HESI exit

A patient experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with partial-thickness burns on the anterior surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

18% According to the rule of nines, each leg accounts for 18% of the total body surface area, and the anterior surface of each leg accounts for half of that, or 9%. Therefore, the patient has partial-thickness burns on 9% + 9% = 18% of the body surface area.

The healthcare provider prescribes and IV solution of regular insulin (Humulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?

30

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

31.6 mL

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36%

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The medication is available at 10 mg/mL. How many mL should the nurse administer? (Enter numeric value only)

4 mL

What environmental factor is most significant when planning care for a client with osteomalacia?

Adequate sunlight

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bedside table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed lip breathing. Which intervention should the nurse implement?

Administer a nebulizer treatment.

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Allow the bladder to empty completely or up to 1,000 mL of urine.

A client with obsessive-compulsive disorder (OCD. is repeatedly washing the top of the same table. Which intervention should the nurse implement?

Allow time for the behavior and then redirect the client to other activities.

After receiving report, the nurse can most safely plan to assess which client last?

An adult client with no postoperative dralnage in the Jackson-Pratt drain with the bulb compressed.

When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)

Apply an allergy identification wrist band. Enter allergy information in the client's electronic medical record. Ensure the client's selections from her dietary menu. Notify the dietary department of the client's egg intolerance.

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Apply the client's positive alrway pressure device.

What nursing intervention is particularly indicated for the second stage of labor?

Assisting the client to push effectively so that expulsion of the fetus can be achieved

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which clients should the nurse recognize as needing additional education? (Select all that apply)

Avoid salt substitutes Consume canned vegetables

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

Avoid urinary catheterization

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Check for a distended bladder

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

Consume foods with saturated fats. Eat more canned vegetables.

An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postburn infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8°F (39.3°C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?

Culture sputum, urine, burn wound, and all intravenous access sites.

An adult exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Current diagnosis of hepatitis B

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. The warfarin dose is prescribed and adjusted based on the client's normal consumption of foods containingvitamin K (an essential clotting factor that counteracts the effects of warfarin), so the client should eat a consistent amount of vitamin K food sources on a daily basis.

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.)

Encourage family to bring the client old photographs. Encourage family to visit frequently. Record the client's desire to live. Teach client how to use guided imagery.

The charge nurse observes a new nurse during the administration of two different liquid medications at once through a gastrostomy tube used for enteral feeding. The charge nurse observes the new nurse's actions, as seen in the video. What action(s) should the charge nurse take? (Select all that apply.)

Encourage the novice to flush the tube with more water. Instruct the novice to administer each medication separately. Add the liquid volumes when documenting fluid intake Confirm that the novice determined the amount of gastric residual.

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm

A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement? Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)

Ensure the client receives frequent small meals containing complete proteins

A preschool-aged child who is being tested for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the clearest indication to the nurse that the child is experiencing a reaction to toxins that are created by Streptococcal bacteria.

Flushed, peeling skin

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Get an eye examination with an ophthalmologist

An adult with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Hemoglobin

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

If the clients has an elevated blood pressure.

An older client admitted for observation following a fall while getting out of the bathtub becomes increasingly confused. The family arrives with the home medication list and the client's healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Increasing confusion of the client.

A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Ineffective coping related to denial

The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

Instruct the daughter to check her mother's temperature. Determine if the mother has recently experienced a fall. Ask if the mother is experiencing any pain with urination

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Keep chest tube container below the site of insertion. The chest tube container should be kept below the level of the client's chest to maintain a gravity-dependent pressure gradient that allows air and fluid to drain from the pleural space. If the container is raised above the site of insertion, it can cause backflow of air or fluid into the pleural space, which can compromise ventilation and cause tension pneumothorax.

A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?

Keep orienting the client to time and place until he is less confused.

A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Maintain a continuous infusion of IV fluids per prescription.

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Maintain a quite , non-stimulating environment.

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Measure urinary output every hour. Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? White Blood Cell (WBC. Reference Range: 5000-10,000/mm^3 (5-10 x 10^9/L)

Moderate amount of foul-smelling lochia.

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Monitor a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM). Perform daily surgical dressing change for a client who had an abdominal hysterectomy. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Note signs of swelling and edema. Report serum albumin and globulin levels, Monitor abdominal girth.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Observe insertion site

An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in the client's plan of care?

Obtain a blood pressure reading before the client gets out of bed

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse prepare the child for next?

Obtain bedside trays for intubation or tracheotomy by the healthcare provider.

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Position bedside table so the client can lean across it.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Practice using muscle relaxation techniques

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?

Provide disposable training pants while calming the mother.

Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

Provide supplemental oxygen.

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

Push the undiluted Dextrose slowly through the currently infusing IV.

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

Reassure the client that facial flushing is a common side effect of the medication. Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.

A male client reports to the on-call nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take?

Reassure the client that skin flushing is a common side effect of the medication.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?

Redress the abdominal incision

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dL (325 µmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Total Bilirubin Reference Range: Newborn: 0.1 to 10.5 mg/dL (1.7 to 180 µmol/L)

Reposition the infant every 2 hours.

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Review the need for the UAP to wear a face mask while in close contact with the client

An adolescent from a poor neighborhood who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a funded nursing facility. Which action is most important for the nurse to implement?

Schedule follow-up appointments with specialists.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the health care provider? Reference Range Blood alcohol level [Reference Range: 0 to 10.9 mmol/L (0% to 0.05%)] Lithium [Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L]

Serum lithium level of 1.6 mEq/L (1.6 mmol/L)

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

Serum potassium, calcium, and phosphorus.

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Start two large bore IV catheters and review Inclusion criteria for IV fibrinolytic therapy.

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which statement(s) should the nurse include in this client's teaching plan? (Select all that apply.)

Take metformin with the morning and evening meal Recognize signs and symptoms of hypoglycemia. Report persistent polyuria to the health care provider

A patient with a prescription for no not resuscitate (DNR) begins to manifest signs of impending death. After notifying the family of the patient's status, what priority action should the nurse implement?

The patient's need for pain medication should be determined.

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

This hernia is a normal variation that resolves without treatment.

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Titrate oxygen to prescribed parameters.

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

Uncontrolled hypertension can lead to renal damage. Weight management is promoted by taking dally walks for thirty minutes. Salt substitutes can help with maintaining a healthy diet. Sodium intake can be regulated by limiting canned foods in the diet.

In caring for a client who is receiving meropenem IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

Watery diarrhea

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

Watery diarrhea Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to ask in the assessment of this client?

What are the voices saying?

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

Withhold the medication until the dosage can be confirmed.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Withhold this dose If vomiting occurs within 30 minutes of administration, it's generally advised to skip that dose to avoid the risk of overdose.

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

an 18 yo with antisocial behavior who is being yelled at by other clients

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client?

aniexty

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

arrange an appointment with a pain specialist