Hesi Remediation

A client is to receive progesterone 10 mg IM daily. The medication is labeled 50 mg/mL. How many mL should the nurse administer?

10mg/50mg x 1ml = 0.2 mL

A client receives a prescription for amoxicillin 2 g/claulanate 125 mg by mouth every 12 hours for 10 days. The medication is available in 1000 mg/62.5 mg extended release tablets. How many tablets should the nurse administer?

2 tabs

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement? A. Assist to a bedside commode 30 mins after meals B. Insert a rectal tube at specified intervals C. Encourage the use of incontinence briefs D. Administer a glycerin suppository 15 mins after meals

A

The nurse educator is conducting a class for UAP. Which action indicates that a UAP understands gloving procedures? A. Puts on new gloves when entering a clients room B. Dons sterile gloves when caring for clients with HIV C. Uses sterile gloves when handling body fluids D. Keeps a pair of gloves in uniform pocket

A

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? A. An older client with multiple problems, including obesity, diabetes, and hypertension B. Young adult client with chronic insomnia and atrial fibrillation being treated with warfarin C. A client who has a bleeding ulcer, high stress job, and takes flurazepam for sleep. D. A client with restless leg syndrome and COPD

A

When entering a clients room, the nurse observes that the UAP has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse? A. A feeding is infusing at 40 mL/hr through an enteral feeding tube B. Purulent drainage is present around insertion site of the feeding tube C. The urine meter attached to the urinary drainage bag is completely full D. There is a large dependent loop in the client's urinary drainage tubing.

A

When entering a male client's room, the nurse observes the client holding up his arm and coughing non-productively into his upper sleeve. What action should the nurse take? A. Provide a box tissues for the client to use when coughing B. Obtain face masks for staff to wear upon entering the room C. Teach the client to cover his mouth with his hand when coughing D. Assist the client in changing into a fresh hospital gown

A

Which client assessment should the nurse perform during NG suctioning? A. Observe the client's skin and mucous membranes B. Palate the clients pedal pulse volume bilaterally C. Auscultate bowel sounds in all four quads D. Determine the elasticity of the clients skin turgor

A

While turning a client who recently suffered a CVA, the nurse assess for pressure areas and skin breakdown. The skin over the sacral area is intact with non-blanchable redness. Which intervention is mot important for the nurse to implement for this immobile client? A. Change position frequently from right to left B. Avoid friction when sliding up in bed C. Offer supplemental nutritional snacks D. Change bed pads to keep skin clean and dry

A

A female client with metastic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which info should the nurse provide regarding hospice? A. Provides comfort, dignity, and emotional support B. Can be provided within comforts of home C. Family members can be involved in the plan of care D. A living will become invalid when receiving hospice care E. Hospice services can be initiated prior to discharge

A B C E

An older adult who has a shuffling, unsteady gait wants to ambulate in the hallway to a family visitation room. To reduce risk for injury, which actions should the nurse take before the client leaves the room? SATA A. Remove carts or other obstacles from clients pathway B. Place a mat on the floor where the client can stop and rest C. Confirm that the hallway floors are clean and dry D. Assist client in applying smooeth-soled shoes E. Review the clients vital signs and activity tolerance

A C D

A client has a prescription for vital sign measurement every four hours. The nurse notes that the clients BP has increased from 140/60 at noon to 180/90 four hours later. Which action should the nurse implement? A. Obtain an automatic BP machine for hourly readings B. Reassess the BP if the client reports other symptoms C. Plan to measure the BP in four hours as prescribed D. Repeat the clients BP measurement in fifteen mins

A or D

A client with end-stage metastatic cancer has a living will stating no extraordinary measures are to be taken as death approaches, and the healthcare provider writes a "DNR". When the client begins to take grasping breaths, the nurse determines the client's oximeter reading is 85%. What action should the nurse implement? A. Administer oxygen via nasal cannula B. Manually ventilate using a bag-valve-mask apparatus C. Determine if client wishes have changed D. Report client status to the healthcare provider

A. Administer oxygen via nasal cannula

Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? A. Turning instead of pulling reduces the likelihood of a skin damage B. The technique is intended to maintain straight spinal alignment C. Using two or three people increases client safety D. Working together can decrease the risk of back injury to the nurses

