HESI Practice question-J1

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? "Be sure to have a complete physical examination before beginning your planned exercise program." "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more." "Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation."

"Be sure to have a complete physical examination before beginning your planned exercise program."

n assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again .B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg .D. Record the presence of pitting edema in the inguinal area.

.B. Document the presence and volume of the pulse palpated. Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment,

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A 10-year-old who was burned by a camp fire earlier today. A 70-year-old who has a postoperative infection from a surgery one week ago. A 23-year-old woman who sprained her knee while bicycling. A 55-year-old woman who has had moderate low back pain for three months.

A 55-year-old woman who has had moderate low back pain for three months. Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation,

An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client? A) Apply the patch at least 4 hours prior to departure. B) Change the patch every other day while on the cruise. C) Place the patch on a hairless area at the base of the skull. D) Drink no more than 2 alcoholic drinks during the cruise.

A) Apply the patch at least 4 hours prior to departure. Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours before departure (A) on the cruise ship. The duration of the transdermal patch is 72 hours, so (B) is not needed. Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so the best application site of the patch is behind the ear, not at the base of the skull (C). Anticholinergic medications are CNS depressants, so the client should be instructed to avoid alcohol (D) while using the patch.

The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty emptying her bladder. These complaints are most likely due to which condition? A. Cystocele B. Bladder infection C. Pyelonephritis D. Irritable bladder

A. Cystocele

A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? Remove the object impaled in the eye and then apply a regular eye patch. Place an ice bag over the eye until the healthcare provider is seen. Irrigate the affected eye copiously with a cool sterile saline solution. Apply a Fox shield to the affected eye and any type of patch to the other eye. Submit

Apply a Fox shield to the affected eye and any type of patch to the other eye.

What action by the nurse demonstrates culturally sensitive care? Asks permission before touching a client. Avoids questions about male-female relationships. Explains the differences between Western medical care and cultural folk remedies. Applies knowledge of a cultural group unless a client embraces Western customs.

Asks permission before touching a client. Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden.

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? Help the client to accept the final stage of life. Assist and support the client in establishing short-term goals. Encourage the client to make future plans, even if they are unrealistic. Instruct the client's family to focus on positive aspects of the client's life. Submit

Assist and support the client in establishing short-term goals. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music

The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. Submit

Avoid allergy medications that contain pseudoephedrine or phenylephrine. Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy meds may contain ephedrine, phenyleprine, or pseudoephedrine, which can cause adregenic side effects, such as increased intraocular pressure, so a client with glacoma should avoid using these OTC meds

Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription? A) As needed. B) Every 12 hours. C) Every 24 hours .D) Every 4 to 6 hours.

B) Every 12 hours. A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours (B) provides the best around-the-clock pain management. Controlled-release oxycodone is not prescribed for breakthrough pain on a PRN or as needed schedule (A). (C) is inadequate for continuous pain management. Using a schedule of every 4 to 6 hours (D) may jeopardize patient safety due to cumulative effects.

.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

B. Consider the sterile field contaminated if it becomes wet during the procedure. Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? -open ended questions -closed ended questions -Problem seeking responses

Closed ended question to obtain specific questions

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? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins. Submit

Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? Raise the bed to a comfortable working level. Bend the client's knee. Move the knee toward the chest as far as it will go. Cradle the client's heel.

Cradle the client's heel. Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? Adequate venous blood flow to the lower extremities. Estimated amount of body fat by an underarm skinfold. Degree of flexion and extension of the client's knee joint. Change in the circumference of the joint in centimeters.

Degree of flexion and extension of the client's knee joint.

When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.

D. Drape the top sheet and covers loosely over the bed cradle. A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? Immediately after exhalation. During the inhalation. At the end of three inhalations. Immediately after inhalation.

During the inhalation.

Miotic drug therapy for the treatment of glaucoma is based chiefly upon which physiologic action? Enhancing aqueous humor outflow. Inhibiting aqueous humor production. Maintaining intraocular pressure. Preventing extraocular infection. Submit

Enhancing aqueous humor outflow.

What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? Instruct the client to look at examiner's nose and not move his/her eyes during the exam. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and then direct it at the client's pupil.

A peak and trough level must be drawn for a client receiving antibiotic therapy. What is the optimum time for the nurse to obtain the trough level? Sixty minutes after the antibiotic dose is administered. Immediately before the next antibiotic dose is given. When the next blood glucose level is to be checked. Thirty minutes before the next antibiotic dose is given. Submit

Immediately before the next antibiotic dose is given. rough levels are drawn when the blood level is at its lowest, which is typically just before the next dose is given

The home health nurse is admitting a client with Parkinson's disease to the home healthcare service. In planning care for this client, which nursing diagnosis has priority? Impaired physical mobility related to muscle rigidity and weakness. Ineffective coping related to depression and dysfunction due to disease progression. Ineffective breathing pattern related to respiratory muscle weakness. Fear related to constant possibility of experiencing seizures.

Impaired physical mobility related to muscle rigidity and weakness. The chief clinical manifestations are impaired movement, muscular rigidity, resting tremor, muscle weakness, and loss of postural reflexes

Which statement is an example of a correctly written nursing diagnosis statement? Altered tissue perfusion related to congestive heart failure. Altered urinary elimination related to urinary tract infection. Risk for impaired tissue integrity related to client's refusal to turn. Ineffective coping related to response to positive biopsy test results. Submit

Ineffective coping related to response to positive biopsy test results. The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?Increase the amount of calcium intake in the diet. Apply alternating heat and cold therapies. Initiate a weight-reduction diet to achieve a healthy body weight. Use a walker for ambulation to lessen weight-bearing on the hips.

