taken from HESI NCLEX-RN book) 2022
OB HESI Study Questions (taken from HESI NCLEX-RN book) 2022 Objective signs that signify ovulation - ANS- Abundant, thin, clear cervical mucus (egg-w... [Show More] hite stretchiness), open cervical os, slight drop in basal body temp & then 0.5 to 1°F rise, ferning Ovulation occurs how many days before the next menstrual period? - ANS- 14 days 3 ways to identify gestation of pregnancy - ANS- 10 lunar months, 9 calendar months, 3 trimesters of 3 months each, 40 wk, 280 days What maternal position provides optimum fetal and placental perfusion during pregnancy? - ANS- Knee-chest but side-lying is most comfortable and removes pressure from abdominal vessels Major discomforts of first trimester and suggestions for relief for each - ANS- N/V: crackers before rising. Fatigue: 7-8hr sleep at night Naegele's Rule - ANS- First day of LMP: Oct 24 Subtract 3 months: July 24 Add 7 days: July 31=Estimated Date of Delivery (Adjust year accordingly) Fundal height at 20 wk gestation - ANS- At the umbilicus Approximate wt of fetus @ 20 wk gestation - ANS- 300-400g Characteristics of fetus @ 20 wk gestation - ANS- Looks like baby with hair, lanugo, vernix. No subcutaneous fat. Normal psychosocial responses to pregnancy in 2nd trimester - ANS- Acceptance of pregnancy (ambivalence wanes) Signs of maternal-fetal bonding Peak of hemodilution in pregnancy - ANS- 28-32 wk (decreases Hct) 3 principles relative to wt gain in pregnancy - ANS- Total gain average 24-30 lb Gain should be consistent throughout pregnancy Average of 0.9 lb/wk in 2nd & 3rd trimesters How many calories should be added daily to the pregnant woman's diet? - ANS- 300 calories How much milk should a pregnant woman consume daily during pregnancy? - ANS1 quart At how many wks can fetal heart tones be auscultated by Doppler? - ANS- 10-12 wks Schedule of prenatal visits for low-risk pregnant woman - ANS- Once a month until 28 wks Every 2 wks from 28-36 wks Once a wk until delivery Five maternal variables associated with diagnosis of high-risk pregnancy - ANS- 1. Age (<17, >34) 2. Parity (>5) 3. Dx of preeclampsia 4. Dx of Diabetes Mellitus 5. Dx of cardiac disease Is one ultrasound exam useful in determining presence of IUGR? - ANS- No, serial measurements are needed What does the biophysical profile determine (BPP)? - ANS- Fetal well-being List 3 nursing actions prior to ultrasound exam for woman in 1st trimester of pregnancy - ANS- 1. Have client fill bladder 2. Don't allow client to void 3. Position client supine w/uterine wedge Advantage of CVS over amniocentesis - ANS- -Can be done during 8-12 wks gestation -Results returned in 1 wk -Allows for decision about termination in 1st trimester Why are serum or amniotic AFP levels done prenatally? - ANS- Elevated AFP levels may indicate presence of neural tube defects. Low AFP levels may indicate trisomy 21 Most important determinant of fetal maturity for extrauterine survival - ANS- L:S ratio (lung maturity, lung surfactant development) 3 most common complications of amniocentesis - ANS- 1. Spontaneous abortion 2. Fetal injury 3. Infection 4 changes of FHR - ANS- 1. Accelerations 2. Early decelerations 3. Variable decelerations 4. Late decelerations Cause of FHR accelerations and nursing treatment - ANS- -Caused by burst of sympathetic activity -Reassuring and require no treatment Cause of FHR early decelerations and nursing treatment - ANS- -Caused by head compression -Benign and alert nurse to monitor for labor progress and fetal descent Cause of FHR variable decelerations and nursing treatment - ANS- -Caused by cord compression -Change of position should be tried first Cause of FHR late decelerations and nursing treatment - ANS- -Caused by uteroplacental insufficiency (UPI) -Place client on side and administer O2 VEAL CHOP (acronym for FHR interpretation) - ANS- Variables=Cord compression Early decel=Head compression Accelerations=OK Late decel=Placental insufficiency Most important indicator of fetal autonomic nervous system integrity and health - ANS- FHR variability 4 causes of decreased FHR variability - ANS- 1. Hypoxia 2. Acidosis 3. Drugs 4. Fetal sleep Most important action when cord prolapse is determined - ANS- Position mother to relieve pressure on cord or push presenting part off cord with fingers until emergency delivery is accomplished Reactive non-stress test - ANS- FHR acceleration of 15 bpm for 15 sec in response to fetal movement Dangers of nipple-stimulation stress test - ANS- -Inability to control oxytocin "dosage" -Tetany/hyperstimulation Normal fetal scalp pH in labor - ANS- 7.25-7.35 Fetal scalp pH in labor of 7.2 indicates what? - ANS- True acidosis 6 prodromal signs of labor - ANS- Lightening, Braxton Hicks contractions, increased bloody show, loss of mucous plug, burst of energy, & nesting behaviors True labor vs. False labor - ANS- True: regular, rhythmic contractions that intensify with ambulation, pain in abdomen sweeping around from back, cervical changes. False: Irregular rhythm, abdominal pain (not in back) that decreases with ambulation 2 ways to determine whether membranes have truly ruptured - ANS- Nitrazine testing paper turns dark blue or black, & Demonstration of fluid ferning under microscope Are psychoprophylactic breathing techniques prescribed for use according to the stage and phase of labor? - ANS- No. Clients should use these techniques according to their discomfort level and should change techniques when one is no longer working for relaxation... [Show Less]
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Exit HESI 3 160 Questions And Answers 2022
Exit HESI 3 160 Questions And Answers 2022 pt is experiencing hyperkalemia - in absence of symptoms and EKG changes it is sufficiency to - ANS- switch c... [Show More] aptopril (an ACE inhibitor that promote K retention) to another (non-K sparing) htn drug such as amlodipine pt is experiencing diplopia, dysphagia, descending muscle weakness and diarrhea and is dianosed w botulism what should nurse tell pts spouse? - ANS- throw out all of your home canned foods. neurotoxin are typically found in home canned foods. premature atrial contractions - ANS- momentary interruption of atrial rhythm (can be caused by stress, caffeine, drugs) -tx if beta-blocker!!! not life-threatening, cannot change dose of prescribed med, fluxetine (prozax) - ANS- antidepressant SSRI's -> first few weeks of SSRI tx the risk of self-harm and suicide is increased. normal PR interval - ANS- 0.12-0.20 seconds a thrombocyte count of 60,000 is - ANS- severely decreased (norm 150k-400k) and could mean that the pt is developing probs w coagulation in addition to the existing pancreatitis and ARDS, MODS is the most severe manifestation of sepsis and occurs when 2 organ systems become dysfunctional and require intervention to maintain homeostasis. -elevated WBC and crackles over both lungs is expected with ARDS LaVeen Shunt - ANS- plastic tube that passes from the jugular vein to the peritoneal cavity where a valve permits absorption of ascitic fluid to be carried back to venous circulation by the way of the superior vena cava. irregular heartbeat in newborns? - ANS- common, normal finding. Frontal Lobe (glioma) - ANS- frontal lobe controls personality and speech, personality changes and expressive aphasia are expected manifestations from tumor Parkland Burn Formula - ANS- 4mL x body weight (kg) x percentage of body surface= total fluid requirement in mL for 24 hours half to be given in 1st 8 hours, 1/4 in second 8 hours and 1/4 in last 8 hours... patient's bill of rights include - ANS- - Right to the least restrictive environment - Right to treatment - Right to refuse treatment - Right to have access to medical records - Access to telephone, mail, visitors, privacy, TV type 2 DM is prescribed daily insulin injections however has limited manual dexterity - ANS- for a reduction in manual dexterity, an insulin pen would ensure that the pt is compliant w daily insulin injections bc insulin pens are easier to handle than syringes. inhaled corticosteroids are often prescribed for asthma tx. steroids reduce - ANSinflammaton and swelling in airways, thereby improving air movement in lungs. an indication of effectiveness is an improvement in peak flow meter rates on pulmonary