HESI Adult Health
After a painful exacerbation of rheumatoid arthritis, a client is scheduled to begin a walking and exercise program. Which statements describes an expected outcome for this client? A. When pain free, begin exercising in a formal activity program. B. Avoid exercising when there is a moderate amount of discomfort. C. Exercise and be active unless the discomfort become too great. D. Walk and exercise even when the pain is severe.
C
Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A Pulse oximetry reading of 80%. B Expiratory stridor and nasal flaring. C Cherry red color to the mucous membranes. D Presence of carbonaceous particles in sputum.
C
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? A Notify the surgeon. B Document the assesment. C Secure a colostomy pouch over the stoma. D Place petrolatum gauze dressing over the stoma.
A
The nurse has administered sublingual nitroglycerin. Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? A.Relief of anginal pain B.Improved cardiac output. C.Decreased blood pressure D.Ease in respiratory effort
A
Which would the nurse consider to be the center of decision-making when providing client care? A. Ethics B. Nursing skills C. Analytical skills D. Research-based practice
A
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 A scalp laceration oozing blood. B Serosanguineous nasal drainage. C Headache rated "10" on a 0-10 scale. D Dizziness, nausea and transient confusion
B
A healthcare provider prescribes transdermal fentanyl 25 mcg/h every 72 hours. During the first 24 hours after starting the fentanyl, the nurse recognizes the need to take which action? A. Titrate the dose until pain is tolerable. B. Manage pain with an analgesic by a different route. C. Assess the client for anticholinergic side effects. D. Instruct the client to take the medication with food.
B
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? A Encourage fluids to 3000 ml/day. B Check stools for occult blood. C Provide oral hygiene every 2 hours. D Check for fever every 4 hours.
B
Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) A pH 6. B Nitrate small. C Protein small. D Sugar negative. E Bilirubin negative. F Specific gravity 1.015.
D F
Which action describes the process of artificial active immunity? A. Antibodies are passed from one person to another. B. Antibodies against an antigen are produced naturally in the body. C. Antibodies are made after an antigen is injected into the body. D. Antibodies produced by one body or animal are transferred to another body or animal.
C
Which discharge instruction would the nurse emphasize when preparing a client with Addison disease for discharge? A. "Limit physical activity." B. "Restrict sodium in your diet." C. "Continue steroid replacement therapy." D. "Schedule frequent health care appointments."
C
Which entity outlines the principles of delegation for registered nurses (RNs)? A. Nurse Practice Act B. Multilevel nursing model C. American Nurses Association (ANA) D. National Council of State Boards of Nursing (NCSBN)
C
Case 2 A nurse is caring for a patient admitted following a surgical wound infection. The vital signs are T- 103, P- 106, RR- 22, BP-182/90, SaO2- 93%. Pertinent labs include a serum magnesium of 1.2 mg/dL and a serum potassium level of 3.2 mEq/dL. •Acetaminophen 650 mg by mouth is ordered for the temperature of 103"° F. The acetaminophen is available in 325 mg tablets. How many tablets would the nurse administer with each dose?
2
The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? A Fresh bleeding noted on abdominal surgical wound dressing. B Pulse change from 85 to160 beats/minute lasting more than 10 minutes. C Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3. D Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.
B
A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? A Rub a liberal amount of cream into the skin thoroughly. B Cover the skin with a gauze dressing after applying the cream. C Leave the cream on the skin for 1 to 2 hours before the procedure. D Use the smallest amount of cream necessary to numb the skin surface.
C
Case 1 •A nurse is caring for a patient admitted 3 days ago following a motor vehicle accident. Vital signs are T- 102, P- 112, RR- 24, BP- 86/48, SaO2- 93%. The morning complete blood cell (CBC) count shows a hemoglobin of 7 g/dL. •With a sudden increase in temperature, sepsis is suspected. The patient has vancomycin 1.5 g/200 mL ordered to be infused IV twice daily over 2 hours. How many milliliters per hour will the nurse program the IV infusion device?
100 ML/HR
•A continuous infusion of diltiazem at 15 mg/h is received for a patient with atrial fibrillation. Pharmacy delivers diltiazem with a 100 mg/100 mL concentration. How many mL/h will the nurse administer the medication?
