HESI 3
PRACTICE TEST ASSESSMENT PERFORMANCE
A female client informs the nurse that she uses herbal therapies to
... [Show More] supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?
Most herbs are toxic or carcinogenic and should be used only when proven effective.
There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health.
Herbs should be obtained from manufacturers with a history of quality control of their supplements.
Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.
Rationale
The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading.
As the nurse prepares the equipment to be used to start an IV on a
4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement?
Take the child back to his room. Recruit others to restrain the child.
Ask the mother to be present to soothe the child. Show the child how to manipulate the equipment.
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened.
A client is demonstrating a positive Chvostek's sign. What action
should the nurse take?
Observe the client's pupil size and response to light.
Ask the client about numbness or tingling in the hands.
Assess the client's serum potassium level. Restrict dietary intake of calcium-rich foods.
Rationale
A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and
C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium.
Which nursing intervention is most beneficial in reducing the risk
of urosepsis in a hospitalized client with an indwelling urinary catheter?
Ensure that the client's perineal area is cleansed twice a day.
Maintain accurate documentation of the fluid intake and output.
Encourage frequent ambulation if allowed or regular turning if on bedrest.
Obtain a prescription for removal of the catheter as soon as possible.
Rationale
The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis.
In assessing a client's femoral pulse, the nurse must use deep
palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement?
Elevate the head of the bed and attempt to palpate the site again.
Document the presence and volume of the pulse palpated. Use a thigh cuff to measure the blood pressure in the leg. Record the presence of pitting edema in the inguinal area.
Rationale
Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D).
The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw- colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?
Stage 1 pressure sore draining sero-sanguineous drainage. Pressure sore at bony prominence with exudate noted.
One-inch pressure sore draining serous fluid.
Pressure sore on heel with a small amount of purulent drainage.
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero- sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells.
A nurse observes a student nurse taking a copy of a client's
medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first?
Ask the nursing supervisor to meet with the students. Notify the student's clinical instructor of the situation.
Ask the student if permission was obtained from the client.
Explain that the records are hospital property and may not be removed.
Rationale
The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B) so that all students can be educated regarding copying and
removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information.
What action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
Avoids questions about male-female relationships.
Explains the differences between Western medical care and cultural folk remedies.
Applies knowledge of a cultural group unless a client embraces Western customs.
Rationale
Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.
A client who has moderate, persistent, chronic neuropathic pain
due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
Continue gabapentin. Discontinue ibuprofen.
Add aspirin to the protocol.
Add oral methadone to the protocol.
Rationale
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given “around the clock” rather than by the client’s PRN requests.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?
Removing the empty food tray from a client with a urinary catheter.
Washing and combing the hair of a client with a fractured leg in traction.
Administering oral medications to a cooperative client with a wound infection.
Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
Rationale
Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves.
A medication is prescribed to be given QID. What schedule should
the nurse use to administer this prescription?
0800, 1200, 1600, 2000.
0800.
Every other day at 0800.
0800, 1200, 1600, 2000, 0000, 0400.
Rationale
(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages.
Prior to administering a newly prescribed medication to a client,
the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process?
Assessment.
Analysis.
Implementation.
Evaluation.
Rationale
The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care.
A 35-year-old female client with cancer refuses to allow the nurse
to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate?
Review the client's medical record for an advance directive.
Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice.
Evaluate the client's mental status for competence to refuse treatment.
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained.
An older client who is able to stand but not to ambulate receives a
prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair?
Use a mechanical lift to transfer from the bed to a chair.
Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
Rationale
A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt. A mechanical lift is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client out of bed places the client and nurses at risk for injury and should only be implemented by skilled "lift teams."
While preparing to insert a rectal suppository in a male adult client,
the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?
Advise the client to continue to bear down without holding his breath. Gently insert the lubricated suppository four inches into the rectum.
Perform a digital exam to determine if a fecal impaction is present. Instruct the client to take slow deep breaths and stop bearing down.
Rationale
During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C).
When teaching a female client to perform intermittent self-
catheterization, the nurse should ensure the client's ability to perform which action?
Locate the perineum.
Transfer to a commode.
Attach the catheter to a drainage bag.
Manipulate a syringe to inflate the balloon.
Rationale
Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D).
Which statement best describes durable power of attorney for
health care?
The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.
The healthcare decisions made by another person designated by the client are not legally binding.
Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding.
Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.
Rationale
The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time.
To obtain the most complete assessment data for a client with
chronic pain, which information should the nurse obtain?
Can you describe where your pain is the most severe? What is your pain intensity on a scale of 1 to 10?
Is your pain best described as aching, throbbing, or sharp?
Which activities during a routine day are impacted by your pain?
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D),
such as sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors elicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number.
Which technique is most important for the nurse to implement
when performing a physical assessment?
A head-to-toe approach.
The medical systems model.
A consistent, systematic approach.
An approach related to a nursing model.
Rationale
The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems.
A middle-aged woman who enjoys being a teacher and mentor
feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?
Generativity. Ego integrity. Identification.
Valuing wisdom.
Rationale
Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory.
The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? [Show Less]