function testing. if the pts peak flow meter rates have remained unchanged after 3 months of steroid use, the current medication does is ineffective and needs to be adjusted. WIC program - ANS- a special supplemental food program for women, infants, and children, sponsored by the USDA; directed at low income pregnant and/or breastfeeding women, infants, and children under age 5. -include supplementation of nutritious foods and education. (dental caries in children) -also screens for immunization status of the participating students PD pts are at risk for excessive - ANS- protein loss, which manifests as weight loss, decreasing muscle mass, and peripheral edema. -albumin levels should be monitored regularly to ensure that pt's protein levels remain within normal range. -PD - RISK FOR HYPERGLYCEMIA due to the dialysate contains dextrose. Enalapril Maleate (Vasotec) - ANS- has a common side effect of male impotence Enalapril MALEate (Vasotec) - ANS- has a common side effect of male impotence paint thinner (Toluene) - ANS- can cause hearing loss!!! testing done to detect any changes in hearing pt receiving tx in a mental health facility becomes agitated and begins to act inappropriately in the pt lounge. which action should nurse take? - ANS- excessive noise or sound can be viewed as a threat by pts with psychiatric conditions. when the nurse observes that one of the pt's is becoming agitated, the best first action is to turn off the stereo to reduce environmental stimuli. if the pt's agitation does not recede, the nurse should then escort the pt to a quiet room to de-escalate behavior Dawn phenomenon - ANS- is the end result of a combination of natural body changes that occur during the sleep cycle. between hours 3a-8a, the body increases the amounts of counter-regulatory hormones that stop the action of insulin to lower blood glucose levels. the increased release of these hormones, at a time when bedtime insulin is wearing out, results in increase in blood sugars. this causes blood glucose to rise in the morning. the bedtime dose of insulin is prescribed to counter the effects of dawn phenomenon CONTINUES... [Show Less]
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HESI NCLEX Review Exam 2022
HESI NCLEX Review Exam 2022 Maslow's Hierarchy of Needs - - Physiologic • Safety • Love and Belonging • Esteem • Self-actualization Nursing P... [Show More] rocess - - Assessment • Diagnosis (Analysis) • Planning • Implementation (treatment) • Evaluation ABCs - - • Airway • Breathing • Circulation Hgb - - 12-18 Hct - - 37-52 RBCs - - 4.2-6.1 WBCs - - 4.5-11K Platelets - - 150-400K BUN - - 10-20 Creatinine - - 0.5-1.2 Glucose - - 70-110 Cholesterol - - <200 Billirubin Newborn - - 1-12 Na+ - - 136-145 K+ - - 3.5-5 HypoK+ - - Prominent U waves, Depressed ST segment, Flat T waves HyperK+ - - Tall T-Waves, Prolonged PR interval, wide QRS Ca+ - - 9-10.5 Hypocalcemia - - muscle spasms, convulsions, cramps/tetany, + Trousseau's, + Chvostek's, prolonged ST interval, prolonged QT segment Mg+ - - 1.5-2.5 Cl- - - 96-106 Phos - - 3-4.5 Albumin - - 3.5-5 Spec Gravity - - 1.005-1.030 Hgb A1c - - 4-6% ideal, < 7.5% = OK (120 days) Lithium - - 0.5-1.5 pH - - 7.35-7.45 CO2 - - 35-45 (Respiratory driver) ... High = Acidosis HCO3 - - 21-28 (Metabolic driver) ... High = Alkalosis Antidote Digoxin - - Digiband Antidote Coumadin - - Vitamin K Antidote Benzo - - Flumzaemil AntidoteMag Sulfate - - Calcium gluconate Antidote Heparin - - Protamine Sulfate Antidote Tylenol - - Mucomist Antidote Opiates - - Narcan Antidote cholinergic meds - - Atropine Rifampin (for TB) - - Rust/orange/red urine and body fluids Pyridium (for bladder infection) - - Orange/red/pink urine Glasgow Coma Scale - - <8 = coma Diabetic Coma vs. Insulin Shock - - Give glucose first - If no help, give insulin Fruity Breath - - Diabetic Ketoacidosis Acidosis - - If it comes out of your ass Alkalosis - - Vomiting Lipitor (statins) - - No grapefruit juice Hold Digoxin - - HR <60 ACE Inhibitor dose - - Stay in bed for 3 hours Pulmonary air embolism prevention - - Trendelenburg (HOB down) + on left side (to trap air in right side of heart) Head Trauma and Seizures - - Maintain airway = primary concern Peptic Ulcers - - Feed a Duodenal Ulcer (pain relieved by food) ... Starve a gastric ulcer Acute Pancreatitis - - Fetal position, Bluish discoloration of flanks (Turner's Sign), Bluish discoloration of pericumbelical region (Cullen's Sign), Board like abdomen with guarding ... Self digestion of pancreas by trypsin Hold tube feeding if - - residual > 100mL Gullain-Barre Syndrome - - Weakness progresses from legs upward - Resp arrest Trough draw - - ~30 min before scheduled administration Peak Draw - - 30-60 min after drug administration. Most suicides occur - - after beginning of improvement with increase in energy levels MAOIs - - Hypertensive Crisis with Tyramine foods Nardil, Marplan, Parnate Need 2 wk gap from SSRIs and TCAs to admin MAOIs Phenothiazines - - (typical antipsychotics) - EPS, Photosensitivity Atypical Antipsychotics - - work on positive and negative symptoms, less EPS Benzos (Ativan, Lorazepam, etc) - - good for Alcohol withdrawal and Status Epilepticus Alcohol Withdrawal - - Delerium Tremens - Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia ... (DTs start 12-36 hrs after last drink) Opiate (Heroin, Morphine, etc.) Withdrawal - - Watery eyes, runny nose, dilated pupils, NVD, cramps Stimulants Withdrawal - - Depression, fatigue, anxiety, disturbed sleep Hypoventilation - - Acidosis (too much CO2) Hyperventilation - - Alkalosis (low CO2) No BP or IV on side of Mastectomy - - No BP or IV on side of Mastectomy Pinpoint Pupils - - Opiate OD Lesions of Midbrain - - Decerebrate Posturing (Extended elbows, head arched back) Lesions of Cortex - - Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) Urine Output of 30 mL/hr - - minimal competency of heart and kidney function Renal Failure - - Restrict protein intake Usually 3 phases (Oligouric, Diuretic, Recovery) Monitor Body Wt and I&Os Fluid and electrolyte problems - - Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias) Pre-renal Problem - - Interference with renal perfusion... [Show Less]
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HESI Obstetrics/Maternity Practice Quiz 2022
HESI Obstetrics/Maternity Practice Quiz 2022 The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for... [Show More] which purpose? - ANS- Screen for neural tube defects A 26 year old, gravid 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethren) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? - ANS- Tachycardia and a feeling of nervousness During labor, the nurse determines that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Place in the first action on top and last action on the bottom) - ANS- 1. Reposition the client 2. Increase IV fluid 3. Provide oxygen via face mask 4. Call the health care provider A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" - ANS- "Your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times a day" A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? - ANS- Infant's condition at birth and treatment received The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? - ANS- Three vessels: two arteries and one vein When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (select all that apply) - ANS- -Mood swings -Tearfulness A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? - ANS- "That is normal; the head will return to a round shape within 7 to 10 days." The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? - ANS- Yellowish tinge to the skin A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? - ANS- -3+ deep tendon reflexes and hyperclonus -epigastric pain Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? - ANS- Provide assistance to the mother to begin breastfeeding as soon as possible after delivery A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? - ANS- "A home pregnancy test can be used right after your first missed period." Which assessment finding should the nursery nurse report to the pediatric healthcare provider? - ANS- Central cyanosis when crying A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? - ANS- It is difficult to consume 18 mg of additional iron by diet alone. The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs - ANS- Two weeks before menstruation A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? - ANS- "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply) - ANS- - Sterile glove - An amniotic hook - A doppler - Lubricant? An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? - ANS- Put the newborn to breast A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? - ANS- Obtain a specimen for urine analysis An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? - ANS- Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement... [Show Less]
