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HESI RN EXIT EXAM 2021
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HESI EXIT EXAM V1
HESI EXIT Exam V1 with Answers Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A client has al... [Show More] tered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? The nurse is discussing with a group of students the disease Kawasaki. What statement A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today’s temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal 30. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s first action should be to A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? The health care provider order reads “aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate.” The pH of the aspirate is 10. Which action should the nurse take? To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response? A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A nurse is assessing several clients in a long-term health care facility. Which client is at the highest risk for the development of decubitus ulcers? Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority? After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A client with diarrhea should avoid which of the following? Which statement best describes the effects of immobility in children? A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client’s comfort? After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to An 85-year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A 20-year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What is the nurse’s best response? The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? Which approach is the best way to prevent infections when providing care to clients in the home setting? A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because 113. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, “I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again.” The nurse should respond by saying 116. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements? A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that 118. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69-year-old surgical client to ambulate for the first time? The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A client tells the nurse, “I have something very important to tell you if you promise not to tell.” The best response by the nurse is Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague “I wonder if he has any idea how ridiculous he looks — he’s a grown man!” The nurse’s response is an example of A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client’s tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A client diagnosed with anorexia nervosa states after lunch, “I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry.” The client’s comments indicate that the client is likely experiencing A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states “everyone’s life is in God’s hands.” The next action for the nurse to take is to A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied by a parent is seen at a community health center a day later. After the initial assessment, the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A client says, “It’s raining outside and it’s raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I’ve never been to Ireland.” The nurse would document this behavior as During the change-of-shift report, the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A nurse in the emergency department suspects domestic violence as the cause of a client’s injuries. What action should the nurse take first? Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? Which statement by the client during the initial assessment in the emergency department is most indicative for suspected domestic violence? A nurse states: “I dislike caring for African-American clients because they are all so hostile.” The nurse’s statement is an example of Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? The nurse manager informs the nursing staff at the morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is The nurse is teaching about non-steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? The nurse admits a 2-year-old child who has had a seizure. Which of the following statement by the child’s parent would be important in determining the etiology of the seizure? A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child’s health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? The nurse is preparing to administer a tube feeding to a postoperative client. To accurately assess for a gastrostomy tube placement, the priority is to [Show Less]
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HESI EXIT EXAM V2
HESI EXIT Exam V2 – Question and Answers The nurse knows that which statement by the mother indicates that the mother understands safety precautions w... [Show More] ith her four-month-old infant and her 4-year-old child? Upon completing the admission documents, the nurse learns that the 87-year-old client does not have an advance directive. What action should the nurse take? A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to Which of these children at the site of a disaster at a child daycare center would the triage nurse put in the “treat last” category? When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to The nurse is having difficulty reading the health care provider’s written order that was written right before the shift change. What action should be taken? An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? Following the change-of-shift report on an orthopedic unit, which client should the nurse see first? A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client’s condition? A client enters the emergency department unconscious via ambulance from the client’s workplace. What document should be given priority to guide the direction of care for this client? The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? As the nurse takes a history of a 3-year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to unlicensed assistive personnel (UAP)? The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A client has been admitted to the Coronary Care Unit with myocardial infarction. Which nursing diagnosis should have priority? The provisions of the law for the Americans with Disabilities Act require nurse managers to A 42-year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his non-compliance? A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? Which statement best describes time management strategies applied to the role of a nurse manager? The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider’s complaints. The nurse manager’s next action should be to A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant’s inability to An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse’s priority assessment should be The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? Which activity can the RN ask unlicensed assistive personnel (UAP) to perform? A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is When interviewing the parents of a child with asthma, it is most important to gather what information about the child’s environment? An 80-year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A 3 year-old child is brought to the clinic by his grandmother to be seen for “scratching his bottom and wetting the bed at night.” Based on these complaints, the nurse would initially assess for which problem? A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, “I will receive tissue from… The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer’s disease with family members. Which of these interventions would be most helpful at this time? The nurse is teaching a client with non-insulin-dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby’s record and expect which immunization to be most associated to the findings in the infant? The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to The nurse planning care for a 12 year-old child with sickle cell disease in a vasoocclusive crisis of the elbow should include which one of the following as a priority? As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A client has been tentatively diagnosed with Graves’ disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A 2 year-old child is brought to the health care provider’s office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? The nurse is teaching an elderly client how to use MDI’s (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse’s best recommendation to improve delivery of the medication? Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client’s history indicate a potential hazard for this test? The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A client with a documented pulmonary embolism has the following arterial blood gases: PO2 – 70 mm hg, PCO2 – 32 mm hg, pH – 7.45, SaO2 – 87%, HCO3 – 22. Based on this data, what is the first nursing action? A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A client is recovering from a thyroidectomy. While monitoring the client’s initial post operative condition, which of the following should the nurse report immediately? A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? The nurse is assessing a 55-year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? An 8-year-old client is admitted to the hospital for surgery. The child’s parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? The nurse is reinforcing teaching to a 24-year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute.What should the nurse do first? What finding signifies that children have attained the stage of concrete operations (Piaget)? The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to The mother of a 2 year-old hospitalized child asks the nurse’s advice about the child’s screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit, the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? During the check up of a 2 month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby’s forehead and eyelid has not gone away. What is an appropriate response by the nurse? A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? The nurse is teaching a client newly diagnosed with asthma how to use the metereddose inhaler (MDI). The client asks when they will know the canister is empty. The best response is While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A 7-month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? An 80-year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? The nurse caring for a 9-year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? The nurse notes that a 2-year-old child recovering from a tonsillectomy has a temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child’s mother reports that the child “feels very warm” to touch. The first action by the nurse should be to 119. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? The parents of a 4-year-old hospitalized child tell the nurse, “We are leaving now and will be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? Therapeutic nurse-client interaction occurs when the nurse A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A female client is admitted for a breast biopsy. She says, tearfully to the nurse, “If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.” The nurse’s best response would be which of these statements? When teaching suicide prevention to the parents of a 15-year-old who recently attempted suicide, the nurse describes the following behavioral cue The nurse is caring for a 4-year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours? The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to Which statement made by a client indicates to the nurse that he may have a thought disorder? The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect? A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client’s attire? Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts “You think you’re so perfect and pure and good.” An appropriate response for the nurse is An important goal in the development of a therapeutic inpatient milieu is to The nurse’s primary intervention for a client who is experiencing a panic attack is to Which intervention best demonstrates the nurse’s sensitivity to a 16-year old’s appropriate need for autonomy? A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A depressed client in an assisted living facility tells the nurse that “life isn’t worth living anymore.” What is the best response to this statement? A client, recovering from alcoholism, asks the nurse, “What can I do when I start recognizing relapse triggers within myself?” How might the nurse best respond? A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states,” This is not my baby, and I do not want it.” The nurse’s best response is Which of the following times is a depressed client at the highest risk for attempting suicide? A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client? A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? Which statements by the client would indicate to the nurse an understanding of the issues with end-stage renal disease? The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? A 2-year-old child is brought to the emergency department at 2:00 in the afternoon.The mother states: “My child has not had a wet diaper all day.” The nurse finds the child is pale with a heart rate of What assessment data should the nurse obtain next? [Show Less]
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HESI EXIT EXAM V3
HESI EXIT Exam V3 – Question with Answers A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures pri... [Show More] or to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? The nurse is planning care for an 18 month-old child. Which action should be included in the child’s care? A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that An appropriate goal for a client with anxiety would be to While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best? While caring for a client, the nurse notes a pulsating mass in the client’s peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? The family of a 6 year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children? The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A client states, “People think I’m no good, you know what I mean?” Which of these responses would be most therapeutic? A client being treated for hypertension returns to the community clinic for follow up. The client says, “I know these pills are important, but I just can’t take these water pills anymore. I drive a truck for a living, and I can’t be stopping every 20 minutes to go to the bathroom.” Which of these is the best nursing diagnosis? When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? When observing 4-year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? When teaching a 10-year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents’ comments? When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? A 52 year-old client is being transfused with one unit of packed cells. A half-hour after the transfusion was initiated, the client complains of chills and headaches. Which action should the nurse implement first? An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse’s immediate attention? A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? The nurse prepares to administer eye drops to a 6-year-old child. Which of these demonstrates the correct method for the instillation of eye drops? A depressed client is experiencing severe insomnia. The health care provider orders Trazadone (Desyrel). The nurse tells the client to expect A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client’s symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? The nurse is planning to administer otic drops to a 6-year-old child. Which of the following is the correct procedure? A 1-year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? Today’s prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention? The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? Which of the following classifications of medications would be most often used for clients with schizophrenia? A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse? A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ? The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? The nurse is caring for a client with renal calculi. Which health care provider order would