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HESI PN Mobility Exam Review:Mobility HESI: HESI Mobility Exam:HESI LPN COMPREHENSIVE EXIT EXAM:HESI LPN- Entrance Exam:HESI PN LPN Fundamentals Exam and HESI LPN-ADN ENTRANCE EXAM
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HESI PN LPN Fundamentals Exam (100 out of 100) Actual Exam GRADED A)
HESI PN LPN Fundamentals Exam (100 out of 100) Actual Exam GRADED A) A client who is in hospice care complains of increasing amounts of pain. The healthcar... [Show More] e provider prescribes an analgesic every f our hours as needed. Which action should the LPN/LVN 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. A. Give an around-the-clock schedule for administration of analgesics. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand arel/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider C. Infuse 10 percent dextrose and water at 54 ml/hr. When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet. B. Upper torso. In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. B. often follows relocation to new surroundings. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine. B. Fowler's. The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. B. Continue asking the mother questions about the child. When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. C. Many complimentary healing practices can be used in conjunction with conventional practices. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors B. Nutritional history. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours D 72 to 96 hours A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? 20 mg x (5mL/12.5mg) = 8 mL A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? 80 mg x 20 kg = 1,600 1,600/4 x day (q6h) = 400 mg A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Label the pump with a defective equipment sticker. b. Unplug the pump. c. Obtain a replacement pump. d. Notified the biomedical department to fix the pump. b. Unplug the pump. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. c. Place the catheter in a location that is clean and dry for later use new line. d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . - NEVER EVER REUSE THE SUCTION CATHETER A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? a. Supine and low-Fowler's position b. Right lateral in Trendelenburg position c. Side lying with the right side of the chest elevated d. Prone with pillows under the extremities b. Right lateral in Trendelenburg position A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear liquids d. Clear liquids- liquids must be THICK. Clear liquids can cause aspiration. A nurse is providing teaching to a client who has a new med prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Ptosis b. Hematuria c. Urticaria d. Nausea c. Urticaria A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of hte following instructions should the nurse include in the teaching? a. Don sterile gloves prior to puncturing the site b. Puncture site after cleansing and before antiseptic dries. c. Gently squeeze the puncture site until a large droplet of blood forms d. Hold the finger to puncture above the level of the heart c. Gently squeeze the puncture site until a large droplet of blood forms A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . b. I will hold my breath when rising from a sitting position c. I will remove my antiembolic stockings while I am in bed d. I will have my partner help me change positions every 4 hours a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care? a. The Hispanic culture views late adulthood as a negative time in the client's life b. The Hispanic culture identifies the eldest female family member as the decision maker c. The Hispanic culture expects individuals to make their own decisions when death is imminent. d. The Hispanic culture expects adult children to care for older adult parents. b. The Hispanic culture identifies the eldest female family member as the decision maker A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take? a.) Perform deep palpation at the end of the admission assessment b.) Auscultate the client's abdomen before palpation c.) Begin palpation of the abdomen at the site of pain d.) Assess the client's bowel sounds using the bell of the stethoscope b.) Auscultate the client's abdomen before palpation A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water while attempting to void b.) Provide the client a bedpan while lying supine c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily a.) Allow the client to hear running water while attempting to void A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL) a.) "I need to set my hot water heater to 140 degrees Fahrenheit" b.) "I will use the grab bars when getting in and out of the bathtub" c.) "I will apply tape over frayed areas of electrical cords" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates" b.) "I will use the grab bars when getting in and out of the bathtub" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates" A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a.) "I should roll the NPH vial between my hands before drawing it up" b.) "I should draw up the NPH insulin before the regular insulin" c.) "I should inject air into the vial of regular insulin first" d.) "I should wait 10 minutes after mixing the insulin to inject it" a.) "I should roll the NPH vial between my hands before drawing it up" A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider? a.) Place the client in a room away from the nurses‟ station b.) Limit the client's visitors c.) Give the client washcloths to fold d.) Close the door of the client's room c.) Give the client washcloths to fold A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report? a.) Where the client ate his breakfast b.) The times for routine vital sign measurements c.) The exact times the client had visitors d.) The type of transmission-based precautions in place d.) The during a mass casualty event. Which of the following clients is the nurse‟s priority? a. A client who received crush injuries to the chest and abdomen and is expected to die. b. A client who has a 4-inch laceration to the head. c. A client who has partial-thickness and full-thickness burns to his face, neck and chest. d. A client who has a fractured fibula and tibia. c. A client who has partial-thickness and full-thickness burns to his face, neck and chest A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) a. Open doors to client rooms. b. