Hesi Fundamentals Practice (7)
A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? 1 Falls 2 Impaired cognition 3 Imbalanced nutrition 4 Impaired gas exchange
1
A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? 1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care 4 Using medical and surgical aseptic techniques at all times
1
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to do what? 1 Restore function and/or appearance 2 Replace an organ or tissue 3 Relieve or reduce symptoms 4 Remove or excise an organ or tissue
1
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? 1 Provide perineal care. 2 Turn and position the client. 3 Give a complete bed bath. 4 Document the bowel movement.
1
Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1 Attention span 2 Primary language 3 Coping mechanisms 4 Activity and coordination
1
Which nursing action would be considered a part of self-regulation in the decision-making process? 1 Reflecting on one's own experiences 2 Looking at all the situations objectively 3 Supporting findings and conclusions 4 Making careful assumptions about a client's information
1
Which nursing practice is associated with the self-regulation skill? 1 Reflecting on one's experience 2 Reflecting on one's own behavior 3 Supporting one's findings and conclusions 4 Clarifying any data that one is uncertain about
1
Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply. 1 Dry cleaners 2 Dye workers 3 Lathe operators 4 Hospital workers 5 Agricultural workers
1,2
Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply. 1 Interventions to restore tissue integrity 2 Interventions to optimize neurologic functions 3 Interventions to manage restricted body movements 4 Interventions to promote comfort using psychosocial techniques 5 Interventions to provide care before, during, and immediately after surgery
1,2,5
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? 1 Hypernatremia 2 Hyponatremia 3 Hyperkalemia 4 Hypokalemia
2
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1 No special precautions are required. 2 Cover the infected site with a dressing. 3 Drape the client with a covering labeled biohazardous. 4 Place a surgical mask on the client.
2
A nurse is reviewing how a hyperglycemic client's blood glucose can be lowered. The nurse recalls that the chemical that buffers the client's excessive acetoacetic acid is what? 1 Potassium 2 Sodium bicarbonate 3 Carbon dioxide 4 Sodium chloride
2
After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing? 1 Place the dressing in the bedside trash can. 2 Place the dressing in a red bag/hazardous materials bag. 3 Contact Environmental Services personnel to pick up the dressing. 4 Transport the dressing to the laboratory to be placed in the incinerator.
2
The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? 1 Care that supports physical functioning 2 Care that supports homeostatic regulation 3 Care that supports psychosocial functioning 4 Care that provides immediate short-term help in physiological crises
2
Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? 1 Knowing 2 Enabling 3 Doing for 4 Being with
2
A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? 1 Decrease peristalsis 2 Minimize electrolyte imbalance 3 Decrease bacteria in the intestines 4 Treat inflammation caused by the malignancy
3
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client does what? 1 Picks up the walker and carries it for short distances 2 Uses the walker only when someone else is present 3 Moves the walker no more than 12 inches (30.5 cm) in front of the client during use 4 States that a walker will be purchased on the way home from the hospita
3
The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1 "I should carry objects about 18 inches from my body." 2 "I should sleep on my stomach with a firm mattress." 3 "I should carry objects close to my body." 4 "I should pull rather than push when moving heavy objects."
3
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin
3
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan? 1 Ensuring the client's skin integrity 2 Reviewing the preoperative instructions 3 Administering general anesthetic to the client 4 Placing the client in the correct position on the operating table
3
A community healthcare nurse is conducting a survey about homeless children in the community. Which finding helps the nurse distinguish absolute homelessness from relative homelessness? 1 The children are under-immunized and at a risk for childhood illnesses. 2 The children are more likely to drop out of school and become unemployable. 3 The children have access to healthcare only through the emergency department. 4 The children do not have a physical shelter and may sleep outdoors or in vehicles
4
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by doing what? 1 Promoting analgesia and circulation 2 Numbing the nerves and dilating the blood vessels 3 Promoting circulation and reducing muscle spasms 4 Causing local vasoconstriction, preventing edema and muscle spasms
4
A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is what? 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the change 4 Perception of the change
4
An 80-year-old client is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated, because she is alert and able to care for herself. The nurse's best response is 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased
4
On the third postoperative day after a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1 Explain why there is a need to increase activity. 2 Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3 Appear cheerful and noncritical regardless of the client's response to attempts at intervention. 4 Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving
4
Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months? 1 Turning from side to back 2 Sitting erect using support 3 Showing good head control 4 Bringing objects from hand to mouth
4
Which nursing action indicates that the nurse is actively listening to the client? 1 The nurse states his or her own opinions when the client is speaking. 2 The nurse refrains from telling his or her own story to the client. 3 The nurse reads the client's health record during the conversation. 4 The nurse interprets what the client is saying and reiterates in his or her own words.
4
Which right of delegation refers to the giving of clear, concise descriptions of a task to the delegatee? 1 Right task 2 Right person 3 Right supervision 4 Right communication
4
Which skill is applicable in an orderly collection of data? 1 Analysis 2 Inference 3 Evaluation 4 Interpretation
4
Which statement is true for attachment in the newborn? 1 Attachment occurs for the first 28 days. 2 Attachment begins in the first week of birth. 3 Attachment is the overlapping of soft skull bones. 4 Attachment is the interaction between parent and child
4
A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1 Prepare to administer an antidote. 2 Draw a sample for type and crossmatch and transfuse the client. 3 Draw a sample for an activated partial thromboplastin time (aPTT) level. 4 Draw a sample for prothrombin time (PT) and international normalized ratio (INR)
4 Draw a sample for prothrombin time (PT) and international normalized ratio (INR). Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.
