Basic Nursing Skills HESI

Which infection requires airborne precautions? Select all that apply. One, some, or all responses may be correct. A. Measles B. Influenza C. C-diff D. Bacterial meningitis E. MRSA

A. Measles

During auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest? A. Base of the heart B. Apex of the heart C. Left lateral border D. Right lateral border

B

A client with COPD exacerbation is receiving oxygen 2 L/min per nasal cannula and has an oxygen saturation of 88%. Which action would the nurse anticipate taking next? A. Increasing the oxygen flow rate to 3 L/min B. Preparing for intubation and assisted ventilation C. Administration of an inhaled rapid-acting bronchodilator D. Continuing to monitor the client with no therapy change

A

During an annual physical assessment, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? A. I B. II C. X D. VII

A (olfactory)

Which data would the nurse use to determine a client's score on the Braden scale to predict a client's risk for developing pressure injuries? Select all that apply. One, some, or all responses may be correct. A. Age B. Anorexia C. Hemiplegia D. History of diabetes E. Urinary incontinence

B, C, D, E,

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue? A. Facial B. Trigeminal C. Hypoglossal D. Glossopharyngeal

C

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. Which describes the character of this documentation. A. Diminished B. Normal C. Full D. Bounding

C. Full

Which statement by the nursing student indicates understanding of the precautions needed in the provision of care to a child who is HIV positive? A. I'll put on a mask B. I'll put on my N-95 C. I'll put on a gown and gloves D. I'll put on gloves if I'm going to be in contact with body fluids

D. I'll put on gloves if I'm going to be in contact with body fluids

Which instruction would the nurse include in a teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? A. Cut an opening about 1/3 inch larger than the stomal pattern B. Avoid the use of soap and other irritating agents C. Eat yogurt and drink buttermilk and parsley D. Empty the pouch before it is one-third full

D

While caring for a client with a portable wound drainage system, the nurse observes that the collection container is half-full. The nurse empties the container. Which nursing intervention would the nurse do next? A. Encircle the drainage on the dressing B. Irrigate the suction tube with sterile saline C. Clean the drainage port with an alcohol wipe D. Compress the container before closing the port

D

Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? A. Report of chest tightness B. Heart rate of 112 beats per minute C. Expiratory wheezes in both lungs D. Markedly decreased breath sounds

D. Markedly decreased breath sounds

After consistently obtaining a blood pressure of 140/76 mm Hg for a client, which stage of hypertension will the nurse document? A. Normal B. Elevated C. Stage 1 D. Stage 2

D. Stage 2

The nurse is obtaining a health history from a newly admitted client who has chronic pain in the right knee. Which would the nurse include in the pain assessment? Select all that apply. One, some, or all responses may be correct. A. Pain history, including location, intensity, and quality of pain B. Client's purposeful body movement in arranging the papers on the bedside table C. Pain pattern, including precipitating and alleviating factors D. Vital signs, such as increased blood pressure and heart rate E. The client's family statement about increases in pain and ambulation

A, C

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. A. Ask the client about the acceptable level of pain B. Eliminated all activities that precipitate the pain C. Administer the pain medications regularly around the clock D. Use a different pain scale each time to promote patient education. E. Assess the client's pain every 15 minutes.

A, C

Which statement is correct regarding negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct A. A suction pump is used B. Necrotizing infections are treated C. Oxygen is administered under high pressure D. A low-voltage current is applied to a wound area E. Chronic ulcers are reduced by removing fluids from the wound

A,E

After the home health nurse obtains a radial pule rate of 136 beats/minute in a client with chronic atrial fibrillation, which action would the nurse take next? A. Ask about any new stressors in the client's life B. Take the client's apical pulse for a full minute C. Notify the provider about the heart rate D. Ask whether prescribed medications have been taken

B

Which mechanism of action for wet-to-damp saline-moistened gauze for wound debridement is correct? A. Promoting the dilution of viscous exudate B. Removing necrotic tissue mechanically C. Causing a breakdown of the denatured protein of the eschar D. Promoting the spontaneous separation of necrotic tissue

B

Which statement(s) related to initial assessment of blood pressure by the nurse require(s) correction? Select all that apply. One, some, or all responses may be correct. A. Deflating the cuff too slowly will show high diastolic readings B. The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading C. Having the clients arm unsupported while assessing blood pressure will result in a false low reading of blood pressure. D. It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm

B, D

Which cranial nerves assist with both sensory and motor function? Select all that apply. One, some, or all responses may be correct. A. Optic B. Facial C. Trochlear D. Accessory E. Trigeminal

B, E

Which reflex is the nurse testing when using a dull object to stroke from the lateral sole of a client's foot upward to the great toe?