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. Draw shades and close drapes. e. Instruct ambulatory clients in the hallways to return to their rooms. b. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. Draw shades and close drapes. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water. b. Wash the affected area with antibacterial soap. c. Brush the chemical off the skin and clothing. d. Leave the clothing in place until emergency personnel arrive. c. Brush the chemical off the skin and clothing. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? a. Give the client information about immunization against meningitis. b. Tell the client to have a TB skin test every 2 years. c. Determine the client's health risks. d. Teach the client about exercise recommendations. c. Determine the client's health risks. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) a. Help the client see the benefits of their actions. b. Identify the client‟s support systems. c. Suggest and recommend community resources. d. Devise and set goals for the client. e. Teach stress management strategies. a. Help the client see the benefits of their actions. b. Identify the client‟s support systems. c. Suggest and recommend community resources. e. Teach stress management strategies. A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique. b. The client is able to demonstrate the appropriate technique. c. The client states an understanding of the process. d. The client is able to write the steps on a piece of paper. b. The client is able to demonstrate the appropriate technique. A nurse in a provider‟s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor d. Kinesthetic b. Affective A nurse is giving a presentation about accident to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) a. Store toxic agents in locked cabinets. b. Keep toilet seats up. c. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. e. Make sure balloons are fully inflated. a. Store toxic agents in locked cabinets. c. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. A nurse is counselling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? a. "I spent my whole life dreaming about retirement, and now I wish I had my job back." b. "It‟s been so stressful for me to have to depend on my child to help around the house." c. "I just heard my friend Al died. That's the third one in 3 months." d. "I keep forgetting which medications I have taken during the day." d. "I keep forgetting which medications I have taken during the day." A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skill of the physical examination process should the nurse perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion b. Auscultation A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. what is the client's pulse deficit (per minutes)? 16 A nurse in a provider‟s office is preparing to assess a client‟s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous macules on the face darker than the surrounding skin color a. Capillary refill less than 3 seconds d. Thick skin on the soles of the feet e. Numerous macules on the face darker than the surrounding skin color A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? 0.3mL A nurse is preparing to administer lactated Ringer‟s (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? 400mL/hr A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? 83 gtt/min A nurse is preparing to administer metoprolol 200-mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? 2 tablets A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30-mg/mL. How many mL should the nurse administer per dose? 0.5 mL A nur [Show Less]
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HESI Exit V2 (100 out of 100) Questions and Answers (100% Verified Answers)
HESI Exit V2 (100 out of 100) Questions and Answers (100% Verified Answers)The LPN/LVN is preparing to ambulate a postoperative client after cardiac surger... [Show More] y. The nurse plans to do which to enable the client to best tolerate the ambulation? Premedicate the client with an ana lgesic before ambulating. A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? Check the client status and lead placement. The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? Status of airway The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? Limiting movement and abduction of the right arm A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life-threatening complication of this condition is which? Pulmonary embolism A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? Smoking history The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? "Moving to a warmer climate should help." A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? Crackles The LPN/LVN is collecting data on a client with a diagnosis of right- sided heart failure. The nurse should expect to note which specific characteristic of this condition? Dependent edema The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? Normal, caused by increased blood flow through the leg A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may stimulate which? Vagus nerve to slow the heart rate A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection? Staphylococcal infection client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? The boot has been applied too tightly A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? Variant angina The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? Hyperactive bowel sounds in the area An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? Denial A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? Prior reaction to contrast media A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? Caffeine An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non cardiac problem? "Does the pain get worse when you breathe in?" A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? Bathroom privileges and self-care activities The LPN/LVN is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? Surgical tourniquet A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? Bed rest, with elevation of the affected extremity A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? With the foot of the bed elevated The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? Bilberry The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level? 