HESI Pretest: N485
A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. In which order should the nurse perform the following actions? 1) Turning the woman on her side 2) Administering oxygen by way of face mask 3) Beginning an intravenous (IV) infusion of magnesium sulfate solution 4) Assessing the maternal blood pressure 5) Contacting the physician
1, 2, 5, 4, 3 If a client has a seizure (eclampsia), the initial nursing action is ensuring a patent airway. This is done by turning the woman on her side, because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse must remain with the woman and press the emergency bell for assistance. Applying oxygen is not useful if the client's airway is blocked, so this would be done after the client has been turned. The physician would be notified, vital signs assessed, and a magnesium sulfate infusion started per the physician's prescription.
A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump through a subclavian central line. The client calls the nurse and complains of difficulty breathing and chest pain. The nurse notes that the client's pulse rate is increased, the blood pressure has dropped, and oxygen saturation is 89%. The nurse should perform the following actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used. 1. Clamping the PN infusion catheter 2. Placing the client in lateral Trendelenburg position on the left side 3. Obtaining an electrocardiogram (ECG) 4. Notifying the physician
1. 2. 3. 4. One complication of subclavian central line insertion is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. On auscultation, the nurse would hear a loud churning sound over the pericardium. If this sign is detected, the PN infusion catheter is immediately clamped and the client placed in a lateral Trendelenburg position on the left side, which helps trap the air in the apex of the ventricle and prevents its ejection into the pulmonary arterial system. The physician would be notified. An ECG may be obtained, but this would not be the immediate action.
A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, the priority nursing action is to: A) Contact the physician B) Assess the patient's pulse oximetry C) Place the client in a supine position D) Administer a nebulizer treatment with the use of a bronchodilator
A) Contact the physician he sound that the nurse hears is stridor. In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort. Suctioning is performed to remove secretions that cannot be expectorated by the client. Pulse oximetry may be performed, but this is not the priority of the options provided. Administering a nebulizer treatment with a bronchodilator is not indicated at this time.
A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by explaining that: A) The pain is a normal, temporary condition B) The pain occurs because nerves have been cut C) This pain will go away once a prosthesis is used D) Pain medication may be needed for life to alleviate the discomfort
A) The pain is a normal, temporary condition Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal. Numerous pharmacological agents are available to help ease postoperative neurogenic pain. Pain medication is not needed for life. The incorrect options will not provide comfort to the child.
A nurse provides instructions to a pregnant woman about foods that contain calcium. Which of the following foods does the nurse recommend? Select all that apply. A) Cheese B) Yogurt C) Spinach D) Sardines E) Shellfish
A, B, D Calcium is essential for fetal skeleton and tooth formation. The body also uses calcium to maintain maternal bone and tooth mineralization during pregnancy. Therefore adequate intake of calcium is of utmost importance for the bone health of both mother and fetus. Cheese, sardines (and other fish eaten with bones left in), and yogurt are good sources of calcium. Shellfish are a good source of zinc and green leafy vegetables (except spinach and Swiss chard) are good sources of calcium. Spinach is a good source of iron and many vitamins.
A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. A) "I should limit activity as much as I possibly can." B) "If I have trouble breathing, I need to call the doctor." C) "I need to drink lots of fluids to keep my mucus thin." D) "I can apply Vaseline to my nose if the oxygen dries it out." E) "I should wear a scarf over my nose and mouth in cold weather." F) "If I get a flu shot, I don't have to worry about being around people with colds."
A, D, F Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures.
A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse perform? Select all that apply. A) Placing the woman in the knee-chest position B) Administering O2 at 2-4 L/min by nasal cannula C) Administering terbutaline (Brethine) to stop contractions D) With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E) wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution
A,D,E When the umbilical cord is protruding, one of the first interventions the nurse should perform is to relieve compression of the cord by exerting upward pressure on the presenting part with two gloved fingers inserted vaginally. The cord must be protected from drying out and from becoming compressed. Therefore it should be wrapped with towels soaked in warm, sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified Sims position or knee-chest position to ease compression. Oxygen should be administered by way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline, but this medication is usually not given in these circumstances.
