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HESI RN EXIT EXAM 2022
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is e... [Show More] vidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope - correct answer B. Sluggish and unequal pupillary responses A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly. - correct answer A. Abdominal pain decreases when lying supine A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family - correct answer A. Instructions about how much fluid the child should drink daily To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot). - correct answer I placed the red dot on the base of the neck on the right side After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity - correct answer D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis - correct answer D. Respiratory alkalosis A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position? A. Supine B. supine; feet elevated higher than head C. supine; head elevated higher than feet D. Fowlers - correct answer Fowlers The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision E. Frequent drooling - correct answer A. Frequent syncope C. Flat affect D. Blurred vision While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Serum albumin B. Culture for sensitive organisms C. Serum blood glucose level D. Creatinine level - correct answer B. Culture for sensitive organisms A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Ask the older brother how he felt during the incident C. Tell the older brother that he seems depressed D. Commend the older brother for his heroic actions - correct answer B. Ask the older brother how he felt during the incident A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? A. Encourage the client to use cooler water and apply calamine lotion after soaking B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief C. Suggest that the client take brief showers and apply oil-based lotion after showering D. Explain that the symptoms are caused by liver damage and cannot be relieved - correct answer A. Encourage the client to use cooler water and apply calamine lotion after soaking An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF? A. Increased cardiac contractility B. Reduced preload C. Relaxed vascular tone D. Decreased afterload - correct answer B. Reduced preload Which intervention should the nurse include in the plan of care for a child with tetanus? A. Encourage coughing and deep breathing B. Minimize the amount of stimuli in the room C. Reposition from side to side every hour D. Open window shades to provide natural light - correct answer B. Minimize the amount of stimuli in the room An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? A. Ate an extra peanut butter sandwich before gym class B. incorrectly administered too much insulin C. Had a cold and ear infection for the past two days D. Skipped eating lunch - correct answer C. Had a cold and ear infection for the past two days A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status - correct answer C. The client's need for pain medication should be determined Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection techniques B. Blood glucose monitoring C. Diabetic diet meal planning D. A realistic exercise plan - correct answer B. Blood glucose monitoring A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breasts for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breasts D. Express small amounts of milk from the breasts to relieve pressure - correct answer A. Apply ice to the breasts for comfort The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A. Avoid range of motion exercises B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Inspect skin for redness E. Wash the stump with soap and water - correct answer B. Use a residual limb shrinker D. Inspect skin for redness E. Wash the stump with soap and water A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about? A. Serum immunoglobulin E (IgE) B. Intradermal test C. Atopy patch test D. Placebo-controlled food challenge - correct answer A. Serum immunoglobulin E (IgE) A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority? A. Allow client to gargle with warm salt water B. Administer a sedative to alleviate anxiety C. Instruct client to write down the questions D. Deny client's request for a midnight snack - correct answer C. Instruct client to write down the questions The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? A. Notify the nurse when the transfusion has finished, so further client assessment can be done B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion - correct answer B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output - correct answer D. Maintain strict intake and output A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures D. Provide a numeric pain scale - correct answer A. Ask the client to describe the pain A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? A. Start an intravenous infusion B. Administer oxygen via facemask C. Perform a vaginal exam D. Begin continuous fetal monitoring - correct answer D. Begin continuous fetal monitoring A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide? A. Consume a high protein diet B. Increase physical activity C. Take vitamin supplements D. Obtain a prostate-specific antigen blood level test - correct answer B. Increase physical activity The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Round to the nearest whole number) - correct answer 42 gtt/min Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema - correct answer A. Observe color of urine A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record? A. The UAP left the client to assist another client B. The last time client was assisted to the bathroom C. The unit was understaffed when the client fell D. The client fell sustaining a fracture to the left hip - correct answer D. The client fell sustaining a fracture to the left hip The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A. Barking cough and vomiting B. Mucopurulent cough and night sweats C. Dry cough and chest tightness D. Chronic cough and fatty stools - correct answer B. Mucopurulent cough and night sweats In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next? A. Temperature B. Breath sounds C. Blood glucose D. White blood cell count - correct answer C. Blood glucose A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? A. Evaluate the skin turgor B. Assess for weakness or dizziness C. Change the perineal pad D. Measure the urinary output - correct answer B. Assess for weakness or dizziness The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit B. Provide the client written information about end-of-life care C. Obtain a detailed report from the nurse transferring the client D. Mark the chart with client's request for no heroic measures - correct answer C. Obtain a detailed report from the nurse transferring the client While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A. Obtain sputum sample B. Document degree of edema C. Initiate hourly urine output measurement D. Administer intravenous diuretics - correct answer A. Obtain sputum sample A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order) - correct answer 1. Observe breathing patterns 2. Assess blood pressure 3. Measure body temperature 4. Palpate for pedal edema A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L B. Fingertips feel numb C. Sodium 135 mEq/L D. Cervical spine stiffness - correct answer B. Fingertips feel numb An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medications B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission - correct answer C. Increasing confusion of the client The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gases results C. Measure ankle circumference D. Document abdominal girth - correct answer A. Auscultate for irregular heart rate The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with Type 2 DM B. Start the second blood transfusion for a client 12 hours following a BKA C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty - correct answer A. Administer a dose of insulin per sliding scale for a client with Type 2 DM D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A. Core strengthening B. Aerobic exercise C. Weight-bearing exercise D. Muscle stretching and toning - correct answer B. Aerobic exercise A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? A. CT scan that was performed 6 months earlier B. Metal hip prosthesis was placed 20 years ago C. Report of client's sobriety for the last 5 years D. Takes metformin for type 2 diabetes mellitus - correct answer D. Takes metformin for type 2 diabetes mellitus A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply) A. Do