BSN 246 Week 3 HESI Prep

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? A. Eschar B. Intact blisters C. Liquefaction necrosis D. Cherry-red, firm tissue

Liquefaction necrosis

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? A. Over the second intercostal space at the left sternal border B. Over the fourth intercostal space at the right sternal border C. Over the second intercostal space at the right sternal border D. Over the fifth intercostal space in the left midclavicular line

Over the fifth intercostal space in the left midclavicular line

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding needs to be reported to the primary health care provider (PHCP)? A. Absence of a bruit B. Concave, midline umbilicus C. Pulsation between the umbilicus and the pubis D. Bowel sound frequency of 15 sounds per minute

Pulsation between the umbilicus and the pubis

A home health nurse is visiting a client with type 1 diabetes mellitus. The client states to the nurse "I am not feeling well and had a respiratory problem for the past week, which seems to be getting worse." After interviewing the client, what would be the initial nursing action? A. Document the assessment data. B. Check the client's blood glucose. C. Notify the primary health care provider (PHCP). D. Obtain the client's sputum for culture and sensitivity.

Check the client's blood glucose.

A client who visits the primary health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse would check for which manifestations? A. Weight loss and thinning skin B. Complaints of weakness and lethargy C. Diaphoresis and increased hair growth D. Increased heart rate and respiratory rate

Complaints of weakness and lethargy.

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse would obtain which item to test the sensory function of this nerve? A. Coffee beans B. A tuning fork C. A wisp of cotton D. Flashlight

A wisp of cotton

The nurse would perform which action to assess for a pulse deficit? A. Count the carotid pulsations for 1 full minute. B. Measure the blood pressure in both the arm and leg. C. Auscultate the apical heartbeat while palpating the radial artery. D. Place the diaphragm of the stethoscope directly over the skin at the mitral area.

Auscultate the apical heartbeat while palpating the radial artery.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve? A. Ask the client to clench the teeth. B. Ask the client to read the letters in a line on a Snellen chart. C. Ask the client to shrug the shoulders against the nurse's resistance. D. Ask the client to close the eyes, occlude one nostril, and identify a specific odor such as coffee.

Ask the client to shrug the shoulders against the nurse's resistance.

The nurse is caring for a pediatric client who just arrived at the emergency department with an extremity fracture. The nurse uses the five "Ps" to assess the extent of the client's injury. What are some of the five "Ps"? Select all that apply. A. Pallor B. Pain and point of tenderness C. Paralysis distal to the fracture site D. Pulses proximal to the fracture site E. Sensation distal to the fracture site

Pallor Pain and point of tenderness Paralysis distal to the fracture site Sensation distal to the fracture site

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds? A.Wheezes B.Rhonchi C.Crackles D.Pleural Friction Rub

Pleural Friction Rub

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? A. Ataxia B. Nystagmus C. Pronator Drift D. Hyperreflexia

Pronator Drift

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse would expect to find which sign or symptom in the client as a result of the anemia? A. Bradycardia B. Muscle cramps C. Increased respiratory rate D. Shortness of breath with activity

Shortness of breath with activity.

The nurse is performing a physical examination on an assigned client. Which item would the nurse select to test the function of cranial nerve II? A. Flashlight B. Snellen Chart C. Reflex Hammer D. Cotton Ball

Snellen Chart

The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, what would the nurse test? A. The corneal reflex B. The six cardinal fields of gaze C. The pupillary response to light D. Pupillary response to light and accommodation

The six cardinal fields of gaze

The nurse is preparing to perform a Weber test on a client. The nurse would obtain which item needed to perform this test? A. A Tuning Fork B. Stethoscope C. Tongue Blade D. Reflex Hammer

Tuning Fork