15 ML/HR
A nurse receives an order to administer cefazolin 2 g/100 mL NS IV every 8 hours. Pharmacy suggests infusing the cefazolin over 30 minutes. How many milliliters per hour would the nurse set the IV infusion device?
200 mL/hr
•A test dose of amphotericin is ordered. The order reads to infuse 1 mg in 20 mL over 15 minutes. How many milliliters per hour would the nurse set the IV infusion device?
80 ML/HR
A client is admitted to the hospital, and benazepril is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? A.Assess for dizziness. B.Assess for dark, tarry stools. C.Administer the medication after meals. D.Monitor the electroencephalogram (EEG).
A
A client with a known history of opioid addiction has a surgical repair of multiple stab wounds to the abdomen. After surgery, the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing which phenomenon? A.Tolerance B.Habituation C.Physical addiction D.Psychological dependence
A
A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information? A Low impact exercise, walking, swimming and water aerobics. B Repetitive strength-building exercises with weights or resistance bands. C Circuit training alternating with frequent rest periods. D High-impact aerobic exercise.
A
A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? A Notify the client's healthcare provider. B Document the finding in the client record. C Prepare a warm enema solution for rectal instillation. D Obtain a large bore needle for aspiration of the corpora cavernosa.
A
A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A Heart palpitations. B Anorexia. C Hypersomnia. D Stress incontinence.
A
According to Quality and Safety Education for Nurses (QSEN), which defines patient-centered care? A.Understanding that the client is the source of control when providing care. B.Functioning effectively within nursing and interprofessional teams to deliver quality care. C.Using data to evaluate outcomes of care processes and designing methods to improve health care. D.Minimizing the risk for harm to clients and health care workers through improved professional performance.
A
An older client is treated in the emergency department for soft tissue injuries that the medical team suspect might be caused by physical abuse. An adult child states that the client is confused and often falls. A mini-mental examination indicates that the client is oriented to person, place, and time. Which action would the nurse take next? A.Interview the client without the presence of family members. B.Suggest that the client call law enforcement officers if threatened by family members. C.Accept the adult child's explanation until more data can be collected. D.Refer the client's clinical record to the hospital ethics committee for review.
A
Six hours after major abdominal surgery, a client reports severe abdominal pain and faintness. The nurse identifies a thready, rapid pulse. The nurse checks the medication administration record (MAR) and determines that the client can receive another injection of pain medication in an hour. Which action would the nurse take? A.Notify the health care provider about the client's symptoms. B.Explain to the client that it is too early to have an injection for pain. C.Reposition the client for greater comfort and turn on the television as a distraction. Prepare the injection to administer it to the client early because of the severe pain
A
The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? A Administer medications for pain relief, shortness of breath, and nausea. B Clarify family members' feelings about the meaning of client behaviors and symptoms. C Develop a plan of care after assessing the needs of the client and family. D Teach the family to recognize restlessness and grimacing as signs of client discomfort.
A
The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? A Compress the flank and upper buttocks. B Measure the client's abdominal girth. C Gently palpate the lower abdomen. D Apply light pressure over the shin
A
The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? A Compress the flank and upper buttocks. B Measure the client's abdominal girth. C Gently palpate the lower abdomen. D Apply light pressure over the shins
A
The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? A Upper chest subcutaneous emphysema. B Tidaling (fluctuation) of fluid in the water-seal chamber. C Constant air bubbling in the suction-control chamber. D Pain rated "8" (0-10) at the insertion site.
A
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? A Dry, itchy skin changes may occur. B There is a possibility of long bone pain. C Permanent pigment changes to the breast may result. D A low-residue diet may be ordered to reduce the likelihood of diarrhea.
A
Which characteristics are observed in clients who have cocaine addiction? (Select all that apply) A. Anxiety B. Palpitations C. Weight loss D. Sedentary habits E. Difficulties with speech
A B C
Which situations accurately represent superego in a client, per Freud? (Select all that apply) A. Controlling the urge to eat candy because he or she knows it will affect blood sugar levels. B. Having a craving for fruit but not stealing it form the next client because that client needs it more. C. Urinating beside the bed instead of waiting for the nurse to assist him or her. D. Experiencing a stomachache but refraining from stealing medications from a friend because it is illegal. E. Feeling the urge to run away from the hospital but refraining from doing so because the security guard is watching.
