HESI part 2

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed

Immediately after the assessments are completed

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?

Albumin

The nurse is providing postoperative care to a client who had a submucosal resection for a deviated septum. The nurse should monitor for what complication?

Expectoration of blood

normal phosphorus levels

2.7-4.5 mg/dL

Urine output indicating renal failure

30 mL/hr

What technique is most important when performing a physical assessment?

A consistent, systematic approach

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the clients plan of care?

Ask client acceptable level of pain Administer pain medication regularly

What action by the nurse demonstrates culturally sensitive care?

Ask permission before touching client

The nurse recognizes which are important components of a neurovascular assessment?

capillary refill pulse and skin temperature movement and sensation

troponin

regulatory protein in striated muscle

normal specific gravity

1.002-1.028

activated partial thromboplastin time

20-36 seconds

3 checks of medication administration

Before pulling, after pulling, at bedside

Low levels of _____ are associated with malnutrition.

albumin

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?

"Which activities during a routine day are impacted by pain?"

Hypertonic IV solutions

-3% saline -5% Saline -10% Dextrose in Water -5% Dextrose in 0.9% Saline -5% Dextrose in 0.45% Saline -5% Dextrose in LR -Causes the cell to shrink, fluid overload w/pulmonary edema -Give to patients with cerebral edema (reduces pressure), hyponatremia (pulls sodium back into the intravascular system)

Hyponatremia signs

-Hyperactive Bowels Sounds -Muscle Weakness -Increased Urine Output -Decreased specific gravity of urine would be noted

protective or reverse isolation

-Immunosuppressed patients (low WBC counts, chemotherapy, large open wounds)-Make sure equipment is disinfected BEFORE it is taken into the room

Airborne precautions

-Includes TB, varicella (chickenpox), SARS (pneumonia), and rubeola (measles)-Wear gown, N-95 mask, gloves-Remove mask OUTSIDE the room after closing the door

contact precautions

-Most common form of transmission -Use gown and gloves -Remove PPE and wash hands BEFORE leaving room

What is the site of choice for IM injections?

-Ventrogluteal muscle-Landmarks are the greater trochanter, anterior superior iliac spine, and iliac crest

Droplet precautions

-Wear gown, mask, gloves-Remove gloves first, then gown and mask

A troponin level higher than _____ indicated myocardial infarction

0.1-0.2 ng/ml

Hypotonic IV solutions

0.45% Saline 0.22% Saline 0.33% Saline -Cause cell lyses -Deplete circulatory systems fluids -These solutions hydrate the cell -Don't use in patients with an increase in intracranial pressure, burns, trauma its w/ hypovolemia

excess fluid volume for cerebral swelling

0.45% saline

Normal creatinine

0.6-1.2

Isotonic IV solutions

0.9% Normal Saline 5% dextrose in water (D5W) 5% Dextrose in 0.225% Saline Lactated Ringers -Causes an increase in Extracellular fluid volume -Dehyrdration

What happens when someone has pain?

1. Transduction 2. Transmission 3. Perception 4. Modulation

Warfarin therapeutic PT range

1.5-2 times higher than normal level

therapeutic dose of heparin for deep vein thrombosis is to keep the PT between _____ times normal

1.5-2.5

In emergencies, turn oxygen all the way up to ______ liters.

15

Sedation rating scale

1=awake and alert 2=slightly drowsy, easily aroused 3=frequently drowsy, arousable by voice 4=arousable by shaking 5=somnolent, not arousable**Stimulate patient and notify physician

The nurse is preparing to administer eardrops to a client with impacted cerumen. Before administering the drops, the nurse should assess for what contraindications?

Allergies, drainage, tympanic membrane rupture

You enter your client's room and find him pulseless and unresponsive. What would be the treatment of choice for this client?

Amiodarone- for ventricular fibrillation Atropine- for bradycardia

normal urine output

60 mL/hr 1500 mL/day

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours

72 to 96 hours

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

83 gtt/min

Prothrombin Time (PT) for female

9.5-11.3

Prothrombin Time (PT) for male

9.6-11.8

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance

Acceptance

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.