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Pharmacology HESI Practice Questions And Answers 2022
Pharmacology HESI Practice Questions And Answers 2022 which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (inder... [Show More] al)? A. Headache, hypertension, and blurred vision. B. Wheezing, hypotension, and AV block. C. Vomiting, dilated pupils, and papilledema. D. Tinnitus, muscle weakness, and tachypnea. - ANS- B. Wheezing, hypotension, and AV block. (B) represents the most serious adverse effects of beta-blocking agents. AV block is generally associated with bradycardia and results in potentially life-threatening decreases in cardiac output. Additionally, wheezing secondary to bronchospasm and hypotension represent life-threatening respiratory and cardiac disorders. (A, C, and D) are not associated with beta-blockers. The healthcare provider prescribes naloxone (Narcan) for a client in the emergency room. Which assessment data would indicate that the naloxone has been effective? The client's... A. Statement that the chest pain is better B) respiratory rate is 16 breaths/minute. C) seizure activity has stopped temporarily. D) pupils are constricted bilaterally. - ANS- B. Naloxone (Narcan) is a narcotic antagonist that reverses the respiratory depression effects of opiate overdose, so assessment of a normal respiratory rate (B) would indicate that the respiratory depression has been halted. (A, C, and D) are not related to naloxone (Narcan) administration. A client has myxedema, which results from a deficiency of thyroid hormone synthesis in adults. The nurse knows that which medication should be contraindicated for this client? A. liothyronine (cytomel) to replace iodine B. Furosemide (Lasix) for relief of fluid retention C. Pentobarbital sodium for sleep D. nitroglycerin for angina pain - ANS- C. persons with myxedema are dangerously hypersensitive to narcotics, barbiturates, and anesthetics. They do not tolerate liothyronine and usually receive iodine replacement therapy. These clients are also suceptable to heart problems such as angina for which nitroglycerine would be indicated and and congestive heart failure for which furosemide would be indicated A client with osteoarthritis receives a new prescription for celecoxib (Celebrex) orally for symptom management. The nurse notes the client is allergic to sulfa. Which action is most important for the nurse to implement prior to administering the first dose? A) Review the client's hemoglobin results. B) Notify the healthcare provider. C) Inquire about the reaction to sulfa. D) Record the client's vital signs. - ANS- B. Celebrex contains a sulfur molecule, which can lead to an allergic reaction in individuals who are sensitive to sulfonamides, so the healthcare provider should be notified of the client's allergies (B). Although (A, C, and D) are important assessments, it is most important to notify the healthcare provider for an alternate prescription. The client with a dysrhythmia is to receive procainamide (pronestyl) in 4 divided doses over the next 24 hours. What dosing schedule is best for the nurse to implement? A. q4h B. QID C. AC and bedtime D. PC and bedtime - ANS- A. q6h A client has a continous IV infusion of dopamine (Intropin) and an IV of normal saline at 50 ml/hour. The nurse notes that the client's urinary output has been 20 ml/hour for the last two hours. Which intervention should the nurse initiate? A. Stop the infusion of dopamine B. Change the normal saline to a keep open rate. C. Replace the urinary catheter. D. Notify the healthcare provider of the urinary output. - ANS- D. Notify the healthcare provider of the urinary output. An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorlac (toradol) 30mg IV q6h. which action should the nurse implement? A. administer both medications according to the prescription B. Hold the ketorolac to prevent an antagonist effect C. Hold the morphine to prevent an additive drug interaction D. Contact the healthcare provider to clarify the prescription - ANS- A. Administer both medications according to the prescription Morphine and ketorolac can be administered concurrently and may produce additive analgesic effect resulting in ability to reduce the dose of morphine, as seen in this prescription A client is being treated for hyperthyridism with propylthiouracil (PTU). The nurse knows that the action of this drug is to: A. decrease the amount of thyroid stimulating hormone circulating in the blood. B. increase the amount of thyroid-stimulating hormone circulating in the blood. C. increase the amount of T4 and decrease the amount of T3 produced by the thyroid. D. inhibit synthesis of T3 and T4 by the thyroid gland. - ANS- D. PTU is an adjunct therapy used to control hyperthyroidism by inhibiting production of thyroid hormones. It is often prescribed in prep for thyroidectomy or radioactive iodine therapy A female client with RA takes ibuprofen (motrin) 600mg PO 4xday. To preven GI bleeding, misoprostol (cytotec) 100mcg PO is prescribed. Which information is most important for the nurse to include in client teaching? A. use contraception during intercourse B. ensure the cytotec is taken on an empty stomach C. encourage oral fluid intake to prevent constipation D. take cytotec 30min prior to motrin - ANS- A. Use contraception during intercourse. Cytotec, a synthetic form of prostaglandin, is classified as pregnancy category X and can act as an abortifacient, so the client should be instructed to use contraception during intercourse to prevent loss of early pregnancy Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition? A) Shock. B) Asthma. C) Hypotension. D) Heart failure - ANS- D. Heart Failure Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure (D) related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of shock (A). Other selective beta-2 adrenergic agonists, such as terbutaline and isoproterenol, are indicated in the treatment of asthma (B). Although dobutamine improves cardiac output, it is not used to treat hypotension (C). Which medications should the nurse caution the client about taking while receiving an opioid analgesic? A. Antacids. B. Benzodiasepines C. Antihypertensives D. Oral antidiabetics - ANS- B. B. Benzodiasepines Respiratory depression increases with the concurrent use of opioid analgesics and other cns depressant agents, such as alcohol, barbiturates, and benzodiasepines Which client should the nurse identify as being at the highest risk for complications during the use of an opioid analgesic? A. an older client with type 2 diabetes B. A client with chronic rheumatoid arthritis C. A client with a open compound fracture D. A young adult with inflammatory bowel disease - ANS- D. A young adult with inflammatory bowel disease Which change in data indicates to the nurse the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved A. Dependent edema reduced form +3 to +1 B. Serum HDL increased from 35 to 55mg/dl C. PUlse rate reduced from 150 to 90 beats/min D. Blood pressure reduced from 160/90 to 130.80 - ANS- D. D. Blood pressure reduced from 160/90 to 130.80 angiotensin II receptor antagonist (blocker), prescribed from treatment of HTN. The desired effect is a decrease in blood pressure. A client with heart failure is prescribed spironolactone (Aldactone). Which information is most important for the nurse to provide to the client about diet modifications? A) Do not add salt to foods during preparation. B) Refrain for eating foods high in potassium. C) Restrict fluid intake to 1000 ml per day. D) Increase intake of milk and milk products. - ANS- B. Spironolactone (Aldactone), an aldosterone antagonist, is a