90 mg/dL A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first? Assist the client to sit or lie down. The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? Reviews the intake and output records for the last 2 days A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure? Digoxin (Lanoxin) 1. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? Restricting the client's potassium intake A client has an inoperabl [Show Less]
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HESI LPN- Entrance Exam (100% Verified Questions & Answers) Already GRADED A
2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limits a... [Show More] nd her sugar is 325 mg/dL. what intervention should the nurse implement first? administer regular insulin per sliding scale A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? nipple feedings with glucose water a 3 year-old admitted with fever of unknown (FUO) has begun vomiting in the past half hour. The child's temp. is 101.8F, and the last does of antipyretic medication was given 5 hours ago. the child has prescriptions of acetaminophen (Tylenol) 160 mg per 5 mL elixir or 16o mg suppositories PRN fever or pain. what action should the nurse take at this time? make the child NPO and hold all mediations until the vomiting has stopped. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. what action should the nurse take? give the client crackers and milk a 6-month child with bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing respiratory distress? A high pitched cry. An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide? rice total number of confirmed pregnancies regardless of the outcome Gravida number of births after 20 weeks Para pregnant for the first time primigravida a 26 year old gravida-4, para-0 had a spontaneous abortion at 9 weeks gestation. at one house post dilation and curettage (D&C) the nurse assess the vital signs and vaginal bleeding. the client begins to cry softly. how should the nurse intervene? express sorrow for the clients grief and offer to sit with her. A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? they can have intercourse when the episiotomy is healed and the lochial flow has stopped 36 hours after delivery, the nurse determines a clients fundus is just above the umbilicus and displaced to the right of midline. what action should the nurse take first? palpate the bladder for distention a 60 year old client with cancer of the liver is in hepatic coma and unresponsive. what should the nurse say to family members were inquiring about the condition of their loved one? "Your loved ones condition is very critical, and there has been no response in the last 24 hours" a 67 year old woman who lives alone tripped on a rug in her home and fractured her right hip. the nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women. osteoporosis resulting from hormonal changes. a 75 year old male client with Alzheimer disease is admitted to an extended care facility. what intervention should the nurse include into the his clients Nursing care plan? plan to have the same nursing staff provide care for the client whenever possible. an 82-year old client is admitted to the hospital with a fractured right hip. following surgical repair, a footboard is placed at the clients feet. what is the reason the nurse will offer concerning the footboard? footboard is used to prevent foot drop. An adult female client is admitted to the psychiatric unit with diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement? ask the client if she has had any recent thoughts of harming herself. an adult m [Show Less]
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HESI Mobility Exam (GRADED A) Questions & Answers (Download To Score An A)
reduce Mr. Mathis' anxiety during the admission process? Explain the room environment to Mr. and Mrs. Mathis. When care is planned for Mr. Mathis, which nu... [Show More] rsing diagnosis should take priority? Impaired physical mobility. Which goal is correct for Mr. Mathis' diagnosis of impaired physical mobility? The client will sit in the chair for each meal beginning on the day of admission. Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in Mr. Mathis' legs? -Teach Mr. Mathis to dorsal flex and plantar flex his feet while in the bed and chair. -Instruct Mr. Mathis to wear sequential compression stockings. -Explain that enoxaparin injections will be administered routinely. The nurse is observing a student nurse perform a peripheral assessment on Mr. Mathis. Which action requires the nurse to intervene? Assessing the Homan's sign in bilateral extremities. The HCP has prescribed thigh-high antiembolic hose for Mr. Mathis. The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP? Unilateral calf edema. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) for positioning Mr. Mathis' legs? Use two pillows and place one lengthwise under each calf. Which nursing diagnosis best applies to Mr. Mathis' nutritional assessment? Imbalanced nutrition: less than body requirements. The nurse instructs Mr. Mathis to increase his intake of which foods to prevent a decrease in bone density? Calcium rich foods. Which foods should the nurse encourage? Milk, oatmeal, and an orange. How should the nurse teach the UAP to position the chair to ensure a safe transfer? Position the chair at a 45 degree angle to the bed on Mr. Mathis' left side. What is the priority nursing action? Gently lower Mr. Mathis to the floor. How does the UAP assess for orthostatic hypotension? Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. Which action should the nurse implement? Teach Mr. Mathis to take ten deep breaths an hour while awake. What is the best response by the nurse? Help the client perform the correct technique for deep breathing exercises. The nurse explains to the UAP that the Braden Scale is used to measure which client parameter? Risk for pressure sores. Which nursing action should be included in the plan? Reposition Mr. Mathis in bed from supine to a 30 degree side-lying position every 2 hours. Before giving the initial dose, which action should the nurse take first? Ask Mr. Mathis if he is aware of any allergies to medications. During the course of antibiotic therapy, the amount of normal body flora is reduced in the gastrointestinal tract. Which client instruction is important to prevent the complications due to reduced body flora? Add buttermilk or active culture yogurt to the diet daily. Which is the best approach for the nurse to prevent muscle atrophy? Teach Mr. Mathis to perform exercises such as gluteal sets and quadriceps sets five times every 2 hours while awake. In planning morning care for Mr. Mathis, what action should the nurse take? Ask the UAP to assist Mr. Mathis in taking a complete bed bath. Which action should the nurse implement in response to Mr. Mathis' concern? Offer to obtain a bedside commode for Mr. Mathis. The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which dietary selection should the nurse encourage Mr. Mathis to eat? Chicken Caesar salad with a whole wheat roll and skim milk. Which is the best therapeutic approach for the nurse to engage in conversation with Mr. Mathis? "I sense a spiritual strength about you." Mr. Mathis replies, "My wife is my rock. She reads the Bible to me every morning." His eyes become teary. What should the nurse do to provide for Mr. Mathis' spiritual needs? Place a sign on the door to allow Mr. Mathis some quiet time in the mornings. Mr. Mathis says he has faith that God will be with him through this challenge to regain his health. What nursing diagnosis should be included in the plan of care? Readiness for enhanced spiritual well being. Show Less [Show Less]
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HESI PN Mobility Exam Review Questions & Answers (100% CORRECT SOLUTIONS)
s and tissues? producing blood cells A patient with severe osteoarthritis is having a surgical hip replacement that is possible because the hip join found ... [Show More] in the hip is? ball and socket A nurse is teach an older adult about activity. What information should be included in the teaching? importance of regular exercise Charles Yu is a 15 year old pt who is complaining of left ankle pain from being tackled while playing football. He's asking the nurse what tests needs to be done to determine if its a sprain or a break? xray The nurse caring for a immobile malnourished patient recognizes the best treatment to protect the patients integument is to? turning the patient every 2 hours Which of the following patients would you expect to have decreased activity? a) 80 years old b) obese Which of the following posture deformities might be assessed in a teenager? scoliosis A nurse is assessing the muscles of an older adult what would be assessed? mass, tone, strength A 32 year old male construction work presents to the ER with complaints of headache, abdominal cramps, nausea, light headiness and extreme fatigue. The patient states that he started feeling ill at the job. the nurse gathered the following data: temp 99.8, pulse 96, RR 30, BP 136/72. The patients skin is cold and clammy, and the patient is having difficulty answering questions. He tells the nurse he is never sick and he's never been in the hospital. What additional information would help determine if he is experiencing heat exhaustion or hyperthermia? the type of work he is doing, his food and fluid intake, and the environmental temperature What term is used to document impaired muscle strength or weakness? Paresis The nurse is helping a patient to perform leg exercises after surgery to prevent phlebitis, what type of muscle is the patient using to do these exercises? skeletal What body system benefits the most from aerobic exercises? cardiovascular system What action is most important in limiting the nurses risk of back injuries? good body mechanics at all times. The nurse is instructing the patient about the need to replace fluid before during and after exercise in order to avoid dehydration. She should teach the patient the amount of fluids to consume on the basis of? the intensity of exercise and the environmental temperature A nurse is providing home health care for an older woman with severe osteopororis complications of this disease process should the nurse consider and the plan of care? fractures Bed rest with results in mobility affects the whole body . What is one affect of the musculoskeletal system? increased risk for contractures A 75 year old woman recently diagnosed with osteoperorsis asked the nurse to explain her health problems. Which of the following is the correct explanation, osteoporosis is? loss of bone density that increases the risk of fractures When caring for the 75 year old woman, which of the following is the most important treatment, Ms Lemay will? start a weight bearing exercise program 6 months has passed since the nurse discussed osteoporosis with Ms Lemay, the nurse knew her teaching was affected because Ms Lemay? participated in a low impact exercise program at the YMCA Which of the following is true of ancilosis? consolation and immobilization of a joint In order to achieve balance and body mass must be distributed around which point? center of gravity Miss Fin has been admitted to the hospital unit with a medical diagnosis of chronic obstructive pulmonary disease, He is on oxygen of 2 liters per minute by nasal cannula, which position technique should will best assist