HESI MINE 2022 00

48. a client with urolithiasis Is preparing for discharge after lithotripsy. which intervention should the nurse include in the clients post operative discharge instructions a. report when hematuria becomes pink tinged b. Use incentive spirometer c. restrict physical activities d. monitor urinary stream for decreasing output

d. monitor urinary stream for decreasing output

41. The health care provider prescribes penicillin 200,000 units intramusculalarly for a client with pneumonia. the available voyl is labeled penicillin 500,000 units/ml. how many ML should the nurse administer to this client. round to the nearest 10th

0.4

17. Client receives a prescription for one liter of lactated ringer's intravenously to be infused over six hours. how many mL/hr should the nurse program the infusion pump to deliver. round to the nearest whole number.

167

23. The nurse is obtaining a health history from a new client who has a history of kidney stones. which statement by the client indicates an INCREASED risk for renal calculi a-eats a vegetarian diet with cheese 2 to 3 times a day b-experiences additional stress since adopting a child c-jogs more frequently than usual daily routine d-drink several bottles of carbonated water daily

A

26. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct which finding is MOST important for the nurse to report to the health care provider a-distended hard and rigid abdomen b-clay colored stool. c-radiating sharp pain in right shoulder d-bile stained emises

A

27. A client with chronic kidney disease is started on hemodialysis. during the first dialysis treatment the client's blood pressure drops from 150 / 90 to 80/ 30 Which action should the nurse take FIRST a- stop the dialysis treatment b-administer 5% albumin Iv c-monitor blood pressure Q 45 minutes d-lower head of the chair and elevate feet

A

30. During spring break a young adult presents to the urgent care clinic I'm reports a stiff neck, a fever for the past six hours, and a headache. which intervention is most important for the nurse to implement FIRST a-initiate isolation precautions b-administer an antipyretic c-draw blood cultures d-prepare for a lumbar puncture

A

32. An older adult client with a long history of chronic obstructive pulmonary disease is admitted with progressive shortness of breath and uh persistent cough. the client is anxious and is complaining of a dry mouth. which intervention should the nurse implement a-assist client to an upright position b-administer prescribed sedative c-apply a high flow venturi mask d-encourage client to drink water

A

33. The nurse is providing discharge instructions to a client who is receiving Prednisone 5 mg PO Daly for a rash due to contact with Poison Ivy. which symptom should the nurse Tao the client to report to the health care provider a-rapid weight gain b-abdominal striae c-moon faces d-gastric irritation

A

35. An adult who was recently diagnosed with glaucoma tells the nurse, it feels like I am driving through a tunnel, the client expresses great concern about going blind. which nursing instruction is MOST important for the nurse to provide to the client a-maintain prescribed eyedrop regime b-avoid frequent eye pressure measurements c-wear prescription glasses d-eat a high diet in carotene

A

40. The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. which instructions regarding skin care of the portal site should the nurse provide a-protect the skin of the radiation portal site from sunlight exposure b-apply moisture lotions daily to the radiation portal site c-avoid washing the skin inside the radiation portal site d-remove the ink marks of the portal after each radiation treatment

A

42. The nurse is caring for a client in the postanesthesia care unit (pacu) who underwent a thoracotomy 2 hours ago. The nurse observes the following vital signs hot right 140 beats a minute respirations 26 breaths a minute and blood pressure 140 / 90. which intervention is MOST important for the nurse to implement a-medicate for pain and monitor vital signs according to protocol b-administer intravenous fluid bolus as prescribed by the health care provider c-apply oxygen at 10 L via non rebreather mask and monitor pulse oximeter d-and courage the client to splint the incision with a pillow to cough and deep breathe

A

44. Or caring for a client with a full thickness burn covering 40% of the body the nurse observes purulent drainage of the wound. before reporting this finding to the health care provider the nurse should review which are the clients laboratory values a-white blood cell (WBC) count b-Platelet count c-blood pH level d-Hematocrit

A

49. The nurse is preparing their client for surgery who was admitted to the emergency center following a motor vehicle collision the client has an open fracture of the femur and bleeding moderately from the bone protrusion site. gerring the preoperative assessment the nurse determines that the client currently receives heparin sodium 5000 units subcutaneously daily. what is the priority nursing action a-notify the health care provider of the client medication history b-observe the heparin injection sites for signs of bruising c-have the client signed the surgical and transfusion permits d-and sure the potential for bleeding is explained to the client