A. Turning instead of pulling reduces the likelihood of a skin damage

Axillary Area Temp

Apply protective sheath to cover thermometer

A client is admitted to rehab unit following a CVA, which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt and curses the nurse. Which is the best first response by the nurse? A. It is important to dress the right arm first B. Dressing must be a frustrating experience for you C. This unit has a policy against staff harassment D. We will give you a class on dressing tomorrow

B

A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple re-enteries to clients room. In which order should the nurse perform the inverventions? A. Change coccyx dressing, perform trach care, restart IV B. Restart the IV, perform trach care, change coccyx dressing C. Perform trach care, change coccyx dressing, restart the IV D. Change coccyx dressing, restart IV, perform trach care

B

A male client presents to the clinic stating he has a high stress job and is having difficulty falling asleep at night. He has tried over the counter meds. including herbals. The client is reporting a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? A. Obtain PRN prescription to be taken for stress B. Determine the clients sleep and activity pattern C. Recommend taking a nap for 15 min after lunch D. Encourage the client to eliminate stressful situations

B

A nursing home resident and their family only speak spanish. during a visit, the entire family begins to cry. When unable to determine why the family is upset, which intervention is most important for the nurse to implemement? A. Ask a spanish speaking staff member to talk with family B. Use a spanish translation reference to interview the family C. Close the oor to clients room to provide privacy D. Sit quietly with the family to offer comfort and support

B

The nurse develops an outcome statement for a male client with the nursing problem activity intolerance. The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the clients ability to tolerate this activity? A. Shuffling gait progresses to deliberate walking steps B. Normal HR range before and after ambulation C. Client states frequently he thinks he can continue D. Stopping frequently to talks to others in hallway

B

The nurse identifies several problems for an older client with diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority? A. Impaid bed mobility B. Fluid volume deficit C. Caregiver role strain D. Bowel incontinence

B

The nurse notes that a clients plan of care includes the problem, "Deficient Knowledge (dietary changes)." In developing a teaching plan, what information is most important for the nurse to obtain? A. Availability of the dietician for consultation B. Etiology of the problem C. Family members involved in the client's care D. Age of the client

B

The nurse observes redness behind both ears of a client receiving oxygen therapy per nasal cannula. Which intervention should the nurse implement? A. Discontinue the use of the nasal cannula B. Place padding around the cannula tubing C. Apply lubricant to cannula tubing D. Decrease flow rate to 1L/min

B

Which assessment is most important for the nurse to perform prior to the application of a heating pad? A. Presence of rebound phenomenon B. Degree of neurosensory impairment C. Muscle tone and strength D. Limitations to ROM

B

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement? A. Provide the client with step-by-step written instructions B. Reduce the stimuli in the area before continuing the teaching C. Reassure the client that the skill is not difficult to learn D. Demonstrate the skill, speaking slowly and using simple terms

B

it is most important for the nurse to recalculate the braden scale score for a client who has developed which problem? A. Hypoactive bowel sounds B. Urinary incontinence C. Plus two ankle edema D. Weakened cough effort

B

The nurse measures a client's body temperature as 102 degrees F. To support and validate this finding with additional assessment data, which actions should the nurse take? SATA A. Palpate skin temp B. Observe skin color C. Check for distal edema D. Note pupil response to light E. Determine pulse rate

B, E, A

A young adult was admitted to psychiatric unit yesterday. The grandparent requests information about the client's treatment plan. Before answering the family member's question, which action should the nurse take? A. Reassure the grandparent by providing an honest response B. Consult with the healthcare provider before sharing this information C. Ask the client about sharing this information with the grandparent D. Ensure that the signed release of information includes the grandparent

B. Consult with healthcare provider

A male hospice client with bone cancer reports to the nurse that his bone is not adequately controlled with his current dose of morphine sulfate, and he is experiencing difficulties with constipation. In addition to increasing the client's dose of laxative, which plan of treatment should the nurse anticipate? A. Reduce the dose of morphine B. Increase the dose of morphine C. Take no additional morphine D. Switch from morphine to codeine

B. Increase the dose of morphine

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear , which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan? A. Information about alternative ways to express sexuality B. Methods used to practice safe sex C. The importance of using vaginal lubricants D. Intercourse positions that can prevent tears

B. Methods used to practice safe sex

The nurse enters a clients room to perform a physical assessment and finds the client crying. What is the best response by the nurse? A. Gives the client a hug and says "it is okay to cry when you are sad." B. While touching the client's forearm, asks "would you like to talk about it?" C. This is a bad time. I can see you are upset. I can come back later. D. I am sorry to disturb you at a difficult time. This can wait until later.