potassium-sparing diuretic, so a diet high in potassium should be avoided (B), including potassium salt substitutes, which can lead to hyperkalemia. Although (A) is a common diet modification in heart failure, the risk of hyperkalemia is more important with Aldactone. Restriction of fluids (C) or increasing milk and milk products (D) are not indicated with this prescription. The nurse is assessing the effectiveness of high dose aspirin therapy for an 88-yearold client with arthritis. The client reports that she can't hear the nurse's questions because her ears are ringing. What action should the nurse implement? A) Refer the client to an audiologist for evaluation of her hearing. B) Advise the client that this is a common side effect of aspirin therapy. C) Notify the healthcare provider of this finding immediately. D) Ask the client to turn off her hearing aid during the exam. - ANS- C. Notify the healthcare provider of this finding immediately. Tinnitus is an early sign of salicylate toxicity. The healthcare provider should be notified immediately (C), and the medication discontinued. (A and D) are not needed, and (B) is inaccurate. The healthcare provider prescribes naproxen (Naproxen) twice daily for a client with osteoarthritis of the hands. The client tells the nurse that the drug does not seem to be effective after three weeks. Which is the best response for the nurse to provide? A) The frequency of the dosing is necessary to increase the effectiveness. B) Therapeutic blood levels of this drug are reached in 4 to 6 weeks. C) Another type of nonsteroidal antiinflammatory drug may be indicated. D) Systemic corticosteroids are the next drugs of choice for pain relief. - ANS- C. Another type of nonsteroidal antiinflammatory drug may be indicated. Individual responses to nonsteroidal antiinflammatory drugs are variable, so (C) is the best response. Naproxen is usually prescribed every 8 hours, so (A) is not indicated. The peak for naproxen is one to two hours, not (B). Corticosteroids are not indicated for osteoarthritis (D). An older client with a decreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process? A) Absorption. B) Metabolism. C) Elimination. D) Distribution. - ANS- D. A decreased lean body mass in an older adult affects the distribution of drugs (D), which affects the pharmacokinetics of drugs. Decreased gastric pH, delayed gastric emptying, decreased splanchnic blood flow, decreased gastrointestinal absorption surface areas and motility affect (A) in the older adult population. Decreased hepatic blood flow, decreased hepatic mass, and decreased activity of hepatic enzymes affect (B) in older adults. Decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons affects (C) in an older adult. A peak and trough level must be drawn for a client receiving antibiotic therapy. What is the optimum time for the nurse to obtain the trough level? A) Sixty minutes after the antibiotic dose is administered. B) Immediately before the next antibiotic dose is given. C) When the next blood glucose level is to be checked. D) Thirty minutes before the next antibiotic dose is given. - ANS- B. Immediately before the next antibiotic dose is given. Trough levels are drawn when the blood level is at its lowest, which is typically just before the next dose is given (B). (A, C, and D) do not describe the optimum time for obtaining a trough level of an antibiotic. A client with Parkinson's disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse should indicate that the desired outcome of the medication is being achieved? A) Decreased blood pressure. B) Lessening of tremors. C) Increased salivation. D) Increased attention span. - ANS- B. Lessening of tremors. Sinemet increases the amount of levodopa to the CNS (dopamine to the brain). Increased amounts of dopamine improve the symptoms of Parkinson's, such as involuntary movements, resting tremors (B), shuffling gait, etc. (A) is a side effect of Sinemet. Decreased drooling would be a desired effect, not (C). Sinemet does not affect (D). A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? A) Weight loss. B) Dizziness. C) Muscle cramps. D) Dry mucous membranes. - ANS- B. Dizziness The client should be prepared to implement measures for constipation (B) which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation (A) and respiratory depression (D) as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention (C) but may subside. A client is receiving metroprolol (Lopressor SR). What assessment is most important for the nurse to obtain? A) Temperature. B) Lung sounds. C) Blood pressure. D) Urinary output. - ANS- C. Blood pressure It is most important to monitor the blood pressure (C) of clients taking this medication because Lopressor is an antianginal, antiarrhythmic, antihypertensive agent. While (A and B) are important data to obtain on any client, they are not as important for a client receiving Lopressor as (C). Intake and output ratios and daily weights should be monitored while taking Lopressor to assess for signs and symptoms of congestive heart failure, but (D) alone does not have the importance of (C). CONTINUES... [Show Less]
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Module three Hesi Questions And Answers 2022
Module three Hesi Questions And Answers 2022 The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her... [Show More] for picking the neighbors' flowers. Which defense mechanism used by the child does the nurse identify in the mother's report? - ANSDisplacement A client says to the nurse, "I've been following my diet and taking my medication. What else do you want to talk about today?" Which response would be most helpful during the working phase of the therapeutic alliance? - ANS- "Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you? As the nurse prepares to interview a client being admitted to the mental health unit, the client says, "I asked my family to bring me in here to talk to someone, but now I don't know where to begin." Which response by the nurse would be most helpful? - ANS- "Perhaps you can start by sharing some of your most recent concerns." During a mental health intake interview, a young adult client who lives with his family rent free says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in taking a drink socially." Which nursing response would be therapeutic? - ANS- "It seems that your parents expect you to follow their rules when you live under their roof." A nurse is participating in a care planning conference regarding care for a client whose spouse recently died. The registered nurse formulates a nursing diagnosis of dysfunctional grieving. Which priority intervention does the nurse expect to see incorporated into the plan? - ANS- Determining the client's risk for violence toward self and others A client in the mental health unit tells the nurse, "My husband makes all the decisions about money, but I'm the one who's making the money now, not him. He needs to back off, but he's always directing every decision we make." Which nursing response would be the most therapeutic? - ANS- "How do you feel the money decisions could best be handled in your household?" A nurse is attending a care planning conference for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. The nurse should question which planned intervention for this client? - ANS- Discouraging social networking to prevent the spread of infection How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. - ANS- Reporting that sleeping alone was hard at first Purchasing a smaller car she is comfortable driving Heard explaining to family that illness "took" her husband Heard explaining to family that illness took her husband A nurse is caring for a 15-year-old girl who has been hospitalized on the mental health unit for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. The nurse recognizes that the client is using which defense mechanism? - ANS- Identification A mental health home care nurse says to the client, "Do you feel ready to try attending a group session at the clinic?" The client shakes his head. Which nursing statement would be therapeutic? - ANS- "You seem to be saying no. Would you tell me more about your reluctance?" A single parent whose son was suspended from school for carrying