A

51. The nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. which information should the nurse provide a-family members can help with regular foot exams b-heating pads are useful on the lowest setting c-I can feet may be soaked in lukewarm water for one hour or more d-shoes should be worn outside the house but it is fine to be barefoot inside

A

55. A client received prescriptions for a multi drug regime for the treatment of tuberculosis. which information should the nurse PRORITIZE a-adherence to the regime is imperative b-medication should be taken with food c-serum liver panels are collected regularly d-enhanced sun protection measures will be needed

A

20. Which food is most important for the nurse to encourage a client with osteomalacia to include in the daily diet a-fortified milk and cereals b-citrus fruits and juices c-green leafy vegetables d-red meats and eggs

A

7. The healthcare provider prescribes diagnostic tests for a client whose chest X ray indicates pneumonia. which diagnostic test should the nurse review for implementation in the MOST therapeutic treatment of the pneumonia. A - sputum culture and sensitivity B - blood cultures C - arterial blood gases (abg) D - computerized tomography (ct) of the chest

A - sputum culture and sensitivity

1. Caring a nurse is caring for a client who with diabetes insipidus which data warrants the most immediate intervention by the nurse a- serum sodium 185 mEq/L b - dry skin with inelastic turgor c -applicable rate have one 110 beats per minute or D -polyurea and excessive thirst

A -serum sodium 185 mEq/L

22. The nurse is caring for a client who is postoperative for a femoral head fracture repair. which intervention (s) should the nurse plan to administer for deep vein thrombosis prophylaxis? (select all that apply) a-pneumatic compression devices b incentives spirometry c-assisted ambulation d-patient controlled analgesia e-calf pump exercises f-prescribe anti-coagulant therapy

A, E, F.

21. A client with herpes zoster (shingles) on the thorax towels the nurse of having difficulty sleeping. which is the probable etiology of this problem a-frequent cough b-pain c-nocturia d-dyspnea

B

53. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. which assessment finding warrants IMMEDIATE intervention by the nurse a-purple marks on skin of the abdomen b-a regular apical pulse c-quarter sized blood spot on dressing d-pitting ankle edema

B

54. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arose. when performing a head to toe assessment the nurse discovers 4 analgesic patches on the client's body. which intervention should the nurse implement FIRST a-remove all the morphine patches b-administer I narcotic antagonist c-apply oxygen per face mask d-measure the clients blood pressure

B

39. An older client with long-term type 2 diabetes mellitus is seen in the clinic for a routine health assessment. which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus is experiencing long term complications (select all that apply) a-signs of respiratory tract infection b-sensation in feet and legs c-skin condition of lower extremities d-serum creatinine and blood urea nitrogen (bun) e-visual acuity

B, C, E

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease which subjective data reported by the client supports this medical diagnosis a. frequent use of chewable and liquid and acids for inter gestion b. severe abdominal cramps and diarrhea after eating spicy food c. upper mid abdominal pain described as gnawing and burning d. marked loss of weight and appetite over the last three or four months

C - upper mid abdominal pain described as gnawing and burning

8. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath productive cough with thickened tenacious mucus and the inability to walk up a flight of stairs without experiencing breathlessness. which action is MOST important for the nurse to instruct the client about self care? A - Call the clinic if undesirable side effects of medications occur B - avoid crowded enclosed areas to reduce pathogen exposure C - increase the daily intake of oral fluids to liquefy secretions D - teach anxiety reduction methods for feelings of suffocation

C -increase the daily intake of oral fluids to liquefy secretions

14. After three days of persistent epigastric pain a female client presents the to the clinic. she has been taking all antacids without relief. her vital signs are heart rate 122 beat per minute respirations 16 breaths per minute oxygenation 96% blood pressure 116 / 70. the nurse obtains a 12 lead electrocardiogram. which assessment finding is MOST critical? a-regular pulse rate b-bile colored emesis c-St elevation in three leads d-complaint of radiating jaw pain

C-St elevation in three leads

28. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing and abdominal pain. to help the client manage the pain, which assessment data is MOST important for the nurse to obtain a-presence and activity of bowel sounds b-color and consistency of feces c-eating patterns and dietary intake d-level and amount of physical activity

C.