A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which of the following physician prescriptions that will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? A)Throat culture B)Blood urea nitrogen (BUN) C) Antistreptolysin (ASO) titer D) White blood cell (WBC) count
Antistreptolysin (ASO) Titer Immunologic studies are important in diagnosing acute poststreptococcal glomerulonephritis. The ASO titer, which indicates the presence of antibodies to streptococcal bacteria, may be increased.
After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result means. The nurse's best response is: A) "We'll have to repeat the test, because the result is inconclusive." B) "The swollen area is small, so that means your test result is negative." C) "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." D) "You need to get started on medication right away, because you've got tuberculosis."
B) "The swollen area is small, so that means your test result is negative." An area of induration of less than 10 mm is considered a negative result. An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive.
A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? A) "Do you think that having asthma will kill you?" B) "You seem very distressed at learning that you have asthma." C) "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" D) "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant."
B) "You seem very distressed at learning that you have asthma." A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with such illnesses. It is important for the nurse to convey an accepting attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at learning that you have asthma" paraphrases the client's words and focuses on the client's feelings. "Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant" lectures the client and does not deal directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's words.
An HIV-positive child is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which of the following nursing actions is appropriate? A) Contacting the physician B) Administering the vaccine C) Asking the laboratory to repeat the CD4+ test D) Informing the child's mother that the vaccine must not be administered at this time
B) Administering the vaccine The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine. Contacting the physician, asking the laboratory to repeat the CD4+ test, and telling the mother that the vaccine should not be administered at this time are all incorrect in light of the results of the CD4+ count.
A client with skeletal traction applied to the right leg complains to the nurse of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? A) Providing pin care B) Calling the physician C) Removing some of the traction weights D) Medicating the client with the prescribed analgesic
B) Calling the physician A client who complains of severe pain may need realignment, or the prescribed traction weights may be too heavy. The nurse realigns the client and, if this is ineffective, calls the physician. The nurse never removes traction weights unless this is specifically prescribed by the physician. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain. Pin care is unrelated to the problem as described.
A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? A) Checking amniotic fluid B) Checking fetal heart rate C) Assessing the contraction pattern D) preparing for immediate delivery
B) Checking fetal heart rate When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Assessing the contraction pattern and amniotic fluid may also be a part of the assessment, but neither is the priority action. There is no information to indicate that immediate delivery is necessary at this time.
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication? A) Keeping a fan running in the client's room B) Keeping the linens wrinkle-free under the client C) Limiting bladder catheterization to once every 12 hours D) Avoiding the administration of enemas and rectal suppositories
B) Keeping the linens wrinkle-free under the client The most frequent causes of autonomic dysreflexia are a distended bladder and impacted feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in these areas.
A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction? A) Spinach B) Tomatoes C) Lima beans D) Whole-grain bread
B) Tomatoes Foods that are high in iron include red meat, whole-grain bread and cereals, lima beans, raisins, spinach, and broccoli. Tomatoes are high in vitamin C.
Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply. A) Enteric B) Droplet C) Contact D) Standard E) Protective isolation
B, C, D Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.
A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A) A client with active herpes virus lesions in the perianal area B) A client who requires frequent abdominal wound irrigations C) A client with a solid sealed implanted radiation source who is restricted to bed rest D) A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions E) A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning
B, D, E Pregnant nurses should not care for clients with solid sealed implanted radiation sources. The client emits radiation while the implant is in place, and the ionizing radiation could have a damaging effect on the fetus. Likewise, pregnant nurses should not care for any client with herpes lesions, because the virus may damage the fetus. There are no contraindications to assigning the other clients to a pregnant nurse.
A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply. A) Diarrhea B) Tachypnea C) Pedal edema D) Intermittent fever E) Dyspnea when ambulating F) expectoration of frothy mucus
B, D, E, Pneumocystis jiroveci pneumonia is a very common and severe opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection.
A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction? A) "I'll call the doctor if she gets dizzy and acts sick." B) "I'll call the doctor if she has severe stomach cramps." C) "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." D) "I'll call the physician if she goes longer than 6 hours without urinating."
C) "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." The mother should call the physician if a fever higher than 100° F, especially one that persists for more than 72 hours, develops. The mother should not wait until the temperature reaches 102° F (38.9°C) . The remaining statements are all accurate because the findings indicate possible dehydration and hypovolemia. Additionally, severe abdominal cramps could indicate the presence of an acute problem.
