AND OTHER HESI EXAMS)
1. A client tells the nurse that he is suffering from insomnia. Which
information is most important for the nurse to obtain?
A.
... [Show More] The client's usual sleeping pattern
B. Whether the client smokes
C. How much liquid the client consumes
before bedtime
D. The amount of caffeine that the client
consumes during the day
Rationale:
The first thing to determine is the client's usual sleeping pattern and how
it has changed to become what the client describes as insomnia. Options
B, C, and D provide additional information after option A is ascertained.
2. A client has been on a mechanical ventilator for several days. What
should the nurse use to document and record this client's
respirations?
A. The respiratory settings on the ventilator
B. Only the client's spontaneous respirations
C. The ventilator-assisted respirations minus
the client's independent breaths
D. The ventilator setting for respiratory rate
and the client-initiated respirations
Rationale:
The nurse should count the client's respirations and document both the
respiratory rate set by the ventilator and the client's independent
respiratory rate. Never rely strictly on option A. Although the client's
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A+
spontaneous breaths will be shallow and machine-assisted breaths will
be deep, it is important to record machine-assisted breaths as well as the
client's spontaneous breaths to get an overall respiratory picture of the
client.
3. Six hours following thoracic surgery, a client has the following
arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg;
HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the
nurse implement based on these results?
A. Increase the oxygen flow rate from 4 to 10
L/min per nasal cannula.
B. Assess the client for pain and administer
pain medication as prescribed.
C. Encourage the client to take short shallow
breaths for 5 minutes.
D. Prepare to administer sodium bicarbonate
IV over 30 minutes.
Rationale:
These ABGs reveal respiratory alkalosis, and treatment depends on the
underlying cause. Because the client is only 6 hours postoperative, he or
she should be assessed for pain because treating the pain will correct the
underlying problem. A PaO2 of 96 mm Hg does not indicate the need for
an increase in oxygen administration. The PaCO2 indicates mild
hyperventilation, so option C is not indicated. In addition, it is very
difficult to change one's breathing pattern. The use of sodium
bicarbonate is indicated for the treatment of metabolic acidosis, not
respiratory alkalosis.
4. A 77-year-old female client states that she has never been so large
around the waist and that she has frequent periods of constipation.
Colon disease has been ruled out with a flexible sigmoidoscopy.
Which information should the nurse provide to this client?
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A+
A. As women age, they often become rounder
in the middle because they do not exercise
properly.
B. Further assessment is indicated because
loss of abdominal muscle tone and
constipation do not occur with aging.
C. With age, more fatty tissue develops in the
abdomen and decreased intestinal
movement can cause constipation.
D. Because there is no evidence of a diseased
colon, there is no need to worry about
abdominal size.
Rationale:
With aging, the abdominal muscles weaken as fatty tissue is deposited
around the trunk and waist. Slowing peristalsis also affects the emptying
of the colon, resulting in constipation. Option A is not the primary
reason for the changes in body structure. Option B is not indicated
because loss of muscle tone and constipation are age-related changes.
Option D dismisses the client's concerns and does not help her
understand the changes that she is experiencing.
5. A mother of a 12-year-old boy states that her son is short and she
fears that he will always be shorter than his peers. She tells the
nurse that her grown daughter only grew 2 inches after she was 12
years of age. To provide health teaching, which question is most
important for the nurse to ask this mother?
A. "Is your son's short stature a social
embarrassment to him or the family?"
B. "What types of foods do both your children
eat now and what did they eat when they
were infants?"
C. "Did any significant trauma occur with the
birth of your son?"
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