29. A client who had a C5 spinal cord injury 2 yes ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. which assessment finding should the nurse expect this client to exhibit a-complaints of chest pain and shortness of breath b-hypo tension and venous pooling in the extremities c-profuse diaphoresis and severe pounding headache d-pain and a burning sensation upon urination and hematuria

D

38. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs and a massive ascites. which mechanism contributes to edema and ascites in the clients with cirrhosis a-hyperaldosteronism causing an increased sodium reabsorption in the renal tubules b-decreased Portacaval pressure with greater collateral circulation c-decreased renin angiotensin response related to an increase in renal blood flow d-Hypoalbuminemia that results in a decreased colloidal on kotick pressure

D

48. While completing a half assessment for a client with migraine headaches the nurse assess is bilateral weakness in the client's hand grips. the client reports joint pain and trouble twisting a doorknob due to weakness. which action should the nurse take in response to these findings a-explain that relief of the migraine pain will reduce related symptoms b-gather additional assessment data about the pain and weakness c-implement all precautions to reduce the clients risk for injury d-consult with the occupational therapist for a functional assessment

D

To reduce the risk for pulmonary complication for a client with amio Tropic lateral sclerosis (ALS) which interventions should the nurse implement (select all that apply) a- perform chest physiotherapy b- teach the client breathing exercises c- initiate passive range of motion exercises d- establish a regular bladder routine e- encourage use of incentive spirometer

a - perform chest physiotherapy b-teach the client breathing exercises e-encourage use of incentive spirometer

6. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). the nurse determines that the clients distal pulses are diminished in the left foot. which interventions should the nurse implement (select all that apply). a- verify pedal pulse is using a Doppler pulse device b - evaluate the application of the splint on the left leg c - offer ice chips and oral clear liquids d- monitor left leg pain, Pallor, paresthesia, paralysis, pressure e - administer oral antispasmodics and narcotic analgesics

a- verify pedal pulse is using a Doppler pulse device b - evaluate the application of the splint on the left leg d- monitor left leg pain, Pallor, paresthesia, paralysis, pressure

12. I client arrives to the medical surgical unit 4 hours after a transurethral resection of the prostate. a triple lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark pink tinged outflow with blood clots in the tubing and collection bag. which action should the nurse take a-monitoring catheter drainage b-decreasing the flow rate c-irrigating the catheter manually d-disconnecting infusing solution

a-monitoring catheter drainage

38. Any on earth is completing an assessment on a patient that is allure but struggles to answer questions. When she attempts to talk she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy symptoms have been caused by a brain attack (stroke) a. a carotid bruett b. a hypotensive blood pressure c. hyperreflexia deep tendon reflexes d. decrease bowel sounds

a. a carotid bruett

An overweight young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. he tells the nurse that he is feeling very weak and jittery. which actions should the nurse implement? (select all that apply) a. check his fingerstick glucose level b. assess his skin temperature and moisture c. measure his pulse and blood pressure d. document anxiety on the surgical checklist e. administer PRN dose of regular insulin

a. check his fingerstick glucose level b. assess his skin temperature and moisture c. measure his pulse and blood pressure

5. A client is hospitalized with heart failure which intervention should the nurse implement to improve ventilation and reduce veinous return? A - Perform passive range of motion exercises b- place the client in high fowlers position c- administer oxygen per nasal cannula d - increase the client's activity level

b- place the client in high fowlers position

18. A client with a history of peptic ulcer disease he's admitted after vomiting bright red blood several times over the course of 2 hours. in reviewing the laboratory results the nurse finds the client's hemoglobin is 12 g/dL (120g/L) And the haematocrit is 35%(0.35). which action should the nurse prepare to take a-continue to monitor for blood loss b-administer 1000 mL (1L) normal saline c-transfused 2 units of platelets d-prepare the client for emergency surgery

b-administer 1000 mL (1L) normal saline

15. A client with acute renal injury why is 50 kilograms and has potassium level of 6.7 mEq/L, (6.7mm0l/L) Is admitted to the hospital. Which prescribed medication should the nurse administer first a-calcium acetate 1 tablet by mouth b-sodium polystyrene sulfonate 15 grams by mouth c-appointing alpha, recombinant 2500 units subcutaneously d-Sevelemer one tablet by mouth

b-sodium polystyrene sulfonate 15 grams by mouth

50. 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 3000ml/day b. check stores for occult blood c. provide oral hygiene every two hours d. check for fever every four hours

b. check stores for occult blood

49. a male client receives a local anesthetic during surgery. during the post operative assessment the nurse notices the client is slurring his speech. which action should the nurse take? a. determine the client is anxious and allow him to sleep b. evaluate his blood pressure pulse and respiratory status c. review the clients preoperative history for alcohol abuse d. continue to monitor for the client to reactivity for anesthesia

b. evaluate his blood pressure pulse and respiratory status

51. A client with peripheral vascular disease has undergone a right femoral popliteal bypass graft, the blood pressure has decreased from 124 / 80 to 94 / 62 what should the nurse assess first? a. IV fluid solution b. pedal pulses c. nasal cannula flow rate d. capillary refill

