NURSING DE MSN5410
HESI PRACTICE TEST MULTIDISCIPLINARY ASSIGNMENT QUIZ
A nurse is preparing to insert a rectal
... [Show More] suppository and observes a small amount of rectal bleeding. What action should the nurse implement?
Administer the medication as scheduled after assessing the client's vital signs.
Ask the pharmacist to send an alternate form of the prescribed medication to the unit. Withhold the administration of the suppository until contacting the healthcare provider.
Insert the suppository very gently being careful not to further injure the rectal mucosa.
Rationale
The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B).
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle strength.
Increase in abdominal fat deposits.
Rationale
An increase in the abdominal girth is a risk factor for the development of metabolic syndrome. According to the American Heart Association, men with a waist size 40 inches or larger and women 35 inches or larger double their risk factor of developing CAD and increase their chances 5Xs of developing DMII.
The home health nursing director is conducting an educational program for registered nurses and practical nurses about Medicare reimbursement. To obtain payment for Medicare services, what must be included in the client's record?
Documentation of a skilled care service provided during the visit. A copy of the client's health history and social security card.
A record of the preventative healthcare services provided during the visit.
Rationale
All home health visits must include documentation of a skilled service (B) to qualify for Medicare reimbursement, and these services must be reasonable and necessary. (A) does not mean that the service prescribed is a skilled service for a homebound client or that it is reasonable and necessary. (C) is not necessary for Medicare reimbursement, but all client records should contain a health history. Medicare does not reimburse for preventative (D) or maintenance health services, such as annual physical examinations or mammograms.
The occupational health nurse is completing a yearly self-evaluation. Which activity should the nurse document as an example of proficient performance criteria in professionalism?
Contributes money to a professional society or organization.
Maintains chairmanship of the hospital nursing council. Documents the nursing process in care management.
Develops policy initiatives that impact occupational health and safety.
Rationale
Leadership roles (B) in advancing the profession is an example of proficient performance criteria in professionalism under occupational and environmental health nursing. Supporting a professional society (A) is an example of competent performance criteria in professionalism. Using and documenting the nursing process in care management (C) is an example of competent performance criteria in clinical and primary care. Participating in or guiding the development of policy initiatives that impact occupational health and safety (D) at all levels is an example of expert performance criteria.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate?
Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.
Rationale
Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention?
Prolonged exhalations. Thick yellow rhinorrhea.
Frequent nonproductive cough.
Oxygen saturation is 95% by pulse oximeter.
Rationale
Prolonged exhalation indicates breathing difficulty, and intervention for this should be taken immediately. According to the
indicative of lower airway obstruction.
A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?
A scalp laceration oozing blood. Serosanguineous nasal drainage.
Headache rated "10" on a 0-10 scale.
Dizziness, nausea and transient confusion.
Rationale
Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.
How should the nurse measure the length of a 14-month-old child ?
Standing height.
Prone recumbent position. Supine recumbent position.
Side-lying position.
Rationale
Children younger than 24 to 36 months of age should be measured for length in the supine position from crown to heel, known as recumbent length.
The nurse is planning a nutrition class for a group of high school students emphasizing the goals for nutrition from Healthy People 2020 . Which meal selection provides the best choices in meeting these goals?
Pasta with cheese sauce, garlic butter bread, and vegetable juice drink. A 6-ounce pork chop, creamed peas, cheese sauce on potatoes, coffee.
Vegetable lasagna, lettuce salad, a whole-wheat roll, 8-ounces of 2% milk.
Bacon, lettuce, tomato sandwich, whole grain chips, 8-ounces of whole milk.
Rationale
Healthy People 2020 sets goals for Nutrition, Physical Activity, and Obesity and recommends a diet high in fiber and low in fat, including nutrient dense foods of fruits and vegetables. The meal of vegetable lasagna, lettuce salad, a whole wheat roll, and 2% milk meets these requirements (C). Pasta with cheese sauce and garlic butter bread (A) are both heavy in fat and refined starches preventing this from being the best choice. The meal of a pork chop, creamed peas, cheese au gratin potatoes (B) are high in fat and carbohydrates. The selection of bacon, lettuce, and tomato sandwich includes vegetables, the bacon, chips and whole milk (D) are high in fat content.
The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action?
Encourage the client to stop pacing and sit down. Reevaluate the client's blood pressure in an hour.
Direct the client to attend recreational therapy.
Review the client's baseline blood pressure.