not contaminate the insulin aspart so that it is available for IV use B. Review with the client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals. E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose F. Fingerstick glucose assessments every 6h with meals - correct answer B. Review with client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals F. Fingerstick glucose assessments every 6h with meals The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? A. A 14yo client with anorexia nervosa who is refusing to eat the evening snack B. A 16yo client diagnosed with major depression who refuses to participate in group C. A 17yo client diagnosed with bipolar disorder who is pacing around the lobby D. An 18yo client with antisocial behavior who is being yelled at by other clients - correct answer D. An 18yo client with antisocial behavior who is being yelled at by other clients A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? A. Obtain the client's 24-hour dietary recall B. Document mucosal membrane status C. Schedule a consult with a nutritionist D. Initiate prescribed intravenous fluids - correct answer D. Initiate prescribed intravenous fluids A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? A. Bradycardia B. Tachypnea C. Hypertension D. Coughing - correct answer A. Bradycardia Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A. Upper body muscle strength B. Balance and posture C. Risk for disuse syndrome D. Pressure sore risk - correct answer A. Upper body muscle strength A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers C. A potty chair should be brought from home so he can maintain his toileting skills D. Children usually resume their toileting behaviors when they leave the hospital - correct answer D. Children usually resume their toileting behaviors when they leave the hospital The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) A. Report any client complaint of pain or discomfort B. Evaluate the client for sleep disturbances C. Assess the client for weakness and fatigue D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks - correct answer A. Report any client complaint of pain or discomfort D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks A young adult visits the client reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Consumes 10 or more drinks of alcohol every weekend B. Snacks on foods with very high salt content on a daily basis C. Exercises vigorously every evening right before going to bed D. Recently became a vegetarian and eats a lot of high fiber foods - correct answer A. Consumes 10 or more drinks of alcohol every weekend After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Ask the client about gastrointestinal pain C. Monitor the client's serum electrolyte levels D. Measure the client's fluid intake and output - correct answer B. Ask the client about gastrointestinal pain When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. The second stage of labor lasted 10 minutes B. She received butorphanol 2mg IVP during labor C. She is over 35 years of age D. She is a gravida 6, para 5 - correct answer D. She is a gravida 6, para 5 When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. Client uses the arm cautiously B. Red streak tracking the vein C. A sluggish blood return D. Spot of dried blood at insertion site - correct answer B. Red streaks tracking the vein An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? (Highest to lowest priority) - correct answer 1. Send emesis sample to the lab 2. Elevate the head of the bed [Show Less]
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HESI CAT EXAM
A client with irritable bowel syndrome is recovering from surgery to create an ileostomy what foods should the nurse instruct the client to avoid to reduce... [Show More] the risk of food blockage - correct answer Dried fruits & nuts Rationale: dried fruits and nuts can cause a blockage in the small intestine the client should be instructed to avoid these food items with an ileostomy A client with malnutrition is assessed for osteomalacia what data show the nurse review to determine their clients risk for this health problem - correct answer Vitamin D levels Rationale: Malnutrition has widespread affects on various organ systems osteomalacia is defective mineralization of newly formed bones secondary to chronic deficiency of vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide the nurse with the most accurate information regarding this health problem The nurse has determine an adolescent client needs reinforcement education about prevention of a sickle cell crisis which instruction should the nurse include select all that apply - correct answer Wear warm clothes outside in cold weather take your hydroxyurea (Droxia) daily as prescribed Drink at least eight 12 ounces glasses of water a day Get regular exercise but do not exercise so much that you become tired Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle cell disease. it occurs when the micro circulation is obstructed by sickling of the red blood cells resulting in local tissue ischemia and severe pain. the three most common identify triggers for the development of a vaso-occlusive crisis are hypoxemia, dehydration, and body temperature changes The nurse is caring for a client with schizophrenia who has refused they are risperidone for the last week the client has been suspicious of nursing staff and periodically aggressive for the past three days today the client broke a chair in their room and is making verbal threats to the nurse and to other clients in the day wrong what is the first action the nurse should take - correct answer Remove the other clients in nonessential staff from the day room Rationale: schizophrenia is a mental health disorder which causes hallucinations, delusions, disorder thought process and impaired behavior function. Safety for all staff clients and visitors is priority and potential violence situations A nurse who normally works on a post surgical care unit has been asked to float to the preoperative care unit what is the best response by the nurse - correct answer I don't feel totally comfortable floating so I would like to be paired with a resource nurse for my shift Rationale: The nurse has acknowledged their discomfort with floating and has also identified a means of making a float shift nurse more comfortable and important part of a successful float shift and identifying using resources on the float unit including a partnership with a specific resource nurse for the shift to answer questions locate supplies etc. The nurse is preparing to administer medication through a client's nasalgastric tube what will the nurse do first when administering these medications - correct answer Assessed for placement of the nasalgastric tube Rationale: Before inserting any medication through the nasal gastric tube the nurse needs to assess for correct placement of the tube A client with an stage renal failure has requested no further treatment be provided when the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have ended in demands that treatment be continue what should the nurse do it this time - correct answer Explained that the client has requested that all treatments be stop Rationale: The nurse is responsible for the following clients wishes for treatment the daughter does not need to leave because there's no evidence that the client is upset resuming Dallas treatment is not what the client wants and should not be done the nurse can explain the change in treatments with a daughter and does not need to ask a physician to have this conversation The education department of a healthcare organization has design client education sheet that explains the process of being admitted to the hospital in English Spanish and French since these are the three major language is spoken by the hospitals client population what does the client education sheet reflects - correct answer Sensitivity to the diverse Client population Rationale: By creating a client education sheet that can be read by the hospitals major client population the education department is demonstrating sensitivity to the diverse client population the education sheet does not reflect racial profiling stereotyping or inappropriate categorizing of the clients population The nurse is emptying the urinary collection bag for a client with history of HIV in which sequence sure the nurse perform the following actions after the urinary collection bag has been drained - correct answer Ensure urinary collection bag is placed below the clients bladder empty that your receptacle remove PPE Wash hands with soap & water Document amount of urine collected Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne illnesses in