HESI Remediation

How can a nurse best meet a preschooler's developmental needs just before a physical examination?

By allowing the child to handle the examination equipment

How can a nurse minimize agitation in a disturbed client?

By limiting unnecessary interactions with the client

A client expresses a desire to breastfeed her preterm infant, who is being cared for in the neonatal intensive care unit. How should the nurse respond to this client's request?

By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI?

By telling the adolescent to shrug the shoulders

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. What does the nurse identify as the drug's mechanism of action?

Restores the dopamine levels in the brain

What is the priority outcome in the planning of care for a client in crisis?

Restoring the client's psychological equilibrium

A nurse is caring for a preschool child who is receiving prednisone. What is most important for the nurse to consider when administering adrenocorticosteroid therapy?

It suppresses inflammation.

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco 2 of 50 mm Hg, HCO 3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis?

Metabolic alkalosis

An infant is born precipitously in the emergency department. What should the nurse's initial action be?

Establish an airway for the newborn

After a tonsillectomy, which finding alerts the nurse to suspect the initial stage of hemorrhage?

Frequent swallowing

A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate what about her toddler?

Has bulky, foul, frothy stools

A nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. What does the nurse expect analysis of the child's urine to reveal?

High protein level

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client?

Hoarseness

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client?

Hyperthyroidism

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent?

Shock

An older client with dementia of the Alzheimer type is residing in a nursing home. When in bed, the client consistently is found sleeping in the semi-Fowler position. What area of the client's body does the nurse determine has the most risk for developing a pressure ulcer?

Sacrum

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy?

Using shields on the eyes to protect them from the light

When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude?

The bladder has become overdistended.

Which is a goal for organized athletics for school-age children?

A life-long enjoyment of fitness.

At which stage of development should the nurse anticipate that pediatric clients will begin to show differences in play activities that are related to gender?

Late school-age

A nurse is planning to administer albuterol to a 4-year-old child. How will the nurse evaluate the effectiveness of this medication?

Auscultate breath sounds

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion?

Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min

A nurse is planning care for a toddler who has ingested aspirin. What assessment warrants close monitoring because an increase can result in further complications?

Body temperature

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis?

Lips

Which diagnostic test may be used to distinguish vascular from nonvascular structures?

Magnetic resonance imaging

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?

Brown or black mole with red, white, or blue areas

A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy?

Recognizing when anxiety is developing

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?

Cranial nerve I

Which gross motor skill should the nurse anticipate when assessing a 15-month-old toddler-age client during a scheduled health maintenance visit?

Creeping up stairs

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion?

Cyanosis

Who completes the developmental questionnaire for a pediatric client who is being assessed using the Developmental (ASQ-3) screening?

Parent

Which toddler behavior should the nurse identify as global organization, a characteristic of preoperational thought?

Refusal to sleep in bedroom because the bed has been moved

What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)?

Removing the catheter

A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy. This has also not been relieved by the administration of analgesics. What does the nurse conclude is the cause of the client's pain?

The use of appropriate equipment A physical examination every two years Participation in warm-up exercises prior to physical activity

At what age is a toddler-age client physiologically and psychologically prepared for toilet training?

22 months

From which client does the nurse expect dramatic physical growth and marked development?

9-month-old infant

A 4-year-old child shows a motor response score of 3 on the Glasgow Coma Scale. What clinical finding does this signify?

Abnormal flexion

What should be used to clean needles and syringes between intravenous drug users (IDUs)?

Bleach

According to the Model for Differentiated Nursing Practice, which entry-level nurse is most prepared for prioritization of client care?

Bachelor's degree registered nurse

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client?

Diminished breath sounds

The nurse is caring for an assignment of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage?

Giving birth to a baby weighing 9 lb 8 oz (4309 g)

The primary healthcare provider prescribes a neuroleptic drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug?

Side effects

A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client?

Softening of nail beds and flat nails

A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention?

Starting an intravenous line with a large-bore catheter

An infant needs emergency surgery. A nurse is aware that the child's mother is 13 years old and that the father is 16 years old. The father and the paternal grandmother, who both take care of the infant, are the only family members at the bedside. From whom should the nurse obtain the informed consent?

