Fundamental HESI, Hesi Fundamentals, Hesi Fundamentals Practice Test, UNIT 1: Foundations of Nursing...D) Rashes in the axillary, groin, and skin fold
... [Show More] regions - ANSWER D) Rashes in the axillary, groin, and skin fold regions
Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
A) Adequate venous blood flow to the lower extremities.
B) Estimated amount of body fat by an underarm skinfold.
C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters - ANSWER C) Degree of flexion and extension of the client's knee joint
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?
A) 42 gtt/min.
B) 83 gtt/min.
C) 125 gtt/min.
D) 250 gtt/min - ANSWER B. 83 gtt/min
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client?
A) Obtain an interpreter to explain the procedure to the client.
B) Encourage the client to make her own decision regarding surgery.
C) Ask the family members to provide an interpretation of the surgeon's explanation to the client.
D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. - ANSWER D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided
Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
A) is to be expected, and progresses with age.
B) often follows relocation to new surroundings.
C) is a result of irreversible brain pathology.
D) can be prevented with adequate sleep - ANSWER B) often follows relocation to new surroundings
Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
A) Explain that anyone who speaks her language can answer her questions.
B) Provide a translator only in an emergency situation.
C) Ask a family member or friend of the client to translate.
D) Request and document the name of the certified translator. - ANSWER D) Request and document the name of the certified translator
A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
A) 31 gtt/min.
B) 62 gtt/min.
C) 93 gtt/min.
D) 124 gtt/min - ANSWER D) 124 gtt/min
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
A) 13 ml/hour.
B) 63 ml/hour.
C) 80 ml/hour.
D) 125 ml/hour - ANSWER B) 63 ml/hour
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
A) Request another nurse to complete the physical assessment.
B) Ask the client to stop crying and tell the nurse what is wrong.
C) Acknowledge the client's distress and tell her it is all right to cry.
D) Leave the room so that the client can be alone to cry in private. - ANSWER C) Acknowledge the client's distress and tell her it is all right to cry
Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met?
A) Expresses concern about the meaning and importance of life
B) Remains angry at God for the continuation of the illness.
C) Accepts that punishment from God is not related to illness.
D) Refuses to participate in religious rituals that have no meaning. - ANSWER C) Accepts that punishment from God is not related to illness
Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
A) Commend the client for selecting a high biologic value protein.
B) Remind the client that protein in the diet should be avoided.
C) Suggest that the client also select orange juice, to promote absorption.
D) Encourage the client to attend classes on dietary management of CRF - ANSWER A) Commend the client for selecting a high biologic value protein
Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client
A) asks relevant questions regarding the dressing change.
B) states he will be able to complete the wound care regimen.
C) demonstrates the wound care procedure correctly.
D) has all the necessary supplies for wound care. - ANSWER C) demonstrates the wound care procedure correctly
A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care
Immediate defibrillation
Explanation:
Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present. - ANSWER You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?
0.24 seconds
Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds would indicate a first-degree heart block. - ANSWER Which PR interval presents a first-degree heart block?
Sinus bradycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a slower than usual (≤60 beats/minute) rate. Sinus bradycardia is a slower than usual (≤60 beats/minute) heart rate. - ANSWER A 66-year-old female client is having cardiac diagnostic tests to determine the cause of her symptoms. In her follow-up visit to the cardiologist, she is told that she has a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia did the tests reveal?
The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. - ANSWER P Wave
The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. - ANSWER PR Interval
The QRS complex represents ventricular depolarization. - ANSWER QRS Complex
The T wave depicts the relative refractory period, representing ventricular repolarization - ANSWER T Wave
The duration of regular insulin is 4 to 6 hours; 3 to 5 hours is the duration for rapid-acting insulin such as Novolog. The duration of NPH insulin is 12 to 16 hours. The duration of Lantus insulin is 24 hours
Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus) - ANSWER Duration of Insulin is:
Once digested, 100% of carbohydrates are converted to glucose. However, approximately 40% of protein foods are also converted to glucose, but this has minimal effect on blood glucose levels - ANSWER Once digested, what percentage of carbohydrates is converted to glucose
Immediate bystander CPR
Explanation:
The treatment of choice for v-fib is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services - ANSWER Which of the following is the treatment of choice for ventricular fibrillation
used to treat ventricular fibrillation and unstable ventricular tachycardia - ANSWER Amiodarone
used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation - ANSWER Lidocaine
used to treat symptomatic bradycardia - ANSWER atropine
Desmopressin
Why? - ANSWER The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
Serum Potassium - ANSWER After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?
Hypoglycemia - ANSWER Glucagon is used primarily to treat a patient with
Early morning hyperglycemia resulting from increased growth hormone circulation - ANSWER dawn phenomenon
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the AV node."
Explanation:
The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. In a normal heart the impulses do not travel backward. The PR interval does not include the time it take to travel through the Purkinje fibers - ANSWER P-R interval
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy.