Rationale
The client is irritable and pacing, which can contribute to the elevated BP. A reevaluation of the client's BP in an hour allows time for the excitement and stress of the admission process to abate. The other actions are not indicated at this time.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns. Alteration in maternal blood pressure.
Rationale
Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client.
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).
A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will always be this way and that there's no hope for me." What information should the nurse provide?
Panic disorder is treatable in a number of different ways, including medication.
Understanding the fact that a cure is not attainable helps the client learn to adjust. This disorder is a biologically determined hereditary disease that has no cure.
Evidence based practice indicates that neuroleptic drugs can be used prophylactically.
Rationale
To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications, should be discussed. The other information does not provide accurate information.
What client statement indicates to the nurse that the client requires assistance with bathing?
"I wasn't able to pack a bag before I left for the hospital."
"I don't understand why I'm so weak and tired."
"I only bathe every other day."
"I left my eyeglasses at home."
Rationale
Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client.
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."
The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented?
Place socks on infant. Elevate feet 15 degrees.
Wrap feet loosely in prewarmed blanket. Report findings to the healthcare provider.
Rationale
Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective resolution of this potentially serious complications.
A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding?
Milk allergy.
Failure to thrive.
Inadequate milk supply in mother.
Normal growth curve of a breast-fed infant.
Rationale
When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast- fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C).
A client is experiencing "back" labor and complains of intense pain in the lower lumbar- sacral area. What action should the nurse implement?
Perform effleurage on the abdomen.
Encourage pant-blow breathing techniques. Apply counter pressure against the sacrum.
Assist the client in guided imagery.
Rationale
Counter pressure against the sacrum (C) during contractions often provides significant relief for "back labor," which results from occipital posterior position. Effleurage (A) is a helpful distraction strategy many clients use during contractions but does not assist with lower back pain. Back labor can occur throughout labor if the fetus does not rotate, and helpful distractions, such as (B), used during transition, and (D), used during phase one of labor, are not effective for back labor.
A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?
Assist the client in verbalizing distress about the disease.
Inquire about emotional factors affecting the client's present condition.
Assess priorities to be set for the client's overall nursing care plan.
Encourage the client to emotionally accept the chronicity of the disease.
Rationale
Holistic care considers biological, psychological, and sociocultural factors that influences one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition should be made. The other actions are not the priority.
A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement?
Notify the healthcare provider of the measurement.
Quiet the child and retake the blood pressure.
Ask the parent if the child has a history of hypertension. Document the finding and recheck in 4 hours.
Rationale
When a child is crying, intra-thoracic and abdominal pressures increase and are reflected in an elevation of systemic blood pressure, so the nurse should quiet the child before retaking the blood pressure.
Which client is at highest risk for compromised psychological adjustment after a hysterectomy?
A 46-year-old woman with three children and a recent promotion at work.
A 55-year-old woman with abnormal bleeding and pain for 3 years.
A 62-year-old widow who has three friends who had uncomplicated hysterectomies.
A 29-year-old woman whose uterus ruptured after giving birth to her first child.
Rationale
The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities.
The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern?
Violation of ethical principles. Poor time management skills. Dissatisfaction of co-workers. Reduction of client complaints.
Rationale
The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for care. This reflects a violation of the ethical principle of justice (A). Counseling the nurse about (B) is important because using time effectively allows the nurse to ensure that all clients receive fair and equal treatment, but this is of less concern than (A). (C and D) may also be important concerns, but they are secondary to ensuring justice.
What is the best action for the nurse to take when initiating contact with a toddler for the first time?
Ask the toddler to point to where it hurts.
Tell the child your name and that you are the nurse. Call the child by name while picking up the toddler.
Kneel in front of the toddler and speak softly to the child.
Rationale
The toddler perceives the nurse as a stranger, so a more positive interaction occurs when the toddler perceives the meeting in a nonthreatening way. Placing oneself at the toddler's eye level and speaking softly can be less threatening for the child. Asking direct questions, giving your name and telling the toddler you are the nurse or picking a toddler up at an initial meeting are perceived as threatening actions by the child and will more likely result in a negative response from the child.
During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client?
On a scale of 1 to 10 how do you rate your anxiety level? How would you describe your mood right now?
Have you had any thoughts of hurting yourself?
What medications have you taken in the last 24 hours?
Assessing for suicidal ideation is most essential. The other assessments should be made, and to ensure client safety, thoughts of self-harm are most important. [Show Less]