cases of hematuria healthcare professionals including nurses need to completely situational risk assessment prior to each client interaction to determine risk and choose the appropriate infection control strategy to minimize risk to themselves and their client population according to the CDC A GRANDSon is concern about the older clients happiness and so much time is spent talking about the past what should the nurse respond to the grandson - correct answer Reminiscing is a common activity in older adults that helps them to stay connected Rationale: The nurse should explain that reminiscing is normal and common activity in older adults talking about the past helps older adult clients stay connected to other people by providing a topic of conversation even if they don't experience much during the day Family of an elderly Japanese woman is upset because the client has not received any pain medication the nurse explains that the client never complain about pain and did not write the pain and severe when assess what should the nurse manager do - correct answer Explain that in the Japanese culture people often show a stoic response to pain so that it is important to look for PHYSICAL clues Rationale: individuals of Japanese descent will not complain about pain as they do not want to dishonor themselves or their families some will either refuse pain medication when offered therefore it is important to look for physical clothes like (rocking, sweat on brows, elevated blood pressure) and input from the family when assessing for pain The nurse assessed audible expiratory wheezes over a clients lower lobes what should the nurse do first after completing this assessment - correct answer Raise the Head of the bed to a 60° angle Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing the nurse should do is raise the head of the bed to a 60° angle in order to improve ventilation The nurse is flushing a clients peripheral intravenous catheter saline lock with sterile normal saline during the flush the nurse notes that resistance is met what action should the nurse take - correct answer Remove the saline lock and re-insert in another site Rationale: The peripheral in a minute IV catheter device also known as a saline lock is a device flushed with saline and applied to a PICC to maintain IV access and patency. To maintain patency the lock should be flush with 3 mL of NS before and after each medication administered, after blood draw, and every 12 hours with the saline lock has been not been in use. While saline locks reduce the need to insert IV lines, they do have a risk and should be removed 72 hours after insertion to reduce the likelihood of infection Infiltration - correct answer The infusion of fluid or medication outside the vein usually caused by poor IV placement skin will appear swollen and cool to the touch Hematoma - correct answer When blood from the veins pools into the surrounding tissues this happens when the needle passes through the rain more than once or if pressure is applied when removing the IV air embolism - correct answer Extremely rare complication in which air travels through the IV line into the vein and creates an envelope that could travel to the lungs or heart since the amount of air tolerating is dependent on weight children are more at risk of developing this complication phlebitis - correct answer Inflammation of the rain caused by irritation solutions medication or the angiocatheter being in place for days superficial thrombophlebitis - correct answer Inflammation of a vein just below the surface of the skin caused by formation of a thrombus this may cause pain, tenderness or hardening of the vein these often resolved without intervention elevating the extremity and applying warm compress can relieve symptoms The case manager on an oncology unit is determining which clients might be appropriate to consider for hospice which client will most likely benefit the most from this level of care - recovering from radioactive iodine for thyroid cancer - metastatic liver cancer receiving IV morphine for pain - recovering from lumpectomy for breast cancer with no nodal involvement - chemotherapy for chronic leukemia w/ low WBC - correct answer ANS: Client with metastatic liver cancer receiving IV morphine for pain. Rationale: The client with my tastic cancer of the liver being treated with IV morphine has the direct prognosis and would most probably benefit from hospice care although the other clients are diagnosed with cancer the health conditions are stabilized with treatment hospice would not be indicated for them at this time The nurse has inserted in indwelling urinary catheter into email client after the flow Of urine has started and the nurse has inserted additional length of tubing through the clients made us what should the nurse do - correct answer Inflate the balloon with 10 mL of sterile water A client recovering from a CABG (coronary artery bypass surgery) asked the nurse why he has bandages on his legs which of the following should the nurse do to assist this client - correct answer Remind the client that the veins from the surgery were harvest for the leg region Rationale: preoperative teaching Would have included the veins to be use for the surgery the nurse to remind the client of this teaching to explain the presence of the bandages at this time A client with community acquired pneumonia is admitted and started on IV vancomycin upon assessment the client reports itching in the nurse observes skin changes. After stopping the infusion which action should the nurse implement first - correct answer Obtain a blood pressure Rationale: Community acquired pneumonia is a lung infection most often caused by streptococcus pneumonia. vancomycin is a powerful antibiotic commonly used to treat community acquired pneumonia the client symptoms of flushing and itching are characteristics of red man syndrome - a known side effect of vancomycin that can occur if infused to quickly Prior to administering a dose of propranolol hydrochloride (Inderal)10 mg by mouth the nurse assesses the client BP as being 88/50 mmHg what should the nurse do at this time - correct answer Hold the medication and notify the doctor with the BP reading Rationale: Propanolol hydrochloride (Inderal) is a medication to lower systolic blood pressure if this is not like pressure is below 90 mmHg the medication should not be provided and the doctor should be notified A client is prescribed nitroglycerin ointment 1/2 inch every 6 hours and has a PRN prescription for nitroglycerin tablets 0.3 mg sublingual as needed for chest pain what should the nurse instruct the client about the use of these medication in the event of an acute angina attack - correct answer Take one nitroglycerin tablet sublingual every five minutes for up to three doses in 15 minutes for chest pain The nurse is evaluating the need for clients on a cardiac step down unit to continue to have central venous access device in place what is the primary reason for removing these devices if they are no longer needed - correct answer Reduce the risk of hospital acquired infections Rationale: Centrally located venous access devices are a source for a hospital acquired infections the need for these devices should be evaluated and remove a soon as the clients health status once the removal The nurse is caring for a client with a fractured tibia what statement show the nurse include in the clients discharge teaching - correct answer We know the bone is healing when we see a callus on x-ray Rationale: In the process of bone healing a callous will be formed at the site of the fracture the calluses seen upon radiological examination and as evidence of bone healing A client with type two diabetes mellitus is diagnosed with protein in the urine on which complication of diabetes will the nurse focus when instructing the client about this finding - correct answer Nephropathy The nurse is preparing to administer a solution of 500 mg of theophylline diluted in 500 mL of dextrose 5% and water. the client is prescribed to receive 25 mL per hour how many mg/per hour with a client received this medication - correct answer 500mg / 500 ml = 1 mg/ml 25mg/hr 25 mg x 1 mg = 25 mg/hr A client has chronic left-sided abdominal pain and rectal bleeding. the results of the colonoscopy show hernations of mucusa and submucosa through the muscularis. Based on this description the nurse should I suspect that the client is experiencing which condition - correct answer Diverticulosis Rationale: Herniations of the Mickelson and submucosa through the muscularis describes diverticulosis or the presence of pouches of the colonic wall it most commonly affect the sigmoid colon. Diverticulitis - correct answer Fecal impaction and obstruction