Explanation:
Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy - ANSWER A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?
subset of type 2 due to hormone release from placenta resist insulin
2nd & 3rd Trimester, give glucose challenge, dx if over 126 - ANSWER Gestational Diabetes
TX: insulin, meal spacing - ANSWER Type I
Treat: Sulfonurea (Increase insulin) + biguanide (incr. isnulin sensitivity), diet & exercise - ANSWER Type 2
Disease in blood vessels, in SMALLER (eyes, diabetic retinapothy) - ANSWER Microangiopathy
Larger vessel damage - ANSWER Macroangiopathy
clots build up, accelorates athro sclerosis, which can lead to myocardial infarction - ANSWER Macrovascualr Angiopathy
blood seeps & protein leaks out, leads to blindness (diabetic retinapothy) - ANSWER Microvascualr Angiopathy
Impaired glucose tolerance 140-199
impaired fasting glucose 110-126
screen at 40 is FHx present
encourage weightloss - ANSWER pre-diabetes
Central Obesity, in a prothrombotic state (prone to clots), proinflammatory state, dyslipidemia, elevated BP 135/85
These people WILL get heart disease & diabetes - ANSWER Metabolic Syndrome
Symptoms + BG >=200ml/dl at any time w/o regard to meal
2hr post-load glucose >200 (oral gluc test)
fasting >126 - ANSWER Diagnostic Criteria
Onset: 10-15 m
Duration:2-4 hours
Peak:1 hours
Lispro (Humalog), Aspart, Apidra
Give with breakfast - ANSWER Rapid Acting
Regular(Humalin), Semilente
Onset: 1-1.5 hr
Duration: 4-6 hours
Peak: 2-3 hours - ANSWER Short Acting
Lente, NPH
Onset: 2-4 hrs
Duration: 16-20 hours
Peak: 4-12 hours - ANSWER Intermediate
Ultra Lente, Glargine (LANTUS)
Onset: 1 hr
Duration: 24 hrs
NO PEAK - ANSWER Long Acting
Hr is 150-250
no p wave (cant determine atrial rate)
No Pulse: defibrillator, amiodarone, cpr, acls
Pulse: cardiovert/amioderano - ANSWER Vtach
Rate is verrrry fast
Defib, acls, amiodarone - ANSWER Vfib
Heart isnt beating fast enough to circulate O2, atropine - ANSWER Sinus brady
Vagus stimulate, adenisone, cardiovert
Narrow QRS - ANSWER Svt
QRS always widened
Treat with lidocaine Irregular rythm
Can lead to vtach or vfib - ANSWER Pvc
Sawtooth
Atrial rate 250-350
Ventricular rate is steady
Cardioversion, cardizem (verapamil), amiodarone - ANSWER Atrial flutter
Spasms in atrial (many pwaves), blood pools-- tx with anticoagulant (warfarin), cardizem, digoxin & cardiovert if symptoms present - ANSWER A fib
Acls and cpr asap! - ANSWER Asystole
When to use?
Morphine, O2, nitroglycerin, aspirin - ANSWER MONA
Atropine
Conduction is slow, rate can be normal - ANSWER 1st degree av block
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma?
1
Chlorothiazide (Diuril)
2
Acetazolamide (Diamox)
3
Bendroflumethiazide (Naturetin)
4
Demecarium bromide (Humorsol) - ANSWER 2
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response?
1
Tell the client it is nothing to worry about.
2
Talk with the client further to identify the specific cause of the problem.
3
Instruct the client to attempt to avoid situations that cause irritation.
4
Interview the client to determine whether other mood swings are being experienced. - ANSWER 4
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response?
1
Tell the client it is nothing to worry about.
2
Talk with the client further to identify the specific cause of the problem.
3
Instruct the client to attempt to avoid situations that cause irritation.
4
Interview the client to determine whether other mood swings are being experienced. - ANSWER 4
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to:
1
Promote equalization of osmotic pressures.
2
Prevent hypoxia associated with diaphoresis.
3
Promote integrity of intracerebral neurons.
4
Reduce brain metabolism and limit hypoxia. - ANSWER 4
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL - ANSWER 1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care?
1
Risk for pressure ulcer
2
Risk for impaired skin integrity
3
Impaired skin integrity, related to infrequent turning and repositioning
4
Impaired skin integrity, related to the effects of pressure and shearing force - ANSWER 4
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?
1
Stage I
2
Stage II
3
Stage III
4
Unstageable - ANSWER 4
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply.
1
After reporting severe pain
2
On admission to the hospital
3
Upon entering the operating room
4
Before transfer to a rehabilitation facility
5
At time of scheduling for the surgical procedure - ANSWER 2, 4
Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values?
1
White blood cell (WBC) count of 15,000 mm3
2
Negative protein in the urine
3
Blood urea nitrogen (BUN) of 20 mg/dL
4
Prothrombin of 12.0 seconds - ANSWER 1
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client?
1
Anger
2
Denial
3
Depression
4
Acceptance - ANSWER 4
In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply.
1
Whole grains
2
Cooked fruit and vegetables
3
Nuts and seeds
4
Lean red meats
5
Milk and eggs - ANSWER 1,2,5
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the b [Show Less]