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NURS 203 HESI Final Exam All Answers Provided

NURS 203 HESI Final Exam All Answers Stuvia.com - The Marketplace to Buy and Sell your Study Material NURS 203HESI Final 1A client with multiple sclerosis... [Show More] is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) aPlatelet count b- White blood cell count (WBC) cSodium and potassium deRed blood cell count (RBC) Albumin and protein 2- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply) aSausage patties and eggs b- Whole wheat toast and jam cBagels and cream cheese de3Toaster pastries and milk Blackberries and oatmeal After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) aTake out dentures and place in a labeled cup bcde4Apply a body shroud Place a small pillow under the head Remove resuscitation equipment from the room Gently close the eyes A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? aTell the client to have a complete blood count (CBC) drawn bcd5Instruct the client to seek medical attention immediately Encourage him to take the medication at night with a snack Explain that these are common side effects of the medication An older adult male is admitted with complications related to chronic obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material a- b- c- d- 6- Restrict daily fluid intake Eat meals at the same time daily Maintain a low protein diet Limit the intake of the high calorie foods A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? a- Granulating tissue in foot ulcer b- c- d- 7- Full volume of pedal pulse Reduced level of pain Improved visual activity. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes? a- The fating blood sugar was 120 mg/dl this morning. b- c- d- 8- Urine ketones have been negative for the past 6 months The hemoglobin A1C was 6.5g/100 ml last week No diabetic ketoacidosis has occurred in 6 months. A heparin infusion is prescribed for a client who weights 220 pounds. After administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. (Enter numeric value only. If rounding to the nearest whole number.) 18 9- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first? a- Assess extremity strength and resistance b- c- d- 10- Report a sodium level of 132 mEq/L or mmol/L (SI units) Measure and record the cardiac QRS complex Check current finger stick glucose The nurse assesses an older adult who is newly admitted to a long term care facility. The client has dry, flaky skin and long thickened fingernails. The clients has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)? a- Soak and file fingernails b- c- d- Offer fluids frequently Monitor skin elasticity Ambulate in the hallway 11- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material pump to deliver how many ml/hr? (Enter numeric value only. If rounding to the nearest whole number.) 45 12- The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique? (Arrange from first action on top to last action on bottom) Remove old dressing using clean gloves. Discard gloves with old dressing Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area” Apply sterile gauze dressing to wound area Secure dressing with tape 13- The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speaker together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next? a- Clarify the client‟s consent through the use of gesture and simple terms b- c- d- Have the interpreter co-sign the consent to validate client understanding Ask for full explanation from the interpreter of the witnessed discussion Have the client sign the consent and the nurse witness the signature 14- A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? a- Signs a no-self-harm contract. b- c- d- Sleep at least 6 hours nightly. Attends group therapy every day Verbalizes a positive self-image. 15- After receiving report, the nurse can most safely plan to assess with client last? a- An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material b- An adult client with no postoperative drainage in the Jackson- Pratt drain with the bulb compressed c- An older client with a distended abdomen and no drainage from the nasogastric tube d- 16- An adult client with rectal tube draining clear pale red liquid drainage The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? a- Wearing gloves when interviewing the client b- Encouraging the client to join a support group c- d- Shaking the client's hand during an introduction. Allowing the client to ventilate feelings 17- A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? a- Fetal heart tones located in upper right quadrant b- Biophysical profile results showing oligohydramnios c- Regular contractions occurring every 10 minutes d- Sterile vaginal exam reveling 3 cm dilatation 18- The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? a- Do not read without direct lighting for 6 weeks b- Avoid straining at stool, bending, or lifting heavy objects. c- Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d- Limit exposure to sunlight during the first 2 weeks when the cornea is healing. 19- After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this?” Based on this response, the nurse decides to include which nursing problem in the client‟s plan of care? a- Ineffective coping b- Spiritual distress c- Acute pain d- Complicated grieving 20- Un infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material C 21- A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply) a- Invite data review by the quality improvement department b- c- Submit a sentinel event report to the research committee Propose clinical practice guidelines to the nursing committee d-Obtain informed consent from clients who will receive care e-Arrange inservice training through the educational department 22- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse best response? (nits liendra) a- When the classroom epidemic subsides b- Two weeks after the last treatment c- As soon as the itching stops d- After the treatment kills all the live lice 23- A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a- Review the heart rhythm on cardiac monitors b- c- Check urinary catheter for obstruction Auscultated bilateral breath sounds d-Give PRN dose of lorazepam (Ativan) 24- What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? a- Prevent spread of infection to others Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material b- c- Improve function of the immune