be a priority? A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching? The nurse is teaching the administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first? A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority? The nurse is caring for a client with Parkinson’s disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? The nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation is correct? The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection? The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider’s order? The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient The nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child’s parents? The nurse is caring for an 81 year-old client with colorectal cancer. The client’s pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority? When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia? The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized? The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate? An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? Which client data should the nurse act upon when a home health aide calls the nurse from the client’s home to report these items? A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection? A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? Which one of these tasks can be safely delegated to a PN? The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? Which of these clients would be most appropriate to assign to a PN? A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? Which of these clients would be appropriate to assign to a PN? Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence? An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? The RN delegates the task of taking vital signs of all the clients on the medical- surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate? As the RN responsible for a client in isolation, which can be delegated to the PN? The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate? The nurse is caring for a 16 year-old client with femur fracture14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client is at risk for The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? On admission to the ambulatory surgery unit, the nurse notices the client’s painted finger nails. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate? The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that When taking the client’s blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first? The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should A client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce that potassium levels will be decreased by A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate? The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action? The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an opening for four-5 inches and no urine is obtained. The most probable reason for this is that After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. The appropriate response by the nurse is The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action? A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should first The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication? In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube? The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter? A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? To obtain data for the nursing assessment, the nurse should: The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse? The nurse is teaching diet restrictions for a client with Addison’s disease. The client would indicate an understanding of the diet by stating A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take? During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client’s knees. The best action for the nurse to take is to A client with considerable pain asks: “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, “I’d forget about it as those weird non-Western treatments can be scary.” The nurse’s response is an example of A 9-year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child’s greatest fear? A nurse arranges for an interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to The nurse is planning care for a 2-year-old hospitalized child. Which of the following will produces the most stress at this age? Which statement describes strategies that help build personal power in an organization? A 24-year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse’s best response would be which of these? Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child’s neck. The parents refuse. The nurse understands that the parents may be concerned about Which statement describes the use of a decision grid for decision making? The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown? Dual diagnosis indicates that there is a substance abuse problem as well as a Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy? The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis? The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? What is the major developmental task that the mother must accomplish during the first trimester of pregnancy? During the two-month well-baby visit, the mother complains that formula seems to stick to her baby’s mouth and tongue. Which of the following would provide the most valuable nursing assessment? After successful alcohol detoxification, a client remarked to a friend, “I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink.” The client’s belief that he needs alcohol indicates his dependence is primarily A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain? A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test: The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity? A mother calls the clinic, concerned that her 5 week-old infant is “sleeping more than her brother did.” What is the best initial response? The nurse is caring for a client with COPD who becomes dyspneic. The nurse should The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse’s immediate attention? A 6-year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse’s best response to this request? Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage? A nurse aide is taking care of a 2-year-old child with Wilm’s tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements? A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is The nurse sees a substance-abusing client occasionally in the outpatient clinic. In evaluating the client’s progress, the nurse recognizes that the most revealing resistant behavior is A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor? Parents of a 6 month old breastfed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first? A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to A victim of domestic violence states, “If I were better, I would not have been beaten.” Which feeling best describes what the victim may be experiencing? A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being “too sick to return to work.” The client is diagnosed as having a somatoform disorder. In formulating a plan of care, the nurse must consider that the client’s behavior Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? The nurse is planning care for a client during the acute phase of a sickle cell vaso- occlusive crisis. Which of the following actions would be most appropriate? Following surgery for placement of a ventriculoperitoneal (VP) shunt as a treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship? A child is sent to the school nurse by a teacher who has a written note that Fifth’s disease is suspected. Which characteristic would the nurse expect to find? Delirium tremens could best be described as An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem? The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68-year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur? While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior? The nurse should initiate discharge planning for a client The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client? When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention? [Show Less]
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HESI EXIT EXAM V4