a gun into the school says to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won't listen to me." Which nursing response would be helpful at this time? - ANS- "There is quite a bit that you can do. Let's talk about what you're already doing first." A client says to the nurse, "My health care provider says he thinks I'm ready to taper off my pain medication, but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain when I try to do things." Which nursing response would be most supportive to the client? - ANS- "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective." A client who was employed as a corporate manager before being laid off says to the nurse, "My wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing response would be therapeutic? - ANS- "Have you shared your feelings with your wife?" A young woman who has been divorced twice says to the nurse, "I've decided not to date men ever again! It never works out for me. Now I'm left with two children to bring up." Which nursing response would be therapeutic? - ANS- "You talk about how the divorces affected you. Tell me how your children are dealing with the loss." A client says to the nurse, "What does my psychiatrist mean when she says that my illness is biologically based?" Which nursing statement would be the most informative? - ANS- "There are many possible physical causes of mental illness, and they include problems in the brain." A nurse is caring for a 39-year-old client who has experienced a mild brain attack (stroke). The client is recently widowed, is very active physically, and has two young sons. The client says to the nurse, "I don't know what my sons will do if anything permanent happens to me. We have no other relatives, even on my late wife's side." Which nursing response would be therapeutic? - ANS- "You seem to be feeling very troubled." A client who has been admitted to a surgical unit with a diagnosis of cancer is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, "I'm not having surgery—you must have the wrong person! My test results were negative. I'll be going home tomorrow." The nurse recognizes that the client is engaging in the use of which defense mechanism? - ANS- Denial A young adult client who is dying says to the nurse, "I keep asking my wife what I can do for her and our daughter before I die, but she refuses to tell me." On the basis of the client's statement, what is the appropriate nursing intervention? - ANS- Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways A 45-year-old client says to the nurse, "Since I left my wife and children, I can hardly make ends meet between child support and trying to support myself. I don't know why I bother going to work when my wife and kids take just about everything I make." Which nursing statement would be therapeutic? - ANS- "Do you feel that child support is designed to help children, not punish spouses who leave?" A survivor of a nightclub fire that killed more than 100 people says to the nurse, "It should have been me. How come I got out and they didn't?" Which response by the nurse is appropriate? - ANS- "It seems that you're blaming yourself for something that was beyond your control." When assisting with the plan of care of a client dying of cancer, the nurse seeks to have the client verbalize acceptance of his impending death. Which statement indicates to the nurse that this goal has been met? - ANS- "I'd like to have my family here when I die." A client says to the nurse at the mental health clinic, "My husband and sister-in-law both have terminal illnesses, and my family thinks that because I'm a nurse I should be able to handle everything." Which nursing response would be therapeutic? - ANS- "You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse." A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just frying up what was supposed to be bacon and eggs. I'm so frustrated and I've already lost 10 pounds this month." Which initial nursing statement should the nurse make to the client? - ANS- "It seems as if you feel lost without your wife and maybe a bit ignored by your children." A physician tells a client that she has cancer, that her illness is terminal, and that she has a 6-month prognosis. After the physician leaves the client's room, which therapeutic statement should the nurse make to the client? - ANS- "What did your health care provider tell you about your condition? Can you tell me what you're thinking about?" CONTINUES... [Show Less]
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HESI Mental Health Questions And Answers 2022
HESI Mental Health Questions And Answers 2022 A - ANS- While interviewing a client, the nurse takes notes to assist with accurate documentation later.... [Show More] Which statement is most accurate regarding note-taking during an interview? A. The nurse' ability to directly observe the client's nonverbal communication is limited with note taking. B. Taking notes during an interview is a legal obligation of the examining nurse. C. The client's comfort level is increased when the nurse breaks eye contact to take note to take note. D. The interview process is enhanced with note taking and allows the client speak at normal pace. B - ANS- An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite. B. The emotional quality of his attitude C. His level of activity. D. The interactions he has with others. B C D - ANS- A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? Select all that apply. A. Purchase a gun to use for protection B. Establish a code with family and friends to signify violence. C. Plan an escape route to use if the abuser blocks the main exit. D. Have a bag ready that has extra clothes for self and children B - ANS- While sitting in the dayroom of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrate the client's behavior. What is the main goal of this therapeutic techniques? A. Discuss the client's feeling when he responds. B. Allow the client to identify the way he interacts. C. Initiate a non-threatening conversation with the client. D. Dialog about the ineffectiveness of his interactions.) C - ANS- A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity. B. Social isolation. C. Refusal to address nutritional needs. D. Low self-esteem. B - ANS- The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia). A - ANS- A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the client's verbal and nonverbal communication. What action does the RN take? A. Pay close attention and document the nonverbal messages. B. Ask the client's husband to interpret the discrepancy. C. Ignore the nonverbal behavior and focus on the client's verbal messages. D. Integrate the verbal and nonverbal messages and interpret them as one. B - ANS- A male client approaches the RN with an angry expression on his face and raises his voice, saying "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The RN recognizes that the client is using which defense mechanism? A. Denial. B. Projection. C. Rationalization. D. Splitting. A - ANS- A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action is needed since polydipsia is a common side effect. D. Tell the client that drinking from the faucet is not allowed. B - ANS- The RN is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A. Completely abstain from heroin or cocaine use. B. Remain alcohol free for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous. D. Admit to others that he is a substance user. D - ANS- A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? A. Have you lost interest in the things that you used to enjoy? B. Is your ability to think or concentrate decreased? C. How many continuous hours do you sleep at night? D. Do you hear sounds or voices that others do not hear? D - ANS- During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. How should the RN respond? A. "Anger is contagious and could result in major confrontation." B. "Try not to let your anger cause you to act impulsively." C. "Expressing your anger to a stranger could result in an unsafe situation." D. "It sounds as if there are many situations that make you feel angry." B - ANS- A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A. Encourage substitution of positive thoughts and negative ones. B. Establish trust by providing