him with his breathing? Fowler's position A nurse has been asked to design an exercise program for Jim latte. The goal of the exercise program is to increase his muscular strength and endurance. The exercise program that would specifically focus on meeting this goal is? resistance training, such as weight lifting A nurse caring for a 25 year old male quadriplegic patient, which of the following treatments would the nurse perform to relieve the risk of joint fractures and promote joint mobility? passive range of motion A middle aged man walks 2 miles each day, what type of exercise is he getting? Isotonic Mr Johnson is a 78 year old patient admitted to the hospital from a fall at home which resulted in a left hip fracture. Yesterday he underwent an open reduction and an internal replacement of his left hip. Mr Johnson has right sided weakness, due to prior CVA and also has a emphazima. He is weak and generally neat conditioned . Mr Johnson is to begin ambulating with a walker and must avoid weight bearing on his left lower extremity. The best intervention is to aide Mr Johnson to utilize the walker successfully is to teach him ? arm exercises Based on the information above, why is it important to teach and role model proper body mechanics ? to promote health and prevent illness The most appropriate goal for Mr Johnson would be is to? Remain from injury or fall through out his hospital stay Mr Wayne has been on a strict bed rest for 5 days. During this time he has not had a BM and he states he is feeling bloated and has never had problems with his bowels before. While discussing this with my Wayne, the nurse should explain that? immobility often causes constipation A nursing diagnosis that best address Mr Waynes problem on constipation is related to? immobility A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What are the goals of the nurse in teaching plan? Want to minimize the stress on the wifes joints Mrs Taylor, a 32 year old underwent an appendectomy yesterday. She feels a little sore but has no complaints of weakness. The nurses help her ambulate in the hallway, suddenly she states I feel dizzy and weak as her knees begin to buckle. The nurse best action at this time is to? assist her to slide down our leg to guide her to a sitting or lying down position A nurse recommends a regular exercise for a patient who has difficulty sleeping. The patient asks how this will help, how should the nurse respond? Good sleep is a benefit of regular exercise A nurse is assessing the vital signs for a patient who has excercised faithfully for several years. What vital signs findings would we expect? decreased pulse and BP A patient at a community health center discussing a planned exercise program,, the patient is being treated for cardiovascular disease. What would the nurse recommend? See your doctor first Of the following guidelines, which would not be recommended to a person who has sustained an orthopedic injury during exercise? RICE (rest, ice, compression, elevation) Immobility affects the body in many ways, what is one serious affect of immobility on the cardiovascular system? increases your cardiac work load Mrs Turner is a 56 year old woman who sustained a spinal injury during a motorvehicle accident. The correct method for turning Mrs Turner in bed is? requesting assistance of additional staff to perform the log rolling An immobile person has a decreased movement of respiratory secretions. What conditions are at a greater risk or result? respiratory tract infection Laboratory results for a patient shows a high level of urinary calcium, what does this pose to the patient? kidney stones What would the most efficient time for the nurse to assess the gate of an ambulatory patient? as soon as they walk in the room A nurse is assessing the activity level of a 5 month old baby what normal findings would be assessed? ability to sit up without support and maintain good head control A nurse is caring for a comatose patient what could happen to the feet if they are unsupported in the dorsiflex position? plantar flexion and foot drop A nurse is evaluating Mr Thompson, a 74 year old male patient for an exercise program to be offered at a local hospital. During the evaluation, the nurse gets the following vital signs: pulse 72, RR 16, BP 132/70, After a minute of moderate running on the treadmill, Mr. Thompson becomes very short of breath and states "I have to stop, I can't do this anymore". The nurse measured his vital signs again, pulse 120, RR 40, BP 172/98. She instructs Mr Thompson to rest and finds it takes 15 minutes for the vital signs to return to baseline. The nurse should recognize this as a symptom associated to? Limited activity tolerance A nurse is ambulating a patient who has had a stroke. The patient has paresis on the right side. Where would the nurse stand to walk the patient? Stand on weak side and a little bit behind Dale Smith, 16 year old was hospitalized 2 weeks ago. He has been bed ridden due to crushed pelvis. Today the parents tell the nurse he is just staring off into space, he wont talk to us, they also state Dale won't listen to his music CD's, watch TV or play his video game for 2 days. The best response the nurse can make is? He's had a major injury and his mobility can cause feelings of isolation and depression A college student fell and sprained his right ankle, the student health physician recommends the student to use crutches to facilitate healing. Which of the following would the nurse teach the student? support should be in the arms and the hands A nurse is following a plan of care for passive range of motion exercises, what specifics would be included on the plan? ROM twice a day, for 2-5 times Nurses should always use body mechanics guidelines when providing care and teaching their patients about safe body movement. Which of the following are included in the body mechanic guidelines? select all that apply a) Stand in good alignment b) use a wide base of support c) keep objects close to your body Show Less [Show Less]
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