Accepts that punishment from God is not related to illness.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

Acknowledge that she is supporting the arm correctly.

What is the rationale for using the nursing process in planning care?

As a tool to organize thinking and clinical decision making

A client is demonstrating a positive Chvostek's sign. What action should the nurse take?

Ask client about numbness or tingling in hands

A male client with AIDS develops a cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

Ask the client if this decision has been discussed with his healthcare provider

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Assess for bladder distention.

What are the steps of the nursing process?

Assessment Diagnosis Planning Implementation Evaluation

A client with pnemonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on this, what interventions should be implemented first?

Assist client back to bed

A client with Raynaud's disease asks the nurse about using biofeedback for self management of symptoms. What response is best for the nurse to provide?

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation

Prothrombin time greater than 30 secs places patient at risk of?

Bleeding

The nurse is providing discharge instructions for a client who has signs of early Alzheimers who lives alone, with children nearby. The client is to take medication six times a day. What is the priority nursing intervention to assist client with taking medication?

Contact the provider and discussing simplifying medication regimen

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin and ibuprofen daily. Which drug protocol should be implemented according to World Health Organization?

Continue gabapentin

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?

Examine one's own culturally based values and beliefs

Which activity should the nurse use in the evaluation phase of the nursing process?

Examine the effectiveness of nursing interventions toward meeting outcomes

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect from the client?

Detachment

In evaluating client care, which action should the nurse take first?

Determine if the expected outcomes of care were acheived

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias

Diarrhea, weakness, dysrhythmias

A client who has been NPO for 3 days is receiving an infusion of D%W 0.45 normal saline with potassium cloride 20mEq at 83 ml/hr. Which action is most important for the nurse to implement?

Document that results are all in normal ranges

A provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug induced hepatitis

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler?

During inhalation

The nurse formulates the nursing diagnosis of "ineffective health maintenance related to lack of motivation" for a client with type 2 diabetes. Which finding supports this?

Eats anything and does not think diet makes a difference

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Encourage additional oral intake of juices and water.

A client with acute hemmorhagic anemia is to receive four units of packed RBCs as rapidly as possible. Which intervention is most important?

Ensure accuracy of blood type match

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens. Which action should the nurse implement?

Flush the lumen with the saline solution and administer the medication through the lumen

What supplements do pregnant women need to take?

Folic acid, iron, calcium (vitamin D)

A 73 year old Hispanic client is seen at the clinic with a history of protein malnutrition. What information should be obtained first?

Foods and liquids consumed within the last 24 hrs

orthopneic position

For shortness of breath; leaning forward over a table with a pillow

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

Fowlers

Which cortex perceives pain?

Frontal cortex

A middle-aged woman who enjoys being a teacher a mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?

Generativity

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

Gently lift the client when moving into a desired position.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified

Healthcare provider notified of client's refusal to have blood specimens collected for testing.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?

Herbs should be obtained from manufacturers with a history of quality control of supplements

To minimize the side effects of vincristine (Oncovin) what should the nurse include in the dietary plan?

High in fluids (for constipation)

The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates teaching has been effective?

I will limit my intake of beef to 4 ounces a week

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition via a central line at 54 ml/ hr. The nurse notes that the TPN solution has run out and the next TPN is not available. What immediate action should the nurse take?

Infuse 10% dextrose and water at 54 ml/hr

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed?

On admission to hospital and before transfer to rehab center

What breathing is noted with diabetic ketoacidosis?

Kussmauls (trying to get rid of CO2)

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

Lower height of enema bag

specific gravity

Measure of dissolved solutes in a solution; an increase in fluid intake dilutes and makes urine lighter as it approaches 1.000; low fluid intake or fluid loss (diarrhea or vomiting) darkens urine and makes the specific gravity rise

A postoperative client says to the nurse "My neighbors sings all night and keeps me awake." The neighboring client has dementia and it awaiting transfer to a nursing home. What should the nurse do?