b. pedal pulses

42. a male client who had a colon surgery 3 days ago is anxious and requesting assistance to reposition. while the nurse is turning him, the wound dehiscences and eviscerates. the nurse moistens and available sterile dressing and places it over the wound. what intervention should the nurse implement next? a. bring additional sterile dressing supplies to the room b. prepare the client to return to the operating room c. obtain a sample of the drainage to send to the lab d. auscultate the abdomen for bowel sound activity

b. prepare the client to return to the operating room

11. four days following an abdominal aortic aneurysm repair the client is exhibiting a deemer of both lower extremities and pedal pulses are not palpable. which action should the nurse implement FIRST a-elevate extremities on a pillow b-evaluate edema for pitting c-assess pulses with a vascular Doppler d - wrap the feet with warm blankets

c-assess pulses with a vascular Doppler

10. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans urethral resection of the prostate (TURP). what is the BEST initial nursing action? a- provide additional oral fluid intake b-measure the client intake and output c-increase the flow of the bladder irrigation d-administer a PRN dose of anti spasmodic agent

c-increase the flow of the bladder irrigation

52. the nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). which assessment finding requires immediate action by the nurse? a. having the urge to void continuously while the catheter is inserted b. passing small blood clots after catheter removal c. having bright red drainage with multiple blood clots d. experiencing urinary frequency after catheter removal

c. having bright red drainage with multiple blood clots

45. following surgical repair of the bladder female client is being discharged from the hospital to home with an indwelling urinary catheter. which instruction is most important for the nurse to provide to this client? a. avoid coiling the tubing and keep it free from kinks b. cleanse the perineal area with soap and water twice daily c. keep the drainage bag lower than the level of the bladder d, drink 1000ML of fluids daily to irrigate catheter

c. keep the drainage bag lower than the level of the bladder

46. an older male client tells the nurse that he is losing sleep because he has to get up several times a night to go to the bathroom, that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. review the client's fluid intake prior to bedtime c. palpate the bladder above the symphysis pubis d. obtain a fingerstick blood glucose level

c. palpate the bladder above the symphysis pubis

41. Well caring for a client with amyotrophic lateral sclerosis (ALS) the nurse performs a neurological assessment every four hours. Which ssessment find in warrants immediate intervention by the nurse? a. inappropriate laughter b. increase in anxiety c. weakened cough effort d. Asymmetrical weakness

c. weakened cough effort

43. mail client with muscular dystrophy fell in his home and his admitted with a right hip fracture. his right foot is cool with palpable pedle pulses. Lungs are course with diminished bibasilar breath sounds. vital signs are temperature 101 F, heart rate 128 beats/min, respirations 28breaths/min and blood pressure 122 / 82. which intervention is most important for the nurse to implement first? a. obtain oxygen saturation level b. encourage incentive spirometry c. access lower extremity circulation d. administer PRN oral antipyretic

d. administer PRN oral antipyretic

40. an older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. she's anxious and is complaining of dry mouth. which interventions should the nurse implement? a. administer a prescribed sedative b. encourage client to drink water c. apply a high flow venturi mask d. assist her to an upright position

d. assist her to an upright position

44. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. which additional finding warrants the most immediate action by the nurse? a. facial puffiness and periorbital edema b. hematocrit of 30% c. Cold and dry skin d. further decline in level of consciousness

d. further decline in level of consciousness

The nurse assesses a client who is newly diagnosed with hypothyroidism and observes the client eyeballs are protuberant causing a wide eyed appearance and eye discomfort. Based on this finding which action should the nurse include in this clients plan of care? A - assess for signs of increased intracranial pressure B - prepare to administer intravenous levothyroxine c- review the client's serum electrolyte values d. obtain a prescription for artificial tear drops

d. obtain a prescription for artificial tear drops

47. a client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. the client is drowsy but responds to verbal stimuli. the nurse programs our blood pressure monitor to take readings every 15 minutes, which assessment should the nurse implement first? a. evaluate distal capillary refill for delayed perfusion b. check the extremities for bruising and petechia c. examine the pretibial regions for pitting edema d. palpate the abdomen for tenderness and rigidity

d. palpate the abdomen for tenderness and rigidity

37. The client with a history of type one diabetes mellitus and asthma is readmitted to the unit for the third time in two months with the current fasting blood sugar 325md/dl (18mmol/L SI), The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. which interventions should the nurse implement (select all that apply) a-have the client describe a typical day at work home and social activities b-determine if the client is using a new insulin need or each administration c-evaluate the clients asthma medications that can elevate the blood glucose d-ask the client if they want a different manufacturers glucose monitoring devicee-half the client demonstrate technique used to monitor blood glucose levels