of the lumen of a diverticulum (pouch) inflammation of the diverticulum A client who has been prescribed codeine for pain is experiencing nausea and vomiting what should the nurse do to assist his client - correct answer Notify the physician Rationale: Nausea vomiting should be reported to the doctor because a change to another analgesic may be necessary The nurse is teaching a group of students on fetal growth and development which statement regarding fetal circulation is correct - correct answer - The umbilical vein transport nutrients and oxygen rich blood to the fetal body - the foreman oval shunts blood from the right atrium directly to the left atrium bypassing the lungs - the umbilical cord contains 1 umbilical vein and 2 umbilical arteries An elderly client admitted for pneumonia score 17 on the Braden scale recession scale which intervention should the nurse include in the clients plan of care - correct answer Implement a two hour turning schedule with a UAP Rationale: The skin is the largest organ on the human body and serves as a barrier to a variety of harmful environmental conditions on a mission the nurse should use a skin risk assessment tool to assess the clients risk for skin breakdown and implement appropriate interventions based on the clients risk I am planning care for a client with cervical spinal injury following MVa which nursing problem has the highest priority - correct answer Ineffective airway clearance Rationale: nursing care should be provided according to the principle ABC The nurse is designing a study to evaluate the effectiveness of grief counseling and caregivers who recently lost a spouse after a long-term illness when determining what previous research studies have a dress effectiveness of grief counseling what should the nurse do first - correct answer Collect research abstracts of studies that focus on the effectiveness of grief counseling Rationale: An astroid provides a quick overview of the study and question address as the research question and gives the reader a very short description of the research method study results and conclusion it's function is to help determine if the research report is relevant to the reader or not 18-year-old child is admitted for treatment of osteosarcoma the nurse notes a stiff body posture elevated heart rate and lack of interaction with the parents which nursing intervention should the nurse implement - correct answer Administer prescribed pain medication Rationale: Fayetteville acute pain in school age children include activation of the sympathetic nervous system elevated heart rate blood pressure and sweating social withdrawal grimacing crying or decrease interest in normal activities school age children have an awareness of bodily harm and will often fear the administration of medication more than the pain itself they may verbally denies pain to avoid a pain management technique A client who has been taking sildenafil citrate (Viagra) as needed is prescribe sublingual nitro glycerin 0.3 mg as needed for chest pain what should the nurse discuss with the client about taking these medication - correct answer Do not take a sub lingual nitroglycerin pill for 24 hours after taking Viagra A client who is partly paralyzed after a spinal injury is intubated and started on mechanical ventilation. the nurse implement several actions in order to reduce the risk of ventilation associated pneumonia (VAP). which nursing intervention is part of a standard that prevention - correct answer - Maintain HOB 35 degrees - perform daily sedation interruptions - provide peptic ulcer disease prophylaxis Rationale: VAP Is the most common complication of mechanical ventilation and affect approximate 28% of all ventilated patients as mortality is high, preventative measures should be implemented the 4-step evidence-based ventilation bundle is considered standard care for all patients receiving mechanical ventilation the four components are 1. raising the head of the bed to 30 to 45°daily 2. interruptions of sedation 3. assessing readiness to extubate, peptic ulcer disease prophylaxis 4. DVT prophylaxis A young client has been diagnosed with celiac disease which food should be restricted from this diet - correct answer BROW Barley Rye Oats Wheat Rationale: celiac disease is a hereditary lifelong autoimmune disorder where the ingestion of gluten causes injury to the intestinal lining. Clients should have a gluten free diet Which test diagnose celiac disease - correct answer Blood test and endoscopy with intestinal biopsy Signs and symptoms of celiac disease - correct answer Weight loss diarrhea abdominal cramping loss of appetite Hint: Think stomach cramp gives you diarrhea with diarrhea you dont wanna eat and if you dont eat you lose weight A client recovering from an ileostomy feels like it we can dizzy the clients vital signs are blood pressure 95/60 weak and rapid pulse, temperature 99.3 and respiratory rate 20 what nursing diagnosis is a priority at this time - correct answer Deficient fluid volume Rationale: Lightheadedness dizziness (orthostatic hypotension) low BP, tachycardia and mild increased respiratory rate are all signs of hypovolemia the nursing diagnosis is deficient fluid volume has highest priority at this time clients with ileostomies are particularly at risk for developing hypovolemia due to impaired water absorption A client with irritable bowel syndrome is recovering from surgery to create an ileostomy what foods should the nurse instruct the client to avoid to reduce the risk of food blockage - correct answer Dried fruits & nuts Rationale: dried fruits and nuts can cause a blockage in the small intestine the client should be instructed to avoid these food items with an ileostomy A client with malnutrition is assessed for osteomalacia what data show the nurse review to determine their clients risk for this health problem - correct answer Vitamin D levels Rationale: Malnutrition has widespread affects on various organ systems osteomalacia is defective mineralization of newly formed bones secondary to chronic deficiency of vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide the nurse with the most accurate information regarding this health problem The nurse has determine an adolescent client needs reinforcement education about prevention of a sickle cell crisis which instruction should the nurse include select all that apply - correct answer Wear warm clothes outside in cold weather take your hydroxyurea (Droxia) daily as prescribed Drink at least eight 12 ounces glasses of water a day Get regular exercise but do not exercise so much that you become tired Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle cell disease. it occurs when the micro circulation is obstructed by sickling of the red blood cells resulting in local tissue ischemia and severe pain. the three most common identify triggers for the development of a vaso-occlusive crisis are hypoxemia, dehydration, and body temperature changes The nurse is caring for a client with schizophrenia who has refused they are risperidone for the last week the client has been suspicious of nursing staff and periodically aggressive for the past three days today the client broke a chair in their room and is making verbal threats to the nurse and to other clients in the day wrong what is the first action the nurse should take - correct answer Remove the other clients in nonessential staff from the day room Rationale: schizophrenia is a mental health disorder which causes hallucinations, delusions, disorder thought process and impaired behavior function. Safety for all staff clients and visitors is priority and potential violence situations A nurse who normally works on a post surgical care unit has been asked to float to the preoperative care unit what is the best response by the nurse - correct answer I don't feel totally comfortable floating so I would like to be paired with a resource nurse for my shift Rationale: The nurse has acknowledged their discomfort with floating and has also identified a means of making a float shift nurse more comfortable and important part of a successful float shift and identifying using resources on the float unit including a partnership with a specific resource nurse for the shift to answer questions locate supplies etc. The nurse is preparing to administer medication through a client's nasalgastric tube what will the nurse do first when administering these medications - correct answer Assessed for placement of the nasalgastric tube Rationale: Before inserting any medication through the nasal gastric tube the nurse needs to assess for correct placement of the tube A client with an stage renal failure has requested no further treatment be provided when