a calm, safe environment. C. Progressively expose the client to larger crowds. D. Encourage deep breathing when anxiety escalates in a crowd. A D E - ANS- Which nursing actions are likely to help promote the self-esteem of a male client with modern depression? A. Ask the client what his long term goals are. B. Discuss the challenges of his medical condition. C. Include the client in determining treatment protocol. D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns. D - ANS- A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the RN take? A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril). B. Offer the client a prescribed physical therapy hot pack for muscle spasms. C. Direct client to occupational therapy to distract him from somatic complaints. D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. A - ANS- A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loid voice to talk to the client. D. Remains at a distance of 4 feet from the client. C - ANS- A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? A. Transport of the client to the seclusion room. B. Quietly approach the client with additional staff members. C. Take other clients in the area to the client lounge. D. Administer medication to chemically restrain the patient. D - ANS- A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? A. "What should I do? Nothing seems to help." B. "I have been so tired lately and needed to sleep." C. "I really think that I don't need to be here." D. "I don't want to walk. Nothing matters anymore." C - ANS- A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed employee's history is most related to the reaction that occurred? A. Is worried about losing his job to a woman. B. Tortured animals as a child. C. Was physically abused by his mother. D. Hates to be touched by anyone. B - ANS- The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here" and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam/ A. Level of concentration. B. Insightandjudgement. C. Remotememory. D. Mood and affect. B - ANS- A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN, "I feel like I'm going to die". Which nursing problem should the RN include in this client's plan of care? A. Mood disturbance. B. Moderate anxiety. C. Alteredthoughts. D. Social isolation. A - ANS- A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? A. Offer the client a safe place to relax before interviewing her. B. Ask the client to describe why she is being stalked. C. Recommend that the client talk with a social worker. D. Assure the client that the HCP will see her today. D - ANS- The RN leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? A. Explore the client's feelings about his pets and home life. B. Encourage his peers to help involve him in the activity. C. Give the client permission to leave and return in 10 minutes. D. Redirect him by encouraging him to read from the handout. B - ANS- A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take? A. Report the behavior to the next shift. B. Offer to play a game of cards with the client. C. Document the behavior in the chart. D. Plan to talk with the client the next day. A - ANS- A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Do not take any over the counter meds. B. Eat a high carb, low fat, low protein diet. C. Call the crisis hotline if feeling lonely. D. Avoid exposure to large crowds. B - ANS- After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take? A. Refer the student to a psychiatrist for further discussion. B. Recommend assignment to the receptionist's office. C. Suggest that student work in the athletic department. D. Determine the parent's opinion of the work assignment. D - ANS- The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To develop treatment plan for this client, which assessment is most important for the RN to obtain? A. Motivation of treatment. B. History of substance use. C. Medicationcompliance. D. Mental status examination. B - ANS- A male client who recently lost a loved one arrives at the mental health center and tells the RN he is no longer interested is his usual activities and has not slept for several days. Which priority nursing problem should the RN include in the client's plan of care? A. Risk for suicide. B. Sleepdeprivation. C. Situational low self-esteem. D. Social isolation. D - ANS- A male client with long history of alcohol dependency arrives in the emergency department describing the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm, and is blood alcohol level is 0mg/dL. Which prescription should the RN administer? A. Haloperidol (Haldol). B. Thiamine (Vitamin B1). C. Diphenhydramine(Benadryl). D. Lorazepam (Ativan). A - ANS- A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words and wanders into client's rooms. The RN decides that the client needs constant observation based on which of these assessment findings? A. Wanders into the clients rooms. B. Refuses antipsychotic medications. C. Talks with nonsensical words. D. Disrupts group activities. B - ANS- A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide/ A. "Let's go ask another RN is this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one if your children." D. "I know that you don't have 20 children." B - ANS- A high school girl reveals to the high school RN that she has been engaging in self- induced vomiting as weight-control measure. Which initial assessment should the RN focus on with this adolescent? A. National percentile of weight and height. B. Frequency of bingeing and purging behaviors. C. Perceptions of family and social relationships. D. School grades and extracurricular activities. C - ANS- Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time? A. Encourage the client to increase fluid intake. B. Obtain the client's serum Vicodin level. C. Observe the client for further narcotic effects. D. Determine the client's reason for attempting suicide. B - ANS- Following surgery, a male client with antisocial personality disorder frequently requests that a specific RN be assigned to is care and is belligerent when another RN is assigned. What action should the charge RN implement? A. Reassure the client that his request will be met whenever possible. B. Advise the client that assignments are not based on the client's request. C. Ask the client to explain why he constantly requests the RN. D. Encourage the client to verbalize his feelings about the RN. B - ANS- When preparing to administer a prescribed medication to a homeless male at a community clinic, the client tells the RN that he usually takes a different dosage. What action should the RN take? A. Tell him to take the medication then verify the dosage at the next healthcare team meeting. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Explain to the client that the dosage has been changed. C - ANS- The nurse orients a female client with depression to the new room on the mental health unit. The client states "It seems strange that I don't have a T.V in my room." Which statement would be best for the RN to provide? A. "You can watch T.V as much as you want outside of your room." B. "Sometimes clients feel like the T.V is sending them messages." C. "It's important to be out of you room and talking to others." D. "Watching T.V is a passive activity and we want you to be active." C - ANS- A client admitted with a closed head injury after a fall has a blood alcohol level of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the RN identify as the priority? A. Give lorazepam (Ativan) PRN for signs of withdrawal. B. Administer disulfiram (Antabuse) immediately. C. Place in a side lying position with head of bed elevated. D. Provide thiamine and folate supplements as prescribed. A - ANS- The RN is completing the admission assessment of an underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the HCP? A. Potassium level of 2.9 mEq/dl. B. Blood pressure of 110/70 mmHg. C. WBCof10,000mm^3. D. Body mass index of 21. D - ANS- The Rn is planning client teaching for a 35-year-old client with alcoholic cirrhosis. Which self-care measure should the RN emphasize for the client's recovery? A. Support group meetings. B. VitaminBandmultivitaminsupplements. C. Diet with adequate calories and protein. D. Alcohol abstinence. B - ANS- A