A, E

19. Hello obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and is determined that the client will be discharged with oxygen. which information is MOST important for the nurse to emphasize in the discharge teaching. a-methods for weight loss b-guidelines for oxygen use c-approaches to conserve energy d-strategies for smoking cessation

B

24. A client tells the clinic nurse about experiencing burning on urination and assessment revealed that the client had sexual intercourse four days ago with a person who was casually met which action should the nurse implement a-observe the perineal area for a chancroid-like lesion b-Obtain a specimen of urethral drainage for culture c-assess for perineal itching erythema and exhoriation d-Identify all sexual partners in the last four days

B

31. The nurse assesses a client with petechiae and ecchymosis Scattered across the arms and legs. which laboratory results should the nurse review a-red blood cell count b-platelet count c-hemoglobin levels d-white blood cell count

B

36. Which client has the HIGHEST risk for developing skin cancer a-a 70 year old fair skinned client who works as a secretary b-a 65 year old fair skinned client who is a construction worker c-a 16 year old dark skinned client who tans in a tanning bed once a week d-25 year old dark skin client whose mother had skin cancer

B

46. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who has human immunodeficiency virus (HIV) positive. which symptom confirms their suspicion a-he has begun to sleep 18 at 24 hours b-a change has recently occurred in his handwriting c-he refuses to see any of his friends or return their calls d-he exhibits angry outbursts when the subject of dying is approached

B

47. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. which statement by the client indicates to the nurse that learning has occurred a-whenever I am sitting in a chair I will keep my legs up to reduce swelling b-I can use a mirror to check the bottoms of my feet for any signs of breakdown c-I will try to keep moving if leg pain occurs to help promote good circulation d-I will use swimming pool early in the day while the water is still very cool

B

52. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has extremely high temperature. which action should the nurse implement a-hold a prescription for dantrolene until fever is reduced b-prepare ice packs for placement in the client's axiliary area c-call the PACU nurse to prepare for prolonged ventilatory support d-determine if prescribed antibiotics were administered preoperatively

B

16. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. the nurse observes the area of inflammation extends above the ankle area. the client receives prescriptions for Colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a-eat high protein foods to achieve ideal body weight b-drink at least eight cups (1920ml) of water per day c-use electric heating pad when pain is at its worst d-encourage active range of motion to limit stiffness

B - drink at least eight cups (1920ml) of water per day

39. a client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic...... what assessment data should the nurse obtain next? a. capillary glucose b. BP c. body temp d. 02 sat

B: BP

13. The nurse is planning care for an older adult client who experienced a cerebral vascular accident several weeks ago. the client has expressive aphasia and often becomes frustrated with the nursing staff. which intervention should the nurse implement? a-teach the client use of basic sign language b-speak slowly to the client c-encourage clients use of picture charts d-ask the client simple questions

C

25. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. what is the PRIORITY nursing action a-monitor hemoglobin and hematocrit b-encourage toning and deep breathing c-administer IV antibiotics as prescribed d-auscultate for presence of bowel sounds

C

34. When conducting discharge teaching for a client diagnosed with diverticulitis which diet instruction should the nurse include a-have small frequent meals and sit up for at least two hours after meals b-eat a bland diet and avoid spicy foods c-eat a high fiber diet and increase fluid d-eat a soft diet with increased intake of milk and milk products

C

43. An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. the healthcare provider prescribes ferrous sulfate 325mg PO daily. which laboratory values should the nurse monitor a-platelet count and hematocrit b-serum electrolytes c-serum iron and ferritin d-neutrophils and eosinophils

C

45. The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. which I comb should the nurse include in the plan of care for this client a-the nurse will encourage the client to walk 30 minutes every day b-the clients family will state signs and symptoms about the disease c-the client daily blood pressure will be less than 140 / 80mmHg this month d-the client's blood pressure readings will be less than 160 / 90mmHg

C

50. A client with orthopnea expresses concern about the ability to get enough air, during a scheduled thoracentesis. on which information should the nurses response be based a-a thoracentesis is a brief procedure that has minimal discomfort b-orthopnea is frequently caused by a client and controlled anxiety c-the procedure is performed with the client in an upright position d-extra pillows can be used if needed to elevate the client's head

C