the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have ended in demands that treatment be continue what should the nurse do it this time - correct answer Explained that the client has requested that all treatments be stop Rationale: The nurse is responsible for the following clients wishes for treatment the daughter does not need to leave because there's no evidence that the client is upset resuming Dallas treatment is not what the client wants and should not be done the nurse can explain the change in treatments with a daughter and does not need to ask a physician to have this conversation The education department of a healthcare organization has design client education sheet that explains the process of being admitted to the hospital in English Spanish and French since these are the three major language is spoken by the hospitals client population what does the client education sheet reflects - correct answer Sensitivity to the diverse Client population Rationale: By creating a client education sheet that can be read by the hospitals major client population the education department is demonstrating sensitivity to the diverse client population the education sheet does not reflect racial profiling stereotyping or inappropriate categorizing of the clients population The nurse is emptying the urinary collection bag for a client with history of HIV in which sequence sure the nurse perform the following actions after the urinary collection bag has been drained - correct answer Ensure urinary collection bag is placed below the clients bladder empty that your receptacle remove PPE Wash hands with soap & water Document amount of urine collected Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne illnesses in cases of hematuria healthcare professionals including nurses need to completely situational risk assessment prior to each client interaction to determine risk and choose the appropriate infection control strategy to minimize risk to themselves and their client population according to the CDC A GRANDSon is concern about the older clients happiness and so much time is spent talking about the past what should the nurse respond to the grandson - correct answer Reminiscing is a common activity in older adults that helps them to stay connected Rationale: The nurse should explain that reminiscing is normal and common activity in older adults talking about the past helps older adult clients stay connected to other people by providing a topic of conversation even if they don't experience much during the day Family of an elderly Japanese woman is upset because the client has not received any pain medication the nurse explains that the client never complain about pain and did not write the pain and severe when assess what should the nurse manager do - correct answer Explain that in the Japanese culture people often show a stoic response to pain so that it is important to look for PHYSICAL clues Rationale: individuals of Japanese descent will not complain about pain as they do not want to [Show Less]
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HESI FINAL EXAM TEST 1
After a thyroidectomy, the nurse should monitor for signs of tetany which can be caused by trauma to the parathyroid gland. The signs of tetany include whi... [Show More] ch of the following? check all answers that apply negative Chvostek's sign positive Trousseau's sign photophobia cardiac dysrhythmias - correct answer positive Trousseau's sign photophobia cardiac dysrhythmias All three of these are signs of tetany. A positive Chvostek's sign would also be a sign of tetany, along with carpopedal spasm, dysphagia, muscle and abdominal cramps, numbness and tingling of the face and extremities, wheezing and dyspnea, and seizures. Your patient has had a uterine artery embolization to treat a fibroid tumor. She is being discharged and you will be giving her instructions for home care. Which of the following would NOT be a part of your instructions? alter diet to eliminate fiber call the health care provider if you run a fever of 101.1 degrees F or more do not use tampons for at least four weeks avoid straining during bowel movements - correct answer alter diet to eliminate fiber This patient would be told to eat a normal diet including fiber and fluids. All of the other choices are appropriate instructions. Other instructions may include: take prescribed medications as ordered; call the physician if she has bleeding, pain, swelling, hematoma at the puncture site, urinary retention or abnormal vaginal drainage; and refrain from using douches or having vaginal intercourse for at least four weeks. Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following? This type of action may cause extreme pain. This type of action will delay healing. This type of action may cause venous thrombosis. This type of action may pop the prosthesis out of the socket. - correct answer This type of action may pop the prosthesis out of the socket. This question asks for the primary reason for this advice. The primary reason is that this type of action may pop the prosthesis out of the socket. A young adult was told that he had a significant reaction to the Mantoux test. The nurse explains that this means he has active tuberculosis. had active tuberculosis has been exposed to tuberculosis is immunocompromised. - correct answer has been exposed to tuberculosis. A reaction to the Mantoux test for tuberculosis means the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction does not mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis. Which of the following would be considered a late sign of colorectal cancer? check all answers that apply blood in stool anemia cachexia abdominal mass - correct answer cachexia abdominal mass These are late signs along with guarding or abdominal distention. Blood in the stool is the most common manifestation of this cancer. The nursing diagnosis deals with which of the following? check all answers that apply disease medical condition human response to health problems care plan - correct answer human response to health problems A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes. A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication is not taken, restraints will be applied and the medication will be given by injection. The nurse's statement constitutes which legal tort? Assault Battery Negligence Right to refuse care - correct answer Assault sault. Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standard of care. The client has the legal right to refuse care. In this situation, the correct action is to try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to client's refusing care. You have a patient who has been diagnosed with asthma. You are teaching him the proper use of an inhaler. Which of the following would NOT be included in your instruction? Exhale completely. Use the bronchodilator before the steroid inhaler. If using a spacer, keep mouth open to bring in volume of air with misted medication. Wait at least one minute between inhaled doses (puffs). - correct answer If using a spacer, keep mouth open to bring in volume of air with misted medication. If using a spacer, the mouthpiece should be gripped in the mouth. If not using a spacer, the mouth should be kept open to bring in volume of air with misted medication. The other choices are correct instructions. Pulmonary edema is a life-threatening event that can result from severe heart failure. If a client develops pulmonary edema which of the following actions is appropriate? check all answers that apply Place the client in a low-Fowler's position. Administer oxygen. Ensure that an intravenous access device is in place. Prepare for intubation if required. - correct answer Administer oxygen. Ensure that an intravenous access device is in place. Prepare for intubation if required. These are all appropriate actions. You should immediately place the client in high-Fowler's position, with the legs in a dependent position, to reduce pulmonary congestion and relieve edema. A female client's gonorrhea culture is positive for gonorrhea. Which of the following actions should the nurse take? instruct the client to wait in the office for 25 minutes after the examination to allow the local anesthesia to wear off instruct the client to wait 24 hours before taking prescribed medication ask the client for the names of all of her sexual partners instruct the client to douche 5 hours after the procedure to get rid of the solution used for the culture - correct answer ask the client for the names of all of her sexual partners k the client for the names of all of her sexual partners. A gonorrhea culture is used to identify if an individual has gonorrhea by using a swab to obtain discharge from the cervix, throat, anus or