HESI remediation management of care
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct?
Keep the drainage system lower than the level of the client's chest.
While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with:
Down syndrome
A client is admitted to the coronary intensive care unit. What is the first step when the nurse is developing a discharge teaching plan for this client?
Identifying the client's needs
A client had a femoral-popliteal bypass graft. Four hours after surgery the client's blood pressure (BP) increases to 200/110. The nurse concludes that the increase in blood pressure is a specific indicator of what postoperative complication?
Rupture of the graft
A school nurse is formulating a plan of care for a 6-year-old boy with attention deficit-hyperactivity disorder (ADHD). What is an appropriate goal for this child?
Seeing himself as an independent person of worth
A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member?
A 77-year-old man with anxiety and mild dementia
A preschool-aged child is about to be admitted to the pediatric intensive care unit after surgery for removal of a brain tumor. The nurse manager should intervene immediately when the child's nurse:
Adjusts the bed to the Trendelenburg position
A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next?
Arrange a unit meeting to discuss what has just happened.
A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do?
Call an ambulance to go to the emergency department.
A nurse overhears a client in a mental health hospital talking on the unit telephone. The conversation concerns a "fix" to be brought to the unit during visiting hours. The nurse knows that the client, who has a history of drug use, has a contract with the practitioner promising not to use street drugs while being treated in the inpatient unit. What is the best nursing intervention?
Calling an immediate staff meeting to share the information and develop a plan for intervention
A community health nurse makes a home visit to a disabled 13-year-old client who has a 6-month-old infant sister. The infant lies quietly in her crib and rarely smiles or vocalizes; it appears that the infant barely has her basic needs met. What is the nurse's most appropriate intervention?
Determine if there is anyone who can help with chores and the infant's care.
When caring for a client with venous insufficiency, the nurse would implement which nursing measure?
Elevate the client's legs above heart level.
On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should:
Notify the surgeon immediately
A male client with a history of schizophrenia comes to the emergency department, accompanied by his wife. What is the emergency department nurse's priority intervention?
Observing and evaluating his behavior
As a nurse is assisting a client with the diagnosis of schizophrenia with morning care, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior?
Somatic delusion
The mother of a 6-year-old boy tells the nurse in the pediatric clinic that her son has become incontinent of stool. The nurse plans to assess the child to determine the cause of his encopresis. In what order should the nurse perform the assessments?
1 Bowl habits 2. nutrition 3. Psychosocial factors 4. Physical examination
An 8-year-old child with viral pneumonia is admitted to the pediatric unit. The admitting nurse reviews the instructions from the health care provider. Which prescription should the nurse question?
Aspirin 325 mg every 4 hours prn for fever higher than 101.4° F.
When a nurse is working with a client with psychiatric problems, a primary goal is the establishment of a therapeutic nurse-client relationship. What is the major purpose of this relationship?
Assisting the client in acquiring more effective behavior
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time?
Helping the client change her position
A nurse epidemiologist is responsible for wound consults at the hospital where a client has been admitted with an infected wound. The client asks, "What is the primary role of a nurse epidemiologist?" The nurse explains that the nurse epidemiologist:
Helps health care providers to control infections
The staff of a mental health unit is conducting an orientation meeting for newly admitted clients. What should the nurse plan to address first at the meeting?
Purpose of the group meeting
The nurse is teaching a client who has asthma about using a peak flow meter. Which statement by the client reflects a correct understanding of the use of a peak flow meter? Select all that apply.
Readings in the green zone mean that my asthma is under control. "If I get a reading in the red zone, then I need to take my reliever drug and have my wife take me to the hospital." "I should check the peak flow readings at least twice a day."
A client's pressure ulcer has minimal drainage and is healing by secondary intention. Which intervention to promote gaseous exchange between the wound and the environment does the nurse anticipate the health care provider to prescribe?
Transparent polyurethane film
A health care provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented. Correct
Verify the health care provider's prescription. Elevate the head of the bed 90 degrees. Inject 20 mL of air into the tube and auscultate over the epigastric area of the abdomen. Check the volume of residual against the parameters prescribed. Administer the volume of feeding as per the prescription. Flush the tube with 30 mL of water after the feeding.