Babinski

The nurse is measuring the blood pressure of toddlers. Which blood pressure finding is the nurse most often to find in the toddlers? A. 85/43 B. 95/65 C. 105/65 D. 110/65

B

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term correctly describes the findings. A. Rhonchi B. Wheezes C. Pleural friction rub D. Bronchovesicular

B

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? A. Vesicular B. Bronchial C. Crackles D. Rhonchi

C

Which transmission based precautions would the nurse use when caring for a 4-year-old child admitted with pertussis? A. Droplet B. Contact C. Respirator D. Standard

A. Droplet

Which reflex would the nurse assess in a newborn to determine auditory ability? A. Startle reflex B. Rooting reflex C. Glabellar reflex D. Extrusion reflex

A

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured? A. Cranial nerve X B. Cranial nerve IX C. Cranial nerve XII D. Cranial nerve VII

D

Which consideration would the nurse make when preparing to give a preschooler an intramuscular injection in the vastus lateralis site? A. The anterior third of the vastus lateralis is used to give an injection B. The vastus lateralis is used to inject volumes greater than 10mL C. the child should keep the knee straight to receive an injection at the vastus lateralis site D. The maximum recommended length of the needle insertion at the vastus lateralis site is 1 inch for preschoolers

D.

True or False? Hydrocolloid dressings, transparent film dressings, and non-adhering dressings with antibiotic ointment are beneficial for the healing of a red wound caused by pressure injuries.

True

True or false? Absorptive dressings and moist gauze dressings with antibiotics to treat yellow wounds, such as wounds with nonviable necrotic tissue

True

What is a pulse deficit?

difference between apical and radial pulse

At which site would the nurse obtain a sterile urinalysis with an indwelling catheter? A. Tubing injection port B. Distal end of the tubing C. Urinary drainage bag D. Catheter insertion bag

A

The nurse is assessing a client who reports SOB. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? A. Assess the client's lungs B. Assess the client for pain C. Obtain details of smoking habits D. Ask about the onset of SOB

A

Which cranial nerve would the nurse assess further for a client whose mouth is drooping to the left? A. Left facial nerve B. Right facial nerve C. Left abducens nerve D. Right abducens nerve

A

Which skin color change would the nurse expect to see if a client with dark skin develops cyanosis? A. Gray B. Purple C. Dark Red D. Purple to brownish

A

The nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. One, some, or all responses may be correct. A. I will elevated the head of the client's head to no more than 30 degrees B. I will ensure that the client is turned and repositioned at least every 2 hours C. I will advise the client to apply talc directly to the perineum D. I will ensure that the client's bodily fluid intake is 2000 to 3000 mL/day E. I will teach the client to refrain from eating a high-protein and calorie diet

A, B, D

When teaching a client with a new Ostomy about appliance care and maintenance, which information would the nurse include? Select all that apply. One, some, or all responses may be correct. A. Change the ostomy pouch on a routine basis B. Replace the ostomy wafer weekly or sooner as needed C. Remove the ostomy pouch when showering D. Empty the ostomy pouch when 3/4 full of stool or gas. E. Empty the ostomy pouch before exercise and at bedtime

A, B, D, E

The nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing the client, the nurse would be alert for which findings that are consistent with these conditions. Select all that apply. One, some, or all responses may be correct. A. Ecchymosis B. Yellow sclera C. Dark brown stool D. Straw-colored urine E. Pain in the right upper quadrant

A, B, E

Which information is obtained by palpation? Select all that apply. One, some, or all responses may be correct. A. Turgor B. Bruises C. Texture D. Lesions E. Moisture content F. Petechiae

A, C, D, E

When performing a focused respiratory assessment, which action would the nurse take first? A. Examine for any abnormal respiratory patterns B. Inspect for changes in skin color or temperature C. Check for any evidence of respiratory distress D. Determine the shape and symmetry of the chest