Move client to a room at the end of the hall

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

Note which actions were not implemented.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

Notify the healthcare provider of the family's request.

Which nursing intervention is most helpful in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter?

Obtain a prescription for removal of catheter as soon as possible

Which orders would you expect if a patient had low H & H?

Oxygen and packed RBCs

A nurse is obtaining a health history from a newly admitted patient who has chronic pain in the knee. What should the nurse include in the pain assessment?

Pain history including location and intensity Pain pattern

What is paralytic ileus?

Paralysis of the bowel due to surgery (common --especially in abdominal surgery)

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture from a fall. Which instructions should be included in the teaching plan?

Place a pillow between your knees to prevent hip dislocation

A male client with an infected wound tells the nurse he follows a macrobiotic diet. What type of foods should the nurse recommend?

Plant proteins to provide amino acids

The nurse is preparing for a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to the chair for the first time following abdominal surgery. What action(s) should the nurse take prior to assisting client to chair?

Pre-medicate with analgesic Inform client of plan moving to chair Ask client to push IV pole to chair Assess clients BP

NSAIDS decrease _______ response.

Prostaglandin (activate nociceptors so trigger pain)

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions

Rashes in the axillary, groin, and skin fold regions

A female client with a NG tube attached to low suction states she is nauseated. There is no drainage from the NG tube in the last two hours. What action should the nurse take first?

Reposition client on her side

The nurse is administering an intermittent infusion of an antibiotic to a client whose IV access is an antecubital saline lock. After the nurse opens the roller claim on the IV tubing, the alarm indicates an obstruction. What action should the nurse take first?

Reposition client's arm

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Reposition in a Sim's position with the client's weight on the anterior ilium.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.

Respiratory rate

Rights of Medication Administration

Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant and severe pain despite around the clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is important for the nurse to obtain?

Sensory pattern, area, intensity, and nature of pain

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.

Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.

Which statement best describes durable power for attorney for healthcare?

The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

The client voluntarily signed the form.

During the initial physical assessment of a client with a pressure ulcer, the nurse observes the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the actions adequate?

The nurse provided supportive care

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

To reduce edema at the operative site

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document which stage of pressure ulcer?

Unstageable

Which statement correctly identifies a learning objective for a client with peripheral vascular disease?

Upon discharge, the client will list three ways to protect feet from injury

What is the preferred IM site for infants?

Vastus lateralis

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan?

Vitamin B12

A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds

WBC count

When are troponins increased?

When an infarction causes damage to myocardium

Early signs of hypoxia

restlessness, irritability, apprehension, tachycardia, anxiety

For men, if the catheter will remain in place long-term, secure tubing to the ______ to prevent damage to penile-scrotal juncture

abdomen

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance

acceptance

deontologic

an action is right or wrong independent of its consequences

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.

battery

utilitarian

the rightness or wrongness of an action depends on the consequences of the action

What assessment data would provide the most accurate determination of proper placement of NG tube?

chest x-ray

A nurse is preparing an ophthalmic medication to a client. What technique should the nurse use for this procedure?

clean eyelid and lashes, apply clean gloves, press on nacrolacrimal duct after giving solution

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause

proximate cause

when giving a bath, wash from _____ to ______

distal to proximal (upward)

Trosseau's sign

hand spasm when BP cuff is inflated in patients with low calcium

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included?

impaired skin integrity, related to pressure and shearing force

normal troponin level

less than 0.6

clients value for aPTT for should be

no less than 30 seconds, no greater than 90

Which mask can deliver 100% oxygen?

non-rebreather

Signs of hypocalcemia include

positive Chvostek's sign positive Triusseau's sign muscle spasms tingling in lips and fingers

RACE

rescue, alarm, contain, extinguish

excess fluid volume for cerebral edema

use 5% sucrose in 0.9% saline

Digital removal can stimulate the ______ nerve, so stop procedure if patient gets bradycardia

vagus

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods should be included?

whole grains, cooked fruit and vegetables, milk and eggs