The nurse is involved in a therapeutic relationship with a depressed client. Which question and/or statement, asked by the nurse, is appropriate for stage 1 of this relationship? Select all that apply.
"I'm here to talk with you about how you've been feeling." "Are you experiencing any suicidal or homicidal thought?" "What we talk about will be shared only with your treatment team."
The nurse is providing postoperative care for a college student who has undergone a knee arthroscopy for tendon repair. The client is scheduled to be discharged in a few hours and plans to return to the college dormitory and spend the weekend there before returning to class in two days. What is most important for the nurse to include in the client's discharge plans?
Ask the client who is available in the dormitory that could provide assistance.
Following a laparoscopic cholescystectomy, a priority nursing action is to:
Assess band-aids for bleeding.
A client admitted with a femur fracture 24 hours ago becomes confused. A nurse should immediately:
Assess for petechiae on the neck and chest.
Following surgery, a client asks the nurse to help measure intake and output. What is the best nursing response?
Assess the client's ability to measure the intake and output
A 10-year-old boy arrives with his mother at the emergency department after being bitten by a stray dog. He has sustained a soft tissue injury on the inner aspect of the left forearm, and it is bleeding. What is the priority nursing action?
Assessing the injury and the child's vital signs and health history
When talking with a client in crisis, the crisis intervention nurse should first:
Assist the client in deciding what will be done and how it will be done.
When checking the cervical dilation of a client in labor, a nurse notes that the umbilical cord has prolapsed. What is the priority nursing action?
Assisting the client into the Trendelenburg position
The mother of a toddler complains that the toddler has not been acting quite right lately. She has had a fever for a couple of days and now presents with decreasing oral intake and a rash over her hands and feet. Which condition does the nurse suspect?
Coxsackievirus infection
A client who has been told she needs a hysterectomy for cervical cancer is upset about being unable to have a third child. What is the next nursing action?
Ensure that other treatment options for her will be explored.
A client is admitted to the hospital with weakness in the right extremities and a slight difficulty with speech. Vital signs are within expected limits. What is the priority nursing action during the first 24 hours?
Evaluating the client's motor status.
A child with recently diagnosed idiopathic scoliosis has a mild structural curve. The child's mother asks whether the problem can be corrected with exercise. What should the nurse tell the mother concerning an exercise program?
Exercise is used in conjunction with a brace.
A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription?
Health care provider who wrote the prescription
An 11-year-old child who recently returned from a camping trip reports chills, fever, and a headache and is taken to the clinic by the parents. What is most important for the nurse to assess initially during the child's history and physical examination? Select all that apply.
History of allergies Duration of clinical findings
The nurse manager of an emergency department who is helping a nurse with burnout should initially facilitate confrontation of the problem by urging the nurse to:
Identify personal responses to daily work stresses.
Which outcome best demonstrates a health care institution's commitment to providing a supportive environment for its psychiatric nursing staff?
Psychiatric nurses are regularly recognized for their contributions to client health care.
An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight and is wearing soiled and inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do?
Report the suspicion of neglect by the adult child to adult protective services.
A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this prescription with the primary health care provider when the client has which condition?
Stage IV pressure ulcer with eschar
The client is receiving multiple blood transfusions after having extensive abdominal surgery. If the client develops fever, chills, and lower back pain, and seems very nervous, what will be the nurse's first action?
Stop the blood and infuse normal saline.
A client is scheduled for a computed tomography (CT) of the brain with contrast. Upon review of the client's medical record, what significant finding should the nurse report to the health care provider before the diagnostic procedure? The client:
Takes metformin (Glucophage) daily.
A client hospitalized for heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. What should be included in the plan of care for the next few days?
Taking the apical pulse before drug administration and teaching the client how to count the pulse.
An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record. Which clinical finding is a priority to be communicated to the primary health care provider?
potassium level