C

A client has a large, open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? A. Use Two square gauze pads to cleanse the wound, one for each half of the wound B. Apply new Montgomery straps each time the dressing is changed C. Hold the wet gauze with the tips of the forceps higher than the wrists D. Cleanse the wound with wet, sterile gauze from the center of the wound outward

D

The nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon? A. Ileum B. Ascending C. Transverse D. Descending

D

The nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How would the nurse test Cranial nerve XI? A. By checking the gag reflex B. By asking the adolescent to swallow C. By stroking the plantar surface of the foot D. By telling the adolescent to shrug the shoulders

D

The respiratory status of a client with Guillain-Barre syndrome progressively deteriorates and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How would the nurse manage the tracheostomy cuff? A. Deflate the cuff before starting each tube feeding B. Inflate the cuff for 1 hour before and after each feeding C. Deflate the cuff after the tube feeding has been completed D. Inflate the cuff before the feeding and for 30 minutes after each feeding

D

Which action will the nurse ask the client to perform when assessing for damage to the glossopharyngeal and vagus nerves? A. Smile B. Shrug C. Smell D. Swallow

D

Which finding obtained during an assessment of the nose and sinuses would be of most concern to the nurse? A. Deviated septum to the left B. Clear watery nasal discharge C. Deep red color of the nasal mucosa D. Tenderness over the maxillary sinuses

D

A client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force? A. Maintain the head of the bed at 30 degrees or less B. Use draw sheets to pull up, transfer, and position the client C. Reposition the client every 2 hours, propping with pillows D. Perform passive range-of-motion exercises every 8 hours

B

The PACU receives a client post-abdominal surgery with a nasogastric tube with low-intermittent wall suction in place. Which initial action would the nurse implement when the client vomits 90 mL of bile-colored fluid? A. Elevate the head of the bed B. Check the patency of the tube C. Administer the prescribed antiemetic D. Encourage the client to take several deep breaths

B

The nurse assess the client's incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? A. Loosening of the sutures B. Sharp increase in serosanguineous drainage C. Purplish color of the incision D. Protrusion of organs through an open incision

B

The nurse identifies that a client's intravenous (IV) site is warm, red, and tender. Which would the nurse conclude is the cause of this finding? A. Rapid fluid delivery B. Phlebitis C. Allergic response D. Infiltration

B

To prevent excessive bruising when administering subcutaneous heparin, which technique will the nurse employ? A. Administer the injection via the Z-track technique B. Avoid massaging the injection site after the injection C. Use 2 mL of sterile normal saline to dilute the heparin D. Inject the medication into the Vastus lateralis muscle in the thigh

B

Which clinical manifestation would the nurse expect the client who has a tumor of the cerebellum to exhibit? A. Absence of the knee-jerk reflex B. Inability to coordinate movement C. Change in level of consciousness D. Failure to execute

B

Which dressings would the nurse view as beneficial for the recovery of a client's red-colored wound that was caused by pressure? Select all that apply. One, some, or all responses may be correct. A. Absorptive dressings B. Hydrocolloid dressings C. Transparent Dressings D. Moist gauze dressings with antibiotics E. Non-adhering dressings with antibiotic ointment

B, C, E

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct. A. Suction the client before starting tracheostomy care B. Use sterile technique when cleaning the inner cannula C. Use sterile-cotton tipped swabs to clean the inner cannula D. Don sterile gloves before removing the inner cannula. E. Use hydrogen peroxide to clean the skin around the stoma

B, D

Which type of asepsis is the nurse using when he/she washes their hands before changing a clients postoperative dressing? A. wound asepsis B. Medical asepsis C. Surgical asepsis D. Concurrent asepsis

B. Medical asepsis

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? A. Fine crackles B. Adventitious sounds C. Vesicular breath sounds D. Diminished breath sounds

C

A client underwent surgery and developed a wound without tissue loss. While caring for the client, the nurse detects abscess formation. Which assessments made by the nurse support the observation? Select all that apply. One, some, or all responses may be correct. A. Necrosis of skin edges B. Swelling of the incision site C. Purulent drainage from the incision site D. Erythema of the incision line of more than 1 cm E. Localized fluctuance beneath the wound when palpated.

C,E

The nurse is caring for a client diagnosed with MRSA in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure? A. Droplet precautions B. Reverse isolation C. Surgical Asepsis D. Medical Asepsis

C. Surgical Asepsis (Sterile technique)