A B D
Which statements about culturally congruent care by the student nurse are correct? (Select all that apply) A."It is the main goal of transcultural nursing. B."It is provided through cultural competence." C."It is provided in accordance with set criteria." D."It is bound to the professional health care system." E."It depends on the patterns and needs of an individual."
A B E
The nurse is obtaining a health history from the newly admitted client who has chronic pain in the right knee. Which would the nurse include in the pain assessment? (Select all that apply). 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 with ambulation.
A C
The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) A Vagal stimulation. B An increased level of stress. C Decreased duodenal inhibition. D Hypersecretion of hydrochloric acid. E An increased number of parietal cells.
A D E
Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. Which physiological response is responsible for this medication's therapeutic effect? A. Reduced cell growth B. Reduced cerebral edema. C. Increased renal reabsorption. D. Increased response to sedation
B
A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? A. Remove the client's clothing. B. Evaluate whether the client has inhaled smoke. C. Insert a venous access device in an unaffected arm. D. Determine the extent of the burns, using the rule of nines.
B
A client with Crohn disease is admitted to the hospital with a history of chronic, bloody diarrhea, weight loss, and signs of general malnutrition. The client has anemia, a low serum albumin level, and signs of negative nitrogen balance. The nurse concludes that the client's health status is related to which major deficiency? A. Ferrous sulfate B. Protein C. Ascorbic acid D. Linoleic acid
B
A client with a history of multiple chronic illnesses comes to the emergency department (ED) reporting a slight progressive weight loss over the past month in addition to frequent urination and felling lethargic, hungry, and thirsty all the time. The client's vital signs are blood pressure (BP) 118/78 mm Hg, oral temperature 99.6°F (37.6°C), and regular pulse of 72 beats per minute with irregular respirations of 22 breaths per minute. Which condition dies the nurse suspect that this client is experiencing? A.Hypervolemia B.Hyperglycemia C.Infectious process D.Respiratory distress
B
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? A Cleanse perineum with warm soapy water 3 times per day. B Instill the first dose of nystatin (Mycostatin) vaginally per applicator. C Perform glucose measurement using a capillary blood sample. D Obtain a blood specimen for sexually transmitted diseases (STDs).
B
An older client's colonoscopy reveals the presence of extensive diverticulosis. Which type of diet would the nurse encourage the client follow? A. Low fat B. High fiber C. High protein D. Low carbohydrate
B
The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client's prescription for morphine: 2 mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse's lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first? A.Determine the documented time of the last administration of pain medication. B.Verify that the written prescription matches the administration record. C.Encourage nonpharmacological measures initially to relieve the pain. D.Explain that the primary nurse will be back from lunch in a few minutes.
B
When a client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions, which action by the nurse will be most helpful? A. Administer continuous oxygen. B. Offer fluids at frequent intervals. C. Place the client in a high-Fowler position. D. Administer prescribed steroid inhaler.
B
Which type of immunity will clients acquire through immunizations with live or killed vaccines? A. Natural active immunity B. Artificial active immunity C. Natural passive immunity D. Artificial passive immunity
B
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) A Only marijuana cigarettes affect sperm count. B Smoking can decrease the quantity and quality of sperm. C The first semen analysis should be repeated to confirm sperm counts. D Cessation of smoking improves general health and fertility. E Sperm specimens should be collected in 2 subsequent days.
B C D
The registered nurse is evaluating the plans of a nursing student for providing preoperative care to a client who has compartment syndrome. Which item listed in the nursing student's plan of care would the nurse need to revise? (Select all that apply) A. Bivalving the cast B. Applying cold compresses C. Loosening the bandage applied D. Evaluating the client's level of pain E. Elevating the extremity above heart level
B E
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? A. The partial pressure of oxygen (PO2) value is 80 mm Hg B. Th partial pressure of carbon dioxide (PCOs) value is 60 mm Hg C. The bicarbonate (HCO3) value is 50 mEq/L D. Serum potassium value is 4 mEq/L
C
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia? A. Red blood cell count B. Sputum culture C. Arterial blood gas D. Total hemoglobin
C
A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? A Serum amylase of 132 units/L. B Serum sodium of 134 mEq/L. C Chest x-ray indicating a mediastinal shift. D Abdominal x-ray air throughout intestines.