urethra. For a positive result on the diagnostic test, the N. gonorrhea organism is present. For this test, the nurse should inform the client to not douche before the examination and douching is not recommended after the examination. The nurse should also obtain from the client a listing of all sexual partners that the client has had in order to contact them so the partners can receive treatment. This way the gonorrhea infection does not spread to other individuals. The type of angina that may occur at rest and results from a coronary artery spasm is which of the following? check all answers that apply stable angina Prinzmetal's angina preinfarction angina intractable angina - correct answer Prinzmetal's angina Prinzmetal's angina is also called variant angina or vasospastic angina. It results from coronary artery spasm. Attacks may be associated with ST-segment elevation noted on the electrocardiogram. stable angina Prinzmetal's angina preinfarction angina intractable angina Postoperative care for a woman following a mastectomy will include arm exercises to: strengthen the affected muscles. increase firmness in the remaining breast tissue. decrease pain as the surgical site heals. promote drainage after lymphatic disruption. - correct answer promote drainage after lymphatic disruption. A mastectomy includes the removal of lymph nodes. The recommended exercises will help promote drainage and prevent swelling. The exercises will not help strength muscles, increase breast firmness, or help with pain control. In your state, screening for neural tube defects is mandated by law. You know that this test is highly associated with both false positives and false negatives reliability of results multiple gestations infections during pregnancy - correct answer both false positives and false negatives There are various techniques to determine fetal and maternal well-being. The screening for neural tube defects by testing either maternal serum alpha-fetoprotein (AFP) levels or amniotic fluid AFP levels is highly associated with both false positives and false negatives. Which of the following is would indicate implied consent to a procedure? check all answers that apply The patient voluntarily submits to the procedure. The patient consents in writing. The patient orally consents. The patient consents orally and in writing. - correct answer The patient voluntarily submits to the procedure. When a patient voluntarily submits to the procedure, this indicates implied consent. Consenting in writing or orally is considered expressed consent. Your patient has been prescribed a bronchodilator for her asthma along with a corticosteroid to reduce inflammation. Which of the following is NOT a corticosteroid? check all answers that apply Salbutamol Beclomethasone dipropionate Fluticasone propionate Flunisolide Budesonide - correct answer Salbutamol Salbutamol is a bronchodilator. All of the other choices are corticosteroids. A person's reaction to pain is subjective. It is influenced by certain factors. Which of the following are factors that may influence a patient's pain experience? check all answers that apply gender culture religion acute hypotension - correct answer gender culture religion A person's pain experience will be subjective. There are many factors that influence how a patient will feel and handle pain. Anxiety, culture, religion, and gender affect a patient's response to pain. You are assessing a child who has been diagnosed with Duchenne muscular dystrophy. Which of the following would NOT be an indicator of this disease? Gowers sign increasing clumsiness vomiting (usually in the morning) waddling gait - correct answer vomiting (usually in the morning) There are a number of assessments that you might make in a patient with Duchenne muscular dystrophy. Vomiting is not one of them. The child may have a waddling gait, increasing clumsiness and muscle weakness, Gower sign (difficulty rising to standing position), delayed cognitive development, elevated CPK and SGOT/AST among other signs. In establishing a teaching plan for a client who is in the first trimester of pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the first visit? Asking the woman what questions and concerns she has about parenting Dealing with heartburn and abdominal discomfort Nutrition and activity during pregnancy Preparation for labor and delivery - correct answer Nutrition and activity during pregnancy. Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a third trimester concern, and parenting is of most concern in either the third trimester or post delivery. Heartburn and abdominal discomfort do not usually occur until the third trimester. All of the following are appropriate guidelines in terms of nutrition and feeding for an infant EXCEPT: check all answers that apply Fluoride supplementation may be needed at about 6 months of age, depending on the infant's intake of fluoridated tap water. At 12 months of age, eggs can be given. Avoid microwaving baby bottles and baby food. Mix any necessary medications with formula. - correct answer Mix any necessary medications with formula. This would not be an appropriate guideline. Never mix food or medications with formula. Also avoid adding honey to formula, water, or other fluid to prevent botulism. The nurse develops a teaching plan for a client who has a 5 cm laceration of the arm. Which of the following is an appropriate learning outcome? the client's wound is healing and there is no infection present the nurse provided instructions to the client the nurse discusses with the client resources available the identification of the signs and symptoms of a wound infection - correct answer the identification of the signs and symptoms of a wound infection. The nurse should expect the client to be able to identify the processes involved in normal wound healing, identify the signs and symptoms of an infection of the wound, show that he or she can use wound cleansing equipment and know when, where and the time to return to the physician for a follow up appointment. Further, the client's wound is healing and there is no infection present, is an incorrect answer choice as this represents a nursing goal of wound care. Then, the nurse provide instructions to the client and the nurse discusses with the client resources available are examples of teaching methods the nurse uses to teach the client regarding wound care. A burn that is dry, leathery, and possibly edematous is which of the following? check all answers that apply superficial, partial thickness first degree burn second degree burn full thickness burn - correct answer full thickness burn A full-thickness burn (third-degree burn) has a dry, leathery, and possibly edematous appearance. Its color is white to charred and there is little or no pain. The depth of the burn is to subcutaneous tissue and possible fascia, muscle, and bone. Which of the following is typical of a fetus at week 16 of fetal development? check all answers that apply Fetus is 11.5 to 13.5 cm in length. Fetus has reflex hand grasp functions. Fetus is 100 g. Lanugo hair begins to develop. - correct answer Fetus is 11.5 to 13.5 cm in length. Fetus is 100 g. Lanugo hair begins to develop. These are all typical of a 16-week-old fetus. Reflex hand grasp functions occur at week 24. Which of the following statements about antineoplastic medications is NOT accurate? check all answers that apply Antineoplastic medications kill or inhibit the reproduction of neoplastic cells. Antineoplastic medications are only used to decrease life-threatening complications. The effect of antineoplastic medications may not be limited to neoplastic cells. Usually only one medication is used in order to increase the therapeutic response. Chemotherapy dosing is usually based on total body surface area and type of cancer. - correct answer Antineoplastic medications are only used to decrease life-threatening complication. Usually only one medication is used in order to increase the therapeutic response. These statements are not accurate. Antineoplastic medications are used to cure, increase survival time, and decrease life-threatening complication. Usually several medications are used in order to increase the therapeutic response. A patient's ability to implement his own decisions is the right to which of the following? check all answers that apply informed consent self-determination professionalism accountability - correct answer self-determination Self-determination is often used synonymously with autonomy. It means having a form of personal liberty to choose and implement one's own decisions, free from deceit, duress, constraint, or coercion. You are assigned to instill eye medication in a patient's eye. All of the following are appropriate