teenager has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the RN to include in the clients plan of care? A. Implement behavioral modification therapy. B. Initiate caloric and nutritional therapy. C. Evaluate the client for low self-esteem. D. Record daily weights and graft trend. D - ANS- While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview? A. The client's comfort level is increased when the RN breaks eye contact to take notes. B. The interview process is enhanced with note taking and allows the client to speak at a normal pace. C. Taking notes during an interview is a legal obligation of examining RN. D. The RN's ability to directly observe the client's non-verbal communication is limited with note taking. C - ANS- A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? a. Client will not demonstrate cross addiction. b. Co-dependent behaviors will be decreased. c. CNS stimulation will be reduced. d. Client's level of consciousness will increase. B - ANS- A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the physician immediately and force fluids. b. Prior to giving the next dose, notify the physician of the symptoms. c. Record the symptoms and continue medication as prescribed. d. Hold the medication and refuse to administer additional amounts of the drug. D - ANS- While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the client Contact, the RN suspects elder abuse. What action should the RN take? A. Report family conversations and anger towards the client when visiting. B. Ask the client specific questions about someone causing the bruising. C. Question the family members and caregiver how the bruising occurred. D. Measure and document size, shape and color of the bruised areas. C - ANS- The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana D - ANS- After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the school's work study program. What action should the RN take? A. Suggest that the student work in the athletic department. B. Determine the parent's opinion of the work assignments. C. Referthestudenttoapsychiatristforfurtherdiscussion. D. Recommend assignment to the receptionist's office. B - ANS- A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to a mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs approximately one month ago. Since hospitalization the client continues to have poor judgment and refuses all medications. What action should the RN take? A. Encourage the client to stay in the hospital so the client does not have to be homeless. B. Provide the client with medication if the client presents an imminent risk to self and others. C. Administer a long acting antipsychotic medication so that the client can be discharged to a shelter. D. Describe to the client treatment options provided at the community mental health clinics. B - ANS- A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? A. When was the last time you drank alcoholic beverage? B. Have you taken any medications for erectile dysfunction? C. Are you having any other sexual dysfunctions or problems? D. Do you have a history of angina or high blood pressure? D - ANS- On admission to the mental health unit, a client diagnosed with schizophrenia tells the RN that he is the son of god. Based on this statement, which intervention should the RN include in this client's plan of care? A. Lead the client by his arm to the seclusion room. B. Ensure the client's environment is safe. C. Schedule activity therapy twice a week. D. Confront his delusion as not consistent with reality. C - ANS- The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes. B - ANS- Which client information indicates the need for the RN to use CAGE questionnaire during the admission interview? A. Client's medication history includes the frequent use of antidepressants. B. Describe self as a social drinker who drinks alcoholic beverages daily. C. Reports difficulties with short term memory since traumatic brain injury. D. Medical history includes that the client was recently sexually assaulted. A - ANS- A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distractherbyofferingherfingerfoods. D. Ignore the client's acting out behavior. D - ANS- A woman is brought to the psychiatric clinic by her husband. He reports that his wife is reluctant to leave home because of what she describes as a fear of open places and crowds. Which nursing problem applies to this client's behavior? A. Ineffective protection to guard self from internal or external threats. B. Risk for injury related to inability to communicate. C. Risk prone health behavior related to self-esteem assault. D. Anxiety related to real or perceived threat to physical integrity. B - ANS- A client is receiving benztropine mesylate (Cogentin) for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the RN should further evaluate the client? A. Decreased bowel movements. B. Presence of a dry mouth. C. Decreasinghandtremors. D. Increased mouth movements. D - ANS- A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate? A. Visual hallucinations. B. Auditory hallucinations. C. Excessive motor activity. D. Delusions of persecution. D - ANS- A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? A. Explain to the client that her behavior invades the rights of the nursing staff. B. Ask the client to explain why she is keeping a detailed record of her nursing care. C. Teach the client strategies to control her obsessive compulsive behavior. D. Encourage the client to express her feelings regarding the upcoming procedure. A - ANS- During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter of fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety. CONTINUES... [Show Less]
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HESI Med Surg Questions And Answers 2022
HESI Med Surg Questions And Answers 2022 The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: ... [Show More] A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base - ANS- D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. 2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes - ANS- B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient. 3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal. - ANS- A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. 4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority assessment would be: A. Airway patency B. Patient comfort C. Incisional drainage D. Blood pressure and heart rate - ANS- A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. 5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which of the following foods should the nurse begin? A. Cola B. Applesauce C. French fries D. White grape juice - ANS- A. ColaWhen learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice to start with. 6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions - ANS- A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum. 7. Which of the following physical assessment findings in a patient with pneumonia best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28 C. Presence of greenish sputum D. Basilar crackles - ANS- D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. 8. Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Fine crackles in all lobes on auscultation C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - ANS- C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area. 9. Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. - ANS- B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed. 10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the following vaccines should the nurse recommend the patient receive? A. S. aureus B. H. influenzae C. Pneumococcal D. Bacille Calmette-Guérin (BCG) - ANS- C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. 11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse? A. "I will increase my food intake to 2400 calories a day to keep my immune system well." B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate." C. "I will seek immediate medical treatment for any upper respiratory infections." D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." - ANS- D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below normal. 