system Increase ability to carry out activities of daily living e- Promote a feeling of general well-being 25- When assessing a client with acute asthma, the nurse is most likely to obtain which finding? a- Pursed lip breathing and clubbing of fingers b- Fever and a high- pitched inspiratory stridor c- A short expiratory phase and hemoptysis d- Cough and musical breath sound on expiration 26- During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client‟s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) 27- Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? a- Intravenous administration of thyroid hormones b- c- d- Oral administration of hypnotic agents Intravenous bolus of hydrocortisone Subcutaneous administration of vitamin k 28- A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? a- Encourage the use of corrective lenses during the day b- Practice visual exercises that focus on a still object c- Alternate an eye patch from eye every 2 hours Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material d- Teach techniques for scanning the environment. 29- The nurse applies a blood pressure cuff around a client‟s left thigh. To measure the client‟s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) “On left thigh with arrow pointing to inner thigh” 30- Which intervention should the nurse include in the plan of care for a patient with tetanus? Open window shades to provide natural light a- Encourage coughing and deep breathing b- Minimize the amount of stimuli in the room c- Reposition from side to side every hour 31- The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant‟s plan of care? a- Initiate infant sepsis protocol b- Implements seizure precautions c- Refer to protective child services d- Formula feed every 3 hours 32- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client‟s teaching plan? (Select all that apply.) a- Take an additional dose for signs of hyperglycemia b- c- Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material d- e- Use sliding scale insulin for finger stick glucose elevation. Take Glucophage with the morning and evening meal. 33- A client with leukemia undergoes a bone marrow biopsy. The client‟s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a- Observe aspiration site. b- c- d- Assess body temperature Monitor skin elasticity Measure urinary output 34- A client collapses while showering and is found discovered by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next? a- Follow the prompts of the AED b- Apply the AED pads to the client’s chest c- Wipe the client’s chest dry d- Move the client from the bathroom 35- A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? a- Encourage family members to cook meals outdoors and bring the cooked food inside b- Advise the client to replace cooked foods with a variety of different nutritional supplements c- Assess the client‟s mucus membranes and report the findings to the healthcare provider d- Instruct the clients to take an antiemetic before every meal to prevent excessive vomiting. 36- A 13 years-old girl, 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 sandwiches before gym class b- Incorrectly drew up and administered too much insulin c- Was not hungry, so she skipped eating lunch d- Has had a cold and ear infection for the past two days 37- At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client‟s electronic health record, which priority nursing action should the nurse implement? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client‟s medical record. Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material a- Administer insulin per sliding scale b- Assess appearance of foot wound c- Obtain antibiotic peak and trough levels d- Initiate hourly urine output measurements 38- Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? a- Relieve any kinks or obstruction in the client‟s Foley tubing b- c- Asses the client‟s blood pressures every 15 minutes Administer a prescribed PRN dose of hydralazine (Apresoline) e-Teach the client to recognize symptoms of dyreflexia 39- After a motor vehicle collision a client admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement? a- Determine serum glucose levels b- Withhold potassium additives to IV fluids c- Give IV corticosteroid replacement d- Prepare to initiate IV vasopressors 40- Which instruction is most important for the nurse to provide a client who receives a new prescription for risedronate sodium to treat osteoporosis a- Remain upright after taking the medication b- c- Increase intake of foods rich in calcium Begin a weight-bearing exercise plan e- Schedule a bone density test every year. 41- The unlicensed assistive personnel (UAP) reports that a client‟s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? a- Advise the UAP to document the last blood pressure obtained on the client graphic sheet b- Estimate the blood pressure by assessing the pulse volume of the client‟s radial pulses c- Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed d- Document why the blood pressure cannot be accurately measured at the present time Downloaded by: mairetpupo | mairetpupo@yahoo.com Distribution of this document is illegalStuvia.com - The Marketplace to Buy and Sell your Study Material 42- The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? a- Change the dressing using a compression bandage b- Test fluid on the dressing for glucose c- Document the findings in the electronic medical record d- Mark drainage area with a pen and continue monitor 43Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client‟s constipation, which suggestions should the nurse provide? (Select all that apply) aDecrease laxative use to every other day, and use oil retention enemas as needed. bcdeInclude oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation. Report constipation to healthcare provider related to cardiac medication side effects. 44- A male client with diabetes mellitus takes NPH/ regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the azithromycin an hour before breakfast as instructed. What action should the nurse implement? a- Provide a PRN dose of an antacid to take with the azithromycin right after breakfast b- Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin c- Instruct the client to eat his breakfast and take the azithromycin two hours after eating d- Tell the client to skip that day‟s dose [Show Less]

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