A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse assess first? A) A client who has been fitted with a closed chest tube drainage system B) A client with a nasogastric tube who underwent bowel resection 2 days ago C) A client who was admitted during the night because of congestive heart failure D) A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.
C) A client who was admitted during the night because of congestive heart failure The nurse would first assess the client who was admitted during the night because of congestive heart failure. This client's problem is directly related to airway, breathing, and circulation, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who has been fitted with a closed chest tube drainage system. This client's problem also involves airway; however, there is no indication that this client is experiencing any acute problems. The nurse would next assess the client with a nasogastric tube who underwent bowel resection 2 days ago to ensure that the client is comfortable and that the nasogastric tube is functioning. The nurse would then assess the client scheduled for a barium enema to ensure that this client understands the reason for the diagnostic test.
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? A) Calling a code B) Administering an inhaled bronchodilator C) Connecting oxygen to the suction catheter D) Encouraging the client to take deep breaths
C) Connecting oxygen to the suction catheter The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia. The physician is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning. The client will be unable to take deep breaths. There is no information in the question indicating the need to call a code.
A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse tells the client that: A) A therapeutic abortion should be considered B) Immunization against rubella is required immediately C) Immunization against rubella is required after delivery D) Antibiotics will be prescribed to prevent the infection
C) Immunization against rubella is required after delivery A rubella titer is performed to determine the pregnant client's immunity to rubella. If the titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are not prescribed. Counseling the client on therapeutic abortion is incorrect.
A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of: A) Refusal to suck B) Frequent diarrhea C) Recurrent otitis media D) Inability to pass stools
C) Recurrent otitis media GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.
In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs of: A) Anemia B) Renal failure C) Thrombus formation D) Gastrointestinal disturbances
C) Thrombus formation Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children. Anemia, renal failure, and gastrointestinal disturbances are not specifically associated with this disorder.
A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which of the following pieces of information should the nurse give to the client? Select all that apply. A) An internal fetal monitor is attached. B) The client will walk on a treadmill until contractions begin. C) A positive test result indicates a need for further evaluation. D) Special body movements will be performed to stimulate contractions. E) The client may be asked to massage one or both nipples to stimulate uterine contractions.
C, E A contraction stress test is used to assess placental oxygenation and function, determine the fetus' capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus may be compromised and requires continued monitoring and further evaluation. A negative result indicates fetal well-being.
A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? A) "Leave the room." B) "Go to the nurses' station until our group therapy session is finished." C) "I will recommend that group therapy be eliminated from your treatment plan." D) "Thank you for your comments. Now, try to stop talking and listen to the others."
D) "Thank you for your comments. Now, try to stop talking and listen to the others." When a client is monopolizing the group, it is important for the nurse to be direct and decisive and set constructive limits. The best action is to acknowledge the client's input and then suggest that the client stop talking and try listening to others. Having the client leave the room, sending the client to the nurses' station until the group therapy session is finished, and eliminating group therapy from the client's treatment plan are all inappropriate interventions.
A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 35 mg/dL (1.9 mmol/L) . The nurse would first: A) Ask the mother to breastfeed the newborn B) Bottle-feed the newborn with diluted glucose C) Start an intravenous line for the administration of glucose D) Ask the laboratory to perform a blood glucose test immediately
D) Ask the laboratory to perform a blood glucose test immediately The normal blood glucose level in a newborn is 40 mg/dL (2.2 mmol/L) or higher. Glucose levels of less than 40 to 45 mg/dL (2.2 to 2.5 mmol/L) measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.
A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first: A) Ask the client to sign a no-harm contract B) Ask the client to report any suicidal thoughts immediately C) Place the client under suicide precautions with 15-minute checks D) Check the dressings that were placed over the client's wrists in the ED
D) Check the dressings that were placed over the client's wrists in the ED The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide.
A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately? A) Disorientation to date B) pupils equaland reactive at 4 mm C) Mild headache relieved by codeine sulfate D) Pain with forward flexion of the neck onto the chest
D) Pain with forward flexion of the neck onto the chest. One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal. Mild headache relieved by codeine sulfate is an expected finding at this point after craniotomy. Disorientation to date is not the matter of greatest concern when the client has been hospitalized for cranial surgery.