for this task EXCEPT: check all answers that apply instructing the patient to tilt the head backward, open the eyes, and look up pulling the upper lid upward before instilling the medication squeezing the bottle gently to allow the drop to fall into the conjunctival sac instructing the client to squeeze the eyes shut after instilling the medication - correct answer pulling the upper lid upward before instilling the medication instructing the client to squeeze the eyes shut after instilling the medication These are not appropriate measures. Pull the lower lid down against the cheekbone and instruct the client to close the eyes gently; not squeeze the eyes shut. The RN is providing discharge instructions to a mother of a 3-year-old child who has undergone an orchiopexy to correct cryptorchidism. Which of the following statements made by the mother would indicate further teaching is necessary? "I'll give him medication so he'll be comfortable." "I'll check his voiding to be sure there is no problem." "I will let him decide when he wants to return to his play activities." "I will check his temperature." - correct answer "I will let him decide when he wants to return to his play activities." Vigorous activities should be restricted for 2 weeks following this type of surgery to allow for healing and prevent injury. Normal 3- year-olds want to be active, therefore, to prevent dislodging of the internal sutures, activity should be restricted. Monitoring the urine output, providing analgesics, and monitoring temperature are all important for the mother to be instructed upon. A nurse is caring for a patient who is in labor. The nurse has assessed a nonreassuring fetal heart rate manifesting as tachycardia unrelated to maternal variables. A pH blood sample is ordered. Which of the following fetal scalp pH values would indicate true acidosis? 7.25 7.15 7.30 7.35 - correct answer 7.15 Normal fetal scalp pH in labor is 7.25 to 7.35. If the value is below 7.2 this would indicate true acidosis. Therefore the 7.15 value would indicate true acidosis. The nurse is caring for an African-American female patient who is 75 years old. The patient complains of a gradual loss of her peripheral vision. Examination has indicated increased IOP. Which of the following is the most likely cause of her symptoms? check all answers that apply subconjunctival hemorrhage primary closed-angle glaucoma primary open-angle glaucoma macular degeneration cataracts - correct answer primary open-angle glaucoma Primary open-angle glaucoma has a gradual onset of increased IOP due to blockage of drainage of the aqueous humor. The optic nerve undergoes ischemic damage resulting in permanent visual loss. It is the most common type of glaucoma and is most commonly seen in elderly patients, especially those of African background or diabetics. You are teaching a class to encourage smokers to quit. You ask each person to write down how many packs they smoke per day and for how many years. The first person has smoked 2 packs per day for 12 years. How many pack-years would that amount to? 6 4 24 12 - correct answer 24 Smoking history is quantified in pack-years. To find this value, you would multiply the number of packs smoked per day by the number of years. In this woman's case she smoked 2 packs per day for 12 years. Her pack-years value is 24. When performing an assessment on a client with dementia, the RN must gather certain information. Which data gathered during the assessment indicates a manifestation associated with dementia? Absence of sundown syndrome. Presence of personal hygienic care. Confabulation. Improvement of sleeping. - correct answer confabulation Dementia has variant findings, from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. The client who uses confabulation is providing the fabrication of events or experiences to fill in memory gaps. As dementia progresses, the client will have episodes of wandering or sundowning. A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend: petroleum jelly. a water-soluble lubricant. body cream or body lotion. less-frequent intercourse. - correct answer a water-soluble lubricant. water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response. You have a patient with cardiomyopathy who presents with tachycardia, hypotension and a narrowed pulse pressure. The patient also has tachypnea and pulmonary congestion evidenced by crackles. This patient is most likely experiencing which of the following? check all answers that apply cardiogenic shock hypovolemic shock obstructive shock distributive shock - correct answer cardiogenic shock Cardiogenic shock occurs when either systolic or diastolic dysfunction of the pumping action of the heart results in reduced cardiac output. This patient shows typical signs of cardiogenic shock. Other signs of peripheral hypoperfusion include: cyanosis, pallor, diaphoresis, and diminished pulses. Part of the RN role involves delegation of client assignments. Which of the following is an appropriate delegation for a nursing assistant? Care for a client requiring colostomy irrigation. Care for a client who requires a urine specimen collected. Care for a client with difficulty swallowing food and fluids. Care for a client receiving continuous tube feeding. - correct answer Care for a client who requires a urine specimen collected. The nurse must delegate tasks by determining the assignment based on the skill level of subordinate staff. The most appropriate in this situation would be to collect the urine specimen. Colostomy irrigation and tube feedings are not permitted skills for unlicensed staff. The client with difficulty swallowing is at risk for aspiration. The ethical principle that is most closely related to the concept of free will is which of the following? check all answers that apply beneficence autonomy justice fidelity - correct answer autonomy Autonomy is a state of being self-regulating, self-defining, and self-reliant. A person, therefore, has the free will to dictate his own thoughts and actions. You have a patient with Alzheimer's disease whose symptoms become more pronounced in the evening. You understand that this is known as which of the following? check all answers that apply sundowning secondary dementia confabulation hyperorality - correct answer sundowning Sundowning (also known as sundown syndrome) is the situation in which symptoms and problem behaviors of those with cognitive disorders become more pronounced in the evening. This may occur in both delirium and dementia. Which of the following should be the nurse's initial action immediately following the birth of the baby? Aspirating mucus from the infant's nose and mouth Drying the infant to stabilize the infant's temperature Promoting parental bonding Identifying the newborn - correct answer Drying the infant to stabilize the infant's temperature The nurse's first action should be to dry the baby and stabilize the infant's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Prompting parental bonding and identifying the neonate are appropriate after the baby has been dried. The gray-blue discoloration of the flanks seen in hemorrhagic pancreatitis is which of the following? check all answers that apply Turner's sign Murphy's sign Cullen's sign Trousseau's sign - correct answer Turner's sign Turner's sign is a gray-blue discoloration of the flanks seen in acute hemorrhagic pancreatitis. Cullen's sign is a bluish discoloration of the abdomen and periumbilical area also seen in acute hemorrhagic pancreatitis. The nurse is obtaining an infant's chest circumference. The nurse should align the tape measure with the lower section of the chest with the center of the chest in line with the nipples directly above the abdomen and transverse to the chest against the center of the chest in line with the child's arm - correct answer with the center of the chest in line with the nipples [Show Less]
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HESI_CAT_Exam_Questions_and_Answers__Verified_Answers__Latest_Update_2023