12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation C. Orthostatic blood pressures D. Sputum culture and sensitivity - ANS- D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be affected by the administration of antibiotics. 13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on right side. B. Maintaining adequate fluid intake C. Performing postural drainage every 4 hours D. Positioning patient with "good lung down" - ANS- D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation. 14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems. C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. - ANS- C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed. 15. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following? A. Reflex bronchoconstriction B. Ability to filter particles from the air C. Cough reflex D. Mucociliary clearance - ANS- D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections. 16. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A. Continue with ambulation as this is a normal response to activity. B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. - ANS- C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to have supplemental oxygen applied. 17. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode? A. Septic embolus from the knee joint B. Pulmonary embolus from deep vein thrombosis C. New onset of angina pectoris D. Pleural effusion related to positioning in the operating room - ANS- B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain. 18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions should the nurse take first? A. Notify the physician. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen. - ANS- D. Sit the patient up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. 19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the patient about the procedure? A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas. B. This test will use special technology to examine cross sections of the chest with use of a contrast dye. C. This test will use magnetic fields to produce images of the lungs and chest. D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs. - ANS- A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli. 20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes? A. Laryngospasm B. Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema - ANSC. Narrowing of the airwayNarrowing of the airway leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. 21. A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which of the following clinical manifestations might be present as an early symptom during an exacerbation of asthma? A. Anxiety B. Cyanosis C. Hypercapnia D. Bradycardia - ANS- A. Anxiety An early symptom during an asthma attack is anxiety because he is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. 22. The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Observe for signs of diaphoresis B. Allow time to calm the patient C. Monitor the patient for bilateral chest expansion D. Evaluate the use of intercostal muscles - ANS- D. Evaluate the use of intercostal muscles The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. 23. Which of the following positions is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? A. Supine B. Lithotomy C. High-Fowler's D. Reverse Trendelenburg - ANS- C. High-Fowler'sThe patient experiencing an asthma attack should be placed in high-Fowler's position to allow for optimal chest expansion and enlist the aid of gravity during inspiration. 24. The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicates to the nurse that the patient's respiratory status is improving? A. Wheezing becomes louder B. Vesicular breath sounds decrease C. Aerosol bronchodilators stimulate coughing D. The cough remains nonproductive - ANS- A. Wheezing becomes louder The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. As the airways begin to dilate, wheezing gets louder because of better air exchange. 25. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma? A. Anxiety and restlessness B. Effects of medications C. Fear of suffocation D. Work of breathing - ANS- D. Work of breathingWhen the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity. 26. The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment? A. Pulmonary function testing B. Systemic corticosteroids C. Biofeedback therapy D. Intravenous fluids - ANS- B. Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. 27. A patient with acute exacerbation of COPD needs to receive precise amounts of oxygen. Which of the following types of equipment should the nurse prepare to use? A. Venturi mask B. Partial non-rebreather mask C. Oxygen tent D. Nasal cannula - ANS- A. Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered. 28. While teaching a patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to do which of the following? A. Use the flow meter each morning after taking medications to evaluate their effectiveness. B. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled. C. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. D. Increase the doses of the long-term control medication if the peak flow numbers decrease. - ANS- C. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily and when the patient's symptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the meters and should be assessed before and after medications to evaluate their effectiveness. 29. The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions? A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." B. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." C. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible." D. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." - ANS- A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." Dry powder inhalers do not require spacer devices. The patient should be instructed to breathe in deeply and quickly to ensure medicine moves down deeply into lungs. The patient may not taste or sense the medicine going into the lungs. 30. The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following? A. Adrenocortical dysfunction and hyperglycemia B. Elevation of blood glucose and calcium levels C. Oropharyngeal candidiasis and hoarseness D. Hypertension and pulmonary edema - ANS- C. Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose... [Show Less]
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Hesi Fundamentals Practice Test Exam 2022
Hesi Fundamentals Practice Test Exam 2022 An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the ... [Show More] client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. - ANS- To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. - ANS- The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. - ANS- The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. - ANS- The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. - ANS- A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - ANS- To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. - ANS- The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. - ANS- Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. - ANS- The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B). Correct Answer: B A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? - ANS- The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150 Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat. - ANS- (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on a knowledge of physiology and is an unsafe action that may harm the client. Correct Answer: D The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase. - ANS- Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2- ounce servings). The low density lipoproteins (D) need to decrease rather than increase. Correct Answer: C The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot. - ANS- (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. Correct Answer: D An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - ANS- The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. Correct Answer: C A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. - ANS- Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Correct Answer: B The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. - ANS- The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Correct Answer: A... [Show Less]
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