The 16-year-old father

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution?

0.9 nacl

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

6

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what?

Grandeur

What common problem affects the client in labor when an external fetal monitor has been applied to her abdomen?

Intrusion on movement

Which theorist suggested that the goal of nursing is to use communication to help clients reestablish a positive adaptations to their environments?

King

Which positioning should be avoided while assessing a client with a history of asthma?

Lateral recumbent

Which statement about psychotherapeutic drugs in elderly clients requires correction?

Low serum levels of the drug are reported in elderly clients on psychotherapeutic drugs.

A child has unknowingly swallowed a poisonous substance and has fallen unconscious. Which nursing intervention is advisable for the child?

Make arrangements so that the child is taken to a hospital.

A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. Which condition does the nurse suspect?

Mastitis

Which group of the pediatric population is at a higher risk of developing respiratory complications upon administration of general anesthesia?

Neonates

An intravenous (IV) antibiotic is prescribed for a child with fever of unknown origin. Within 10 minutes of the antibiotic infusion, the child's face and neck are flushed but the remainder of the body is unchanged. The nurse checks the child's record. In light of this information, what will the nurse do?

Notify the primary healthcare provider after stopping the infusion.

A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include?

Obtaining a prescription to administer Rho(D) immune globulin to the mother

How should the nurse prevent footdrop in a client with a leg cast?

Support the foot with 90 degrees of flexion.

A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. What does the nurse expect the child's mother to report?

The child had a sore throat a few weeks ago.

A client has a tuberculin purified protein derivative test as part of a yearly physical examination. The area of induration is 10 mm within 48 hours after having the test. What does the nurse conclude about the client based on this response?

The client has been exposed to the tubercle bacillus.

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response?

The client has some feelings of self-worth.

An intravenous injection of morphine sulfate, 2 mg, is prescribed for an 8-month-old infant weighing 15 lb 7 oz (7 kg). The recommended dose for an infant is 0.1 mg/kg. Why should the nurse question the prescription?

This amount of morphine sulfate is unsafe for an infant of this weight.

What does the A of the mnemonic "ABCDE" of primary nursing survey stand for?

airway

Which pregnancy safety category shows a proven risk of fetal harm, but potential benefits of use during pregnancy may be acceptable despite its risks?

Category D

A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition?

Anhedonia

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care?

Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

An adolescent with leukemia is to be given a chemotherapeutic agent that is known to cause nausea and vomiting. When is the best time for the nurse to administer the prescribed antiemetic?

Before each dose of chemotherapy

How can a school nurse help determine a young child's readiness to learn?

By assessing the child's vision and hearing

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?

Calcium

A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What is the best response by the nurse?

Call the Poison Control Center.

The nurse admits a client with preeclampsia to the high-risk prenatal unit. What is the next nursing action after the vital signs have been obtained?

Checking the client's reflexes

A nurse counseling a client on the inpatient psychiatric unit responds to a statement made by the client by stating, "I'm confused about exactly what is upsetting you. Would you go over that again, please?" What is the nurse using?

Clarifying

Which statement is true regarding antipsychotic drugs?

Clozapine is more effective than other second-generation antipsychotics.

A 3-year-old child with the diagnosis of tetralogy of Fallot is brought to the United States by a charitable organization for cardiac surgery. What should the nurse expect when conducting an admission assessment of the child?

Clubbing of fingers

The home healthcare nurse is evaluating the environments of several preschool-age pediatric clients. Which activities noted during the visits places a child at risk for bodily harm? Select all that apply.

Correct 1 The client is swimming in the pool unsupervised. Correct 2 The parents leave medications within reach of the client. Correct 3 A parent tricks the client to eat a vitamin by saying, "This is candy."

Which hormones are secreted by the posterior pituitary gland? Select all that apply.

Oxytocin Antidiuretic hormone

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention?

Restlessness with dyspnea

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis?

pH: 7.28; PCO 2: 28; HCO 3: 18