A nurse is counseling the spouse of a client who has a history of alcohol abuse. What does the nurse explain is the main reason for drinking alcohol in peo... [Show More] ple with a long history of alcohol abuse? 1 They are dependent on it. 2 They lack the motivation to stop. 3 They use it for coping. 4 They enjoy the associated socialization. - Correct Answers ✅1 Alcohol causes both physical and psychological dependence; the individual needs the alcohol to function. Alcoholism is a disorder that entails physical and psychological dependence. Because alcohol is so physiologically addictive, the client's body craves the alcohol, so most clients lack the motivation to stop because they will go into withdrawal. Clients who abuse alcohol have numbed their ability to utilize other coping mechanisms, so alcohol is used as an excuse for coping. People with alcoholism usually drink alone or feel alone in a crowd; socialization is not the prime reason for their drinking. How do adolescents establish family identity during psychosocial development? Select all that apply. 1 By acting independently to make his or her own decisions 2 By evaluating his or her own health with a feeling of well-being 3 By fostering his or her own development within a balanced family structure 4 By building close peer relationships to achieve acceptance in the society 5 By achieving marked physical changes - Correct Answers ✅13 An adolescent establishes family identity by acting independently for taking important decisions about self. They also need to foster their development along with maintaining a balanced family structure. Health identity is associated with the evaluation of one's own health with a feeling of well- being. By building close peer relationships, an adolescent develops a sense of belonging, approval, and the opportunity to learn acceptable behavior. These actions establish an adolescent's group identity. The sound and healthy growth of the adolescent, with marked physical changes, helps to build an adolescent's sexual identity. A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1 Asking the father about his relationship with his wife 2 Asking the father how he held the child when she was an infant 3 Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4 Telling the father not to be concerned and stressing that the child will outgrow this developmental phase - Correct Answers ✅3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong. What is most appropriate for a nurse to say when interviewing a newly admitted depressed client whose thoughts are focused on feelings of worthlessness and failure? 1 "Tell me how you feel about yourself." 2 "Tell me what has been bothering you." 3 "Why do you feel so bad about yourself?" "What can we do to help you while you're here?" - Correct Answers ✅1 Because major depression is a result of the client's feelings of self-rejection, it is important for the nurse to have the client initially identify these feelings before developing a plan of care. Later discussion should be focused on other topics to prevent reinforcement of negative thoughts and feelings. "Tell me what has been bothering you" is asking the client to draw a conclusion; the client may be unable to do so at this time. Also, depression may be related not to external events but instead to a client's psychobiology. Asking why does not let a client explore feelings; it usually elicits an "I don't know" response. "What can we do to help you while you're here?" is beyond the scope of the client's abilities at this time. A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? 1 "I don't feel too good today." 2 "I feel much better; today is a lovely day." "I feel a little better, but it probably won't last." 4 "I'm really tired today, so I'll take things a little slower." - Correct Answers ✅2 A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't last"; and "I'm really tired today, so I'll take things a little slower" are all typical of the depressed client; none of these statements signals a change in mood. During a group discussion it is learned that a group member hid suicidal urges and committed suicide several days ago. What should the nurse leading the group be prepared to manage? 1 Guilt of the co-leaders for failing to anticipate and prevent the suicide 2 Guilt of group members because they could not prevent another's suicide 3 Lack of concern over the suicide expressed by several of the members in the group Fear by some members that their own suicidal urges may go unnoticed and that they may go unprotected - Correct Answers ✅4 Ambivalence about life and death, plus the introspection commonly found in clients with emotional problems, can lead to increased anxiety and fear among the group members. These feelings must be handled within the support and supervisory systems for the staff; the group members are the primary concern. Guilt that the group's leaders or members might feel because they could not prevent another's suicide will probably be a secondary concern of the group leader. Lack of concern over the suicide expressed by several of the members in the group is not a primary concern, but this should be explored later to determine the reason for such apparent indifference, which may be a mask to cover true feelings. Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test - Correct Answers ✅2 Skeletal growth in a child can be determined from the ossification centers. At 5 to 6 months of age, the capitate and hamate bones in the wrist are the earliest centers. Therefore radiographs of the hand and wrist will help determine skeletal growth in the child. Electroencephalogram reports will help assess a child's brain activity. MRI is used to scan the internal structures of a client. The Denver Developmental Screening Test is used to understand developmental issues of a child. A client describes his delusions in minute detail to the nurse. How should the nurse respond? 1 Changing the topic to reality-based events 2 Continuing to discuss the delusion with the client Getting the client involved in a social project with peers 4 Disputing the perceptions with the use of logical thinking - Correct Answers ✅1 Decreasing time spent on delusions prevents reinforcement of psychotic thinking. Discussing reality-based events improves contact with reality. Encouraging discussion will give validity to the delusion. The client will have difficulty getting involved in a social activity; the activity will not stop the delusion. Challenging the client may increase anxiety. A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Older single man just found to have pancreatic cancer Middle-age woman experiencing dysfunctional grieving - Correct Answers ✅3 Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems. Which stages would the nurse explain that a toddler goes through, according to Freud's theory? Select all that apply. 1 Anal 3 Phallic 4 Genital 5 Latency - Correct Answers ✅12 According to Freud's theory, a toddler goes through the oral and anal stages. The phallic stage is seen in children between the ages of 3 to 6 years. The genital stage is seen during puberty through adulthood. The latency stage is seen in children ages 6 to 12 years of age. A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? 1 Inept 2 Eccentric 3 Impulsive 4 Dependent - Correct Answers ✅3 Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder. An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. What initial statement by the nurse during the admission procedure would be most helpful to this client? 1 "You're a little disoriented now, but don't worry. You'll be all right in a few days." 2 "Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you." 3 "I'm the nurse on duty today. You're in the hospital. Your family can stay with you for a while." 4 "Let me introduce you to the staff here first. In a little while I'll get you acquainted with our unit routine." - Correct Answers ✅2 Familiarity with the environment and a self-introduction may help promote security and feelings of trust. Telling the client "You're a little disoriented now, but don't worry. You'll be all right in a few days" denies the client's feelings and provides false reassurance. A self-introducing one's self followed by telling the client that of being in the hospital and that the family may stay for a while denies the client's feelings but does provide self- introduction and orientation regarding the client's location. A person under stress cannot assimilate much information; verbiage could lead to more confusion. Which identity may fail to develop if the adolescent fails to feel a sense of belonging and acceptance? 1 Sexual identity 2 Group identity 3 Family identity 4 Health identity - Correct Answers ✅2 Failure to feel acceptance and belonging results in failure to establish a group identity. A lack of physical evidence of maturity can predispose the adolescent to fail to establish a sexual identity. Adolescents depend on these physical cues because they want assurance of maleness or femaleness and do not wish to be different from their peers. If an adolescent fails to foster independence and balance in the family structure, it may hamper family identity. Healthy adolescents evaluate their own health on the basis of feelings of well-being, ability to function normally, and absence of symptoms. In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting? [Show Less]
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