C
A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? A Notify the healthcare provider. B Decrease the IV solution flow rate. C Document the finding as the only action. D Administer potassium replacement as prescribed.
C
A client with colon cancer had surgery for resection of the tumor and creation of a colostomy. During the 6-week postoperative checkup, the nurse teaches the client about nutrition. Which response by the client indicates learning has taken place? A. 'I should follow a diet that is rich in protein." B. "I should follow a diet that is low in sodium content." C. "I should follow a diet that is as close to normal as possible." D. "I should follow a diet that is higher is calories than before."
C
The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty? A. Caring B. Veracity C. Advocacy D. Confidentiality
C
A construction worker sustains a puncture wound from a rusty nail and the last immunization for tetanus in unknown. The primary health care provider prescribes tetanus immune globulin. Which type of protection does this immunization offer? A. Lifelong passive immunity B. Long-lasting active protection C. Stimulation of antibody production D. Immediate passive short-term immunity
D
A hospice client who has severe pain asks for another dose of oxycodone. Which consideration is the nurse's primary concern when responding to the client's request? A. Prevent addiction. B. Determine why the medication is needed. C. Provide alternative comfort measures. D. Reduce the client's pain.
D
According to the nursing process, which would the nurse do after administering pain medication to a postoperative client? A. Administer nonpharmacological comfort measures. B. Inform the health care provider of the nursing action. C. Create a care plan that addresses the client's pain level. D. Determine whether the pain medicine relieved the client's pain.
D
A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? A. Radiating abdominal pain with left lower quadrant palpation. B. Grimacing after palpation of the right hypochondriac region. C. Rebound tenderness with abdominal palpation. D. Bluish periumbilical skin discoloration.
D
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? A Encourage fluids to 3000 ml per day. B Change the client's position every two hours. C Keep the head of the bed elevated 30 degrees. D Turn off the television and darken the room.
D
A client with Parkinson disease reports problems with bowel elimination. Which instruction should the nurse provide for the client? A. Eat a banana daily. B. Decrease fluid intake. C. Take cathartics regularly. D. Increase residue in the diet.
D
After a subtotal gastrectomy, a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. Which would the nurse determine is the cause of the latter effect? A. A second, more extensive rise in glucose B. An overwhelmed insulin-adjusting mechanism C. A distention of the duodenum from an excessive amount of chyme D. An overproduction of insulin that occurs in response to the rise in blood glucose.
D
The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A A description of inflammation, infection, and tumors. B Continuous visualization of intracranial neoplasms. C Imaging of tumors without exposure to radiation. D An image that describes metastatic sites of cancer.
D
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? A Ask the client to try to speak. B Assess for respiratory distress. C Auscultate for pulmonary crackles after the client drinks a small amount of clear water. D Observe the client for coughing colored sputum after drinking a small amount of colored water
D
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A Thinning hair and dry scalp. B Increase in appetite and taste-bud acuity. C Increase in muscle tone but decreased muscle strength. D Increase in abdominal fat deposits.
D
The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? A Prognosis after treatment is excellent. B Techniques for esophageal speech are relatively easy to learn with practice. C The stoma should never be covered after this type of surgery. D There is a radical change in appearance as a result of this surgery.
D
Which Quality and Safety Education for Nurses (QSEN) competency is involved in the situation where the nurse coordinates care with a dietician and a certified diabetes educator (CDE)? A. Safety B. Patient-centered care C. Evidence-based practice D. Teamwork and collaboration
D
Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? A. Feels that he or she leads a completely worthless life. B. Shows signs of lack of interest in carrying out social interaction. C. Conveys to the nurse that he or she is estranged from all family members. D. Has multiple fainting episodes due to lack of proper nutrition.
D
Which important step would the nurse take to evaluate lifestyle change in the client? A. Ask which barriers the client perceives with the planned lifestyle change. B. Instruct the client to include family members to support the lifestyle change. C. Advise the client to refrain from discussing the time spent in activity or actual number of fruits and vegetables eaten. D. Encourage the client to maintain an exercise and eating calendar to track adherence and provide positive reinforcement.
D