B. While touching the client's forearm, asks "would you like to talk about it?"

A client is discharged to a long term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client's risk for infection related to the catheter? A. Secure the drainage bag at bladder level during transport B. Encourage increased intake of oral fluids C. Administer a PRN antipyretic if a fever develops D. Flush the catheter daily with sterile saline

B?

The parent of a child born with myelomeningocele asks the nurse "what did i do to deserve this?". Which response is most helpful? A. You didnt do anything wrong B With surgery, your baby should have a full recovery C. This must be a very difficult time for you D. Is there any particular reason why you think this is your fault?

C

While suctioning a client's nasopharynx, the nurse observes that the clients oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A. Reposition the pulse oximeter clip to obtain to a new reading B. Stop suctioning until the pulse oximeter reading is above 95% C. Complete the intermittent suction of the nasopharynx D. Apply an oxygen mask over the clients nose and mouth

C

The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an UAP to provide routine foot care and file the clients toenails? SATA A. Urinary incontinence B. Shuffling gait C. Hand tremors D. Diminished visual activity E. Syncope when bending

C, D, E

The nurse is preparing a teaching plan for a client with low back pain. Which sleeping position should be included in the teaching? A. Head of the bed elevated to 30 degrees B. Prone with pillow under lower abdomen C. Supine with hip and knees in neutral, straight position D. Side-lying with hip and knees flexed

D

To assess the quality of an adult clients pain, what approach should the nurse use? A. Observe body language B. Identify effective pain relief measures C. Numeric pain scale D. Ask client to describe pain

D

The nurse observes unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement? A. Complete an adverse occurence/incident report B. Initiate the facility's restraint flow sheet C. Demonstrate proper securing of the restraints D. Ensure that the restraints are not too tight

C. Demonstrate proper securing of restraints

A 24 hour urine specimen is being collected for analysis of creatinine clearance. After explaining the procedure, the client tells the nurse that the first sample is in the urinal. When discarding the specimen, which action should the nurse take? A. Observe the sample for sedimentary particles B. Check the samples pH and specific gravity C. Initiate the collection the following day D. Note the beginning time of the 24 hour sample

D

A debilitated older client who has chronic lung disease tells the nurse that sitting up in bed makes breathing easier. Which instruction is most important for the nurse to provide the UAP who is assigned to care for this client? A. Encourage the client to eat all of meals that are sent B. Lower the bed prior to helping the client to move up in bed C. Offer fruit juice at least twice during both the day and evening shifts D. Have client hold pillow over her abdomen to cough and deep breathe

D

The nurse is conducting an initial admission assessment for a woman who is muslim and who is scheduled to deliver a baby by C-section within the next 24 hours. What should the nurse include in assessment? A. Focus the discussion solely on data related to clients primary health concern B. Shake clients hand and bow the head when firat meeting to demonstrate respect C. Use the clients family as primary source for obtaining info when possible D. Determine what the client and family members consider to be their ethnic identity

D

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating? A. Urine specific gravity B. Pulse rate C. Serum hematocrit D. Urinary output

D

When assessing a skin rash, the nurse should put on PPE until the etiology of rash is identified

PPE is first

Which statement by a client indicates to the nurse that the client understands how a newly prescribed transdermal medicaiton will be administered? A. The needle is injected just barely under skin B. I will place med directly under my tongue C. The med is injected in tissue just below skin layer D. The med will be applied directly on my skin

D

The nurse implements a change in the approach to the client care after gathering evidence in support of the new approach. Which action should the nurse take next? A. Consult with a clinical nursing expert B. Revise clinical practice guidelines C. Engage staff in evidence-based practice D. Evaluate effectiveness of the change.

D. Evaluate effectiveness of the change

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a TV program and requests not to take the medication. Which action should the nurse implement? A. Credit the medication back and put in clients medication box B. Explain that since the medication is a controlled substance it must be taken C. Keep the medication and see if the client will want to take it later D. Have another nurse watch disposal of the medication into a disposable container

D. Have another nurse watch disposal of the medication into a disposable container

The nurse returning back to the anxious client as promised after responding to the other situation

Fidelity

The nurse assesses that a disoriented client drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which lab value should the nurse monitor? A. Serum sodium levels B. WBC C. Serum potassium levels D. Creatinine clearance

Serum sodium levels

3 mL syringe with a 22 guage, 1 1/2 in needle

administer 2.5 mL