Initiate a weight-reduction diet to achieve a healthy body weight. Achieving a healthy weight (C) is critical to protect the joints of clients with OA. Increasing the amount of calcium in the client's diet (A) will not protect hip joints from the effects of OA. Thermal therapies may lessen pain and stiffness from OA but are not protective of the joints

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Inquire about the source and type of pain. Examine the nose for congestion and discharge. Take vital signs for temperature elevation .Explore the abdominal area for distension.

Inquire about the source and type of pain. Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "miseries"

The low-birth-weight (LBW) infant requires a neutral thermal environment. What action should the nurse implement? Use wool blankets for covers. Avoid using disposable diapers. Maintain a high-humidity atmosphere. Continue cool oxygenation via a hood.

Maintain a high-humidity atmosphere.

A client's IV infusion of 0.9% Sodium Chloride (normal saline) infiltrated earlier today, and approximately 500 ml of normal saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What action is most important for the nurse to take? Ask about any past history of drug abuse or addiction. Measure the pulse volume and capillary refill distal to the infiltration. Compress the infiltrated tissue to measure the degree of edema. Evaluate the extent of ecchymosis over the forearm area.

Measure the pulse volume and capillary refill distal to the infiltration.

The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? Method of insertion. Location of the tubes. Diameter of the tubes. Procedure for feedings.

Method of insertion. The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incisions in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a stab wound in the abdominal wall.

The nurse is assessing the effectiveness of high dose aspirin therapy for an 88-year-old client with arthritis. The client reports that she can't hear the nurse's questions because her ears are ringing. What action should the nurse implement? Refer the client to an audiologist for evaluation of her hearing. Advise the client that this is a common side effect of aspirin therapy. Notify the healthcare provider of this finding immediately. Ask the client to turn off her hearing aid during the exam.

Notify the healthcare provider of this finding immediately. Tinnitus is an early sign of salicylate toxicity. The healthcare provider should be notified immediately

Which method of medication administration provides the client with the greatest first-pass effect? ORAL IV SQ SUBLINGUAL

ORAL The first-pass effect is a pharmacokinetic phenomenon that is related to the drug's metabolism in the liver. After oral medications are absorbed from the gastrointestinal tract, the drug is carried directly to the liver via the hepatic portal circulation where hepatic inactivation occurs and reduces the bioavailability of the drug. Alternative method of administration, such as sublingual, IV, and subcutaneous routes, avoid this first-pass effect.

The nurse must prevent a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? Obtain gloves for the child's hands. Apply finger cots on the child's fingers. Place elbow restraints on the child's arms. Apply soft restraints to the child's wrists.

Place elbow restraints on the child's arms.

A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement? Postpone the abdominal palpation until the next examination. Place the child's hand under the examiner's hand while palpating. Touch the abdomen firmly as the child takes short, quick breaths. Press the abdomen with the child bearing down and holding the breath.

Place the child's hand under the examiner's hand while palpating.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation.

Position prone with a small pillow below the diaphragm.

A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement? Leave the room without saying a word. Provide information about infection prevention. Allow the client to change the dressing himself. Explain the healthcare provider's prescription. Submit

Provide information about infection prevention.

A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? Notify the healthcare provider of the measurement. Quiet the child and retake the blood pressure. Ask the parent if the child has a history of hypertension. Document the finding and recheck in 4 hours. Submit

Quiet the child and retake the blood pressure. Crying has caused the elevated blood pressure

A client with chronic gouty arthritis takes allopurinol (Zyloprim) and experiences an acute attack of gouty arthritis. The healthcare provider prescribes concurrent low-dose colchicine. What information should the nurse provide the client that best explains the action of the colchicine? Acts like aspirin to relieve pain. Facilitates the excretion of uric acid. Reduces inflammation at the affected site. Prevents formation of uric acid crystals. Submit

Reduces inflammation at the affected site. Allopurinol (Zyloprim) improves joint function in chronic gouty arthritis by reducing blood uric acid levels to prevent and promote regression of tophi. Low-dose colchicine, an antiinflammatory agent specific for gout, is used concurrently with allopurinol, which can precipitate an incident of acute gouty arthritis.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? Irrigate the nasogastric tube with sterile normal saline. Reposition the client on her side. Advance the nasogastric tube an additional five centimeters. Administer an intravenous antiemetic prescribed for PRN use.

Reposition the client on her side. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first, followed by irrigating the NG tube with sterile normal saline and advancing the NG tube an additional 5cm, unless contraindicated. If these procedures do not work, the client may require an antiemetic.

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

Respiratory rate.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 F, Pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? Tell the student to proceed directly to his regularly scheduled class. Call the parent and suggest re-taking the student's temperature at home. Give the student a glass of cool fluids, then retake his temperature. Send the student to class, but re-verify his temperature after lunch.

Tell the student to proceed directly to his regularly scheduled class.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? The drainage tubing is secured over the siderail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame. Submit

The clamp on the urinary drainage bag is open.

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

The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent

The healthcare provider prescribes oral antifungal therapy for a client with onychomycosis. What information should the nurse tell the client? A single dose of the oral antifungal agent is usually sufficient to treat the infection. The infection is difficult to eradicate and requires prolonged therapy for 3 to 6 months. Complete eradicate is important because of the risk of a systemic infection. Prolonged therapy provides no benefit and increases the risk of adverse effects.

The infection is difficult to eradicate and requires prolonged therapy for 3 to 6 months.

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? Administer a PRN antihypertensive prescription. Provide the client with an additional blanket. Encourage additional fluid intake. Turn the client q2h. Submit

Turn the client q2h. D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? Arms. Upper torso. Head. Feet.

Upper torso.

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 in the dietary plan? Fiber. Folate. Ascorbic acid. Vitamin B12.

Vitamin B12.

Nosocomial infections are

hospital acquired infections