HESI EXIT Exam V4 – Question and Answers The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is ap... [Show More] propriate for this child? The nurse is assessing a healthy child at the 2 year check-up. Which of the following should the nurse report immediately to the health care provider? The parents of a 2-year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? The nurse is assessing the mental status of a client admitted with a possible organic brain disorder. Which of these questions will best assess the function of the client’s recent memory? In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? What is the most important consideration when teaching parents how to reduce risks in the home? A 35-year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should While caring for a toddler with croup, which initial sign of croup requires the nurse’s immediate attention? A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A recovering alcoholic asked the nurse, “Will it be ok for me to just drink at special family gatherings?” Which initial response by the nurse would be best? In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A postpartum mother is unwilling to allow the father to participate in the newborn’s care, although he is interested in doing so. She states, “I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers.” The nurse’s initial intervention should be what focus? A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A Hispanic client in the postpartum period refuses the hospital food because it is “cold.” The best initial action by the nurse is to The father of an 8 month-old infant asks the nurse if his infant’s vocalizations are normal for his age. Which of the following would the nurse expect at this age? The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and An eighteen month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of A client who has been drinking for five years states that he drinks when he gets upset about “things” such as being unemployed or feeling like life is not leading anywhere. The nurse understands that the client is using alcohol as a way to deal with The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M. and ending at 10:01 A.M. Another begins at 10:15 The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate finding? During the evaluation phase for a client, the nurse should focus on The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? The nurse is talking with a client. The client abruptly says to the nurse, “The moon is full. Astronauts walk on the moon. Walking is a good health habit.” The client’s behavior most likely indicates A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is The nurse enters a 2 year-old child’s hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, “No!”. What would be the most appropriate next action? A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should A nurse is assigned to a client who is a new admission for the treatment of a frontal lobe brain tumor. Which history offered by the family members would be anticipated by the nurse as associated with the diagnosis and communicated? The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse’s best response about the purpose of the Denver? The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and concerned about the child’s reaction to impending surgery. Which nursing intervention would be best to prepare the child? The nurse, assisting in applying a cast to a client with a broken arm, knows that Based on principles of teaching and learning, what is the best initial approach to pre- op teaching for a client scheduled for coronary artery bypass? A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child? The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? The nurse assesses a client who has been re-admitted to the psychiatric in-patient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment? The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care? A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning? During an examination of a 2 year-old child with a tentative diagnosis of Wilm’s tumor, the nurse would be most concerned about which statement by the mother? What is the most important aspect to include when developing a home care plan for a client with severe arthritis? A mother asks the nurse if she should be concerned about the tendency of her child to stutter. What assessment data will be most useful in counseling the parent? A pre-term newborn is to be fed breast milk through nasogastric tube. Why is breast milk preferred over formula for premature infants? Which of the following nursing assessments in an infant is most valuable in identifying serious visual defects? A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A 2 year-old child has just been diagnosed with cystic fibrosis. The child’s father asks the nurse “What is our major concern now, and what will we have to deal with in the future?” Which of the following is the best response? Which type of accidental poisoning would the nurse expect to occur in children under age 6? A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to “see old buddies.” The nurse understands that the client’s behavior is a warning sign to indicate that the client may be A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client’s partner asked to stay a few hours beyond the visiting time, in the client’s private room. What would be the best response by the nurse demonstrating emotional support for the client? At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform? The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? At the geriatric day care program a client is crying and repeating “I want to go home. Call my daddy to come for me.” The nurse should A victim of domestic violence states to the nurse, “If only I could change and be how my companion wants me to be, I know things would be different.” Which would be the best response by the nurse? A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn’t really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? Post-procedure nursing interventions for electroconvulsive therapy include The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? The mother of a 15 month-old child asks the nurse to explain her child’s lab results and how they show her child has iron deficiency anemia. The nurse’s best response is In a child with suspected coarctation of the aorta, the nurse would expect to find At the day treatment center a client diagnosed with Schizophrenia – Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client’s behavior most likely indicates A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to When teaching adolescents about sexually transmitted diseases, what should the nurse emphasize that is the most common infection? First-time parents bring their 5 day-old infant to the pediatrician’s office because they are extremely concerned about its breathing pattern. The nurse assesses the baby and finds that the breath sounds are clear with equal chest expansion. The respiratory rate is 38-42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect in assessing this client? Clients taking which of the following drugs are at risk for depression? When a client is having a general tonic clonic seizure, the nurse should 101 After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, “My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t want my husband to leave me.” Which response by the nurse would assist the client? A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority? The nurse is caring for a post-myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider? A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? The nurse walks into a client’s room and finds the client lying still and silent on the floor. The nurse should first The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: “The manager makes all decisions and rarely asks for our input.” The best description of the nurse manager’s management style is A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse “I’ve made some decisions about my life.” What should be the nurse’s initial response? The nurse caring for a 14-year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? When an autistic client begins to eat with her hands, the nurse can best handle the problem by In assessing the healing of a client’s wound during a home visit, which of the following is the best indicator of good healing? Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings? In order to enhance a client’s response to medication for chest pain from acute angina, the nurse should emphasize The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? Clients with mitral stenosis would likely manifest findings associated with congestion in the The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? What is the best way for the nurse to accomplish a health history on a 14-year-old client? What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? While planning care for a preschool-aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states “I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax.” The client is using which defense mechanism? One reason that domestic violence remains extensively undetected is A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 20-40 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization? Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the health care provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse’s best response would be The nursing care plan for a client with decreased adrenal function should include The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)? The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? During the use of an interpreter to teach a client about a procedure to do in the home the nurse should take which approach? A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority? A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions? A nurse who is evaluating a mentally retarded 2-year-old in a clinic should stress which goal when talking to the child’s mother? The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the client with nutrition needs, the nurse should The nurse is assessing a 2-year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is Upon examining the mouth of a 3-year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones? A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? [Show Less]
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HESI EXIT EXAM V5
HESI EXIT Exam V5 with Answers The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursin... [Show More] g diagnosis? While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age? The nurse enters the room as a 3-year-old is having a generalized seizure. Which intervention should the nurse do first? The nurse is reviewing a depressed client’s history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A client has just returned to the medical-surgical unit following segmental lung resection. After assessing the client, the first nursing action would be to While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task? Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children? The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A 23-year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at the highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A priority goal of involuntary hospitalization of the severely mentally ill client is The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A 57-year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? Following mitral valve replacement surgery, a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parents remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse? A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale? The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect? Which of the following measures would be appropriate for the nurse to teach the parent of a nine-month-old infant about diaper dermatitis? A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “no” and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? Which behavioral characteristic describes the domestic abuser? Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”? While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action? An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness? In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action? The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be 64 In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has A client was admitted with a diagnosis of pneumonia. When auscultating the client’s breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess The nurse is providing instructions for a client with asthma who is sensitive to house dust mites. Which information about the prevention of asthma episodes would be the most helpful to include during the teaching? A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate? The nurse is caring for a client with Parkinson’s disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? The nurse is assessing a 12-year-old who has Hemophilia A. Which finding would the nurse anticipate? The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority? The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model? The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal? The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? The nurse would expect which eating disorder to have the greatest fluctuations in potassium? When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? The nurse is planning care for a client with increased intracranial pressure. The best position for this client is While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality? The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse’s immediate attention? You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which indicates further teaching may be needed by the client? When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport? On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding? A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding? A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver? A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client’s obstetric history by the nurse? On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client? A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client? While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication? While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately? The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed (“knocked out”). After recovering the tooth, the initial response should be to The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? During the care of a client with Legionnaire’s disease, which finding would require the nurse’s immediate attention? A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a The nurse is assigned to a client with Parkinson’s disease. Which findings would the nurse anticipate? Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults? A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select? The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care? A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the “evil eye.” The nurse should communicate to other personnel that the appropriate approach is to A client is admitted for COPD. Which finding would require the nurse’s immediate attention? A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information? A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager do initially? The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information? A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective? A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart? The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager? The nurse would teach a client with Raynaud’s phenomenon that it is most important to The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the “unfreezing” phase of change. With this approach and phase the nurse manager should Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older? At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best? A client comes into the community health center upset and crying stating “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: “Pheochromocytoma.” Which response should the nurse state initially? A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs? The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to Which finding would be the most characteristic of an acute episode of reactive airway disease? Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager? An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? The nurse uses the DRG (Diagnosis Related Group) manual to The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension and is 22 weeks in to a pregnancy. Which of these lab reports sent to the clinic need to be called to the teens health care provider within the next hour? The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins? The nurse is teaching a 27 year-old client with asthma about the management of their therapeutic regime. Which statement would indicate the need for additional instruction? While caring for a child with Reye’s Syndrome, the nurse should give which action the highest priority? A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care? A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider? Which of these clients would the triage nurse request for the health care provider to examine immediately? An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:”When can the tube can be used for feeding?” The nurse’s best response would be which of these comments? A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider’s diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed? The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid? A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy? A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager’s best response is to The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention? A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure? The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity? The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? [Show Less]
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HESI EXIT EXAM V6
HESI EXIT Exam V6 with Answers A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandm... [Show More] other died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings? The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change? The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client? The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that “staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting.” The nurse manager’s leadership style is best described as A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug? The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is: The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states “ I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next? The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse? The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care? An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements? In order to be effective in administering cardiopulmonary resuscitation to a 5 year- old, the nurse must The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care? For which of the following mother-baby pairs should the nurse review the Coomb’s test in preparation for administering RhO (D) immune globulin within 72 hours of birth? An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first? What is the major purpose of community health research? The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor? A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed? The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor? After the shift report in a labor and delivery unit which of these clients would the nurse check first? The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately? The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is “Asthma causes… The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find? The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client’s impending death. What action should the nurse do first? The nurse is caring for a client with Meniere’s disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority? The nurse is taking a health history from parents of a child admitted with possible Reye’s Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye’s Syndrome? While giving care to a 2 year-old client, the nurse should remember that the toddler’s tendency to say “no” to almost everything is an indication of what psychosocial skill? A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? When teaching parents about sickle cell disease, the nurse should tell them that their child’s anemia is caused by The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? The nurse is caring for a client with congestive heart failure. Which finding requires the nurse’s immediate attention? The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? Which action is most likely to ensure the safety of the nurse while making a home visit? An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a “feeling of being hot all the time.” The nurse should assign the client to share a room with a client with the diagnosis of A client’s admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach? At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs? A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member? The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to Which individual is at greatest risk for developing hypertension? The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? Which of these statements best describes the characteristic of an effective reward- feedback system? The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A 3-year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre- operative client. Which action should the nurse take first? In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? When teaching a client with coronary artery disease about nutrition, the nurse should emphasize The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should While assessing a 1 month-old infant, which finding should the nurse report immediately? A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention? The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? What would the nurse expect to see while assessing the growth of children during their school age years? The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan to The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score? A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remedies The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? The nurse is caring for a 1-year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child? At senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical? A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration? A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy? The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding? When suctioning a client’s tracheostomy, the nurse should instill saline in order to A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention? A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolate. Which action is a nursing priority? The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse’s immediate action? A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering A 70-year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis? Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by Which contraindication should the nurse assess for prior to giving a child immunizations? The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication? In addition to standard precautions, a nurse should implement contact precautions for which client? Which of the following situations is most likely to produce sepsis in the neonate? Which client is at highest risk for developing a pressure ulcer? A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach? A client who is 12-hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client’s behavior? A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately? The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents? A 16-year-old boy is admitted for Ewing’s sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially? What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention? Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client’s total protein level is reported as 4.5. Which of the following would the nurse anticipate? A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse? A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are ‘hot.’” The next action for the nurse to take is to Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse’s immediate attention? Which approach is a priority for the nurse who works with clients from many different cultures? A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention? The nurse is planning care for an 8-year-old child. Which of the following should be included in the plan of care? A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering? The nurse is caring for a client with Hodgkin’s disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first? A client with a panic disorder has a new prescription for Xanax (Alprazolam). In teaching the client about the drug’s actions and side effects, which of the following should the nurse emphasize? Which of these questions is priority when assessing a client with hypertension? During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize? Which of these clients would the nurse monitor for the complication of C. difficile diarrhea? The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse? The nurse is preparing to take a toddler’s blood pressure for the first time. Which of the following actions should the nurse do first? A 72-year-old client is scheduled to have cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy? [Show Less]
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HESI COMPREHENSIVE EXIT EXAM
HESI Comprehensive Exit Exam Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority ... [Show More] before administering the medication? A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A nurse on the evening shift checks a physician’s prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician’s answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client’s carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client’s record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A client who recently underwent coronary artery bypass graft surgery comes to the physician’s office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A rape victim being treated in the emergency department says to the nurse, “I’m really worried that I’ve got HIV now.” What is the appropriate response by the nurse? A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: A client’s oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client’s Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client’s total intake during the 24-hour period? Type your answer in the space provided. Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client’s medical record would prompt the nurse to contact the prescribing physician before administering the medication? A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client’s record, would indicate a need to contact the physician who is scheduled to perform the ECT? A client scheduled for suprapubic prostatectomy has listened to the surgeon’s explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d’orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client’s breast? The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child’s participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, “Why should I even bother to watch what I eat and drink? It doesn’t really matter what I do if I’m never going to get better!” On the basis of the client’s statement, the nurse determines that the client is experiencing which problem? A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client’s concern, which problem does the nurse identify? A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads “4 mg/mL.” How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson’s disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply. A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, “I’m really thirsty — may I have something to drink?” Before giving the client a drink, the nurse should: A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client’s bedside? A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client’s heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer. A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred? A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided. A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? Chlorpromazine (Thorazine) has been prescribed to a client with Huntington’s disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client’s foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client’s temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks’ gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client’s vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client’s plan of care, which client concern does the nurse identify as the priority at this time? A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? A nurse in a physician’s office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is: A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse? A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is: A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician’s instructions, understanding that the gait was selected after assessment of the client’s: A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, “I don’t think I’ll be able to do these feedings by myself.” Which response by the nurse is appropriate? A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client’s alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse A client says to the nurse, “My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it’s probably cancer. Does this mean I’m going to die?” The nurse interprets the client’s initial reaction as: A nurse notes documentation in the client’s medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note? A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? A client with post–traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn’t like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate? A nurse provides information to a client with peripheral vascular disease about ways to limit the disease’s progression. Which of the following measures does the nurse tell the client to take? Select all that apply. A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client: A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, “I can’t draw or paint.” Which of the following responses by the nurse is therapeutic? A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, “Boys in blue are fun to do! Boys in blue are fun to do!” What is the appropriate response by the nurse? A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to: Stay with the client and observe her behavior Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder? A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client’s symptoms? A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? A client on the mental health unit says to the nurse, “Everything is contaminated.” The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior: A male client arrives at the emergency department and reports to the nurse, “I woke up this morning and couldn’t move my arms.” He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee’s hands were severed by a machine. What is the priority response by the nurse? A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: A client experiencing delusions says to the nurse, “I am the only one who can save the world from all of the terrorists.” What is the appropriate response by the nurse? A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. A client who is scheduled to undergo chemotherapy asks the nurse, “Is my hair going to fall out?” The nurse responds by telling the client that: A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:122. An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? An emergency department nurse assessing a client with Bell’s palsy collects subjective and objective data. Which of the following findings does the nurse expect to note? A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: A client living in a long-term care facility shouts at the nurse, “Get out of my room! I don’t need your help!” What is the appropriate way for the nurse to document this occurrence in the client’s record? A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client’s bedside? Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: [Show Less]
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