Hesi review

While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response?

"I'm sorry, I can't disclose client information."

The laboratory comes to draw an Hgb AIc. The client asks the nurse what this test represents. Which statement would be correct?

"This test reflects the average blood glucose over a period of approximately 2-3 months."

A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:

2. monitoring the blood glucose level closely.

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks

Acetaminophen

A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first?

Discuss the breach of practice with the physician

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Dyspnea, tachycardia, and pallor

A nurse is working on a surgical floor. The nurse must logroll a client following a

Laminectomy

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?

Maintain a regular program of weight bearing exercise

For a client with Graves' disease, which nursing intervention promotes comfort?

Maintaining room temperature in the low-normal range

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance

Which nursing intervention is essential in caring for a client with compartment syndrome

Removing all external sources of pressure, such as clothing and jewelry

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to

Rest in an air conditioned room

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? You Selected:

Taking with the nurse

The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is:

Washing hands frequently

Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next:

discuss the situation and possible courses of action with the dietitian and the client.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution.

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance

metabolic alkalosis

Which finding is normal for a client during the icteric phase of hepatitis A?

yellowed sclera

A client with posttraumatic stress disorder states, "You don't know what I've been through. What can you do?" The nurse should respond:

• "I haven't been through what you have, but I'll be better able to understand if you tell me more about it."

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next?

• Place the infant skin to skin with the mother.

During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates?

"This test will screen for spina bifida, Down syndrome, or other genetic defects."

A client, with heart failure, is receiving furosemide, 40 mg IV. The provider orders 40 mEq of potassium chloride in 100 ml of dextrose 5% in water, to infuse over four hours. The client's most recent serum potassium level is 3.0 mEq/L. At which infusion rate should the nurse set the IV pump? Record your answer using a whole number.

25

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should

3. collect the specimen in a sterile container.

The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia?

A client with digoxin toxicity

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child anise

The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client

Apply form pressure on the site for 5 minutes after removal

A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?

Collaborate with the inter professional team to make a referral to social services

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

In the supine, sitting , and standing positions

A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next?

Instruct the client to use a pant blow pattern of breathing

A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief?

Intravenous

A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse's priority intervention?

Place the client on her left side and apply oxygen

A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do?

Prevent late night hypoglycemia

The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate

Tell me what you found in your reading that lead you to that conclusion

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy?

To prevent compression of the vena cava

A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse?

What activities did you enjoy in the past

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

chicken and orange slices

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

urinary retention

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

Assessing present voiding patterns

A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official's electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation?

Assessing the officials medical record is a breach of confidentiality

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

Assessing the vital signs and oxygenation saturation

A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks' gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do?

Avoid mineral oil because it interferes with the absorption of fat soluble vitamins

A medication nurse is preparing to administer 0900 medications to a client with liver cancer. Which consideration is the nurse's highest priority?

metabolism of the medication

A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation?

Contact the surgeon to explain that the client needs further clarification regarding surgery

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy?

Cough and shortness of breath

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should the nurse report to the surgeon and anesthesiologist?

Creatinine 2.6

A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse's best response?

"Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs."

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

-Cover the draining areas with sterile gauze.

A client with an uncomplicated term pregnancy arrives at the laborand-delivery unit in early labor saying that she thinks her water has broken. What is the nurse's best action?

Ask what time this happened and note the color, amount and odor of the fluid

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priorityintervention?

Ask for additional information from the client

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

Daily weight

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to

Distribute weight away from the involved side

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care

Involve the client in usual at home activities

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because

It may induce bronchospasm

The nurse is assessing a client with thigh high antiembolism stockings. Assessment findings include redness, swelling, and pain in the left calf. What is the priority action by the nurse?

Notify the healthcare provider

Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals

Offer the client nutritious finger foods.

A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care?

Offering support by reviewing the short pant form of breathing

After an intravenous pyelogram (IVP), the nurse should include which measure in the client's plan of care?

encourage adequate fluid intake

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on time spent in bed during the day.

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following?

referral. Explanation: Referring is the process of sending or guiding a client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply.

• Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication.

A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents?

• Protect your child from infections because his resistance to infection is decreased

A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine 75 mg three times a day and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client?

• The depression is improving, and the suicidal ideation is lessening.

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel?

• an 8-month-old with pneumonia who will be discharged today

After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom?

• inability to extend the fingers on the right hand

A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving I.V. push morphine for pain management. During rounds, the nurse discusses with the physician the need to start the client on a continuous morphine infusion. The nurse bases this request on the fact that:

• serving as a client advocate is an important role.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

A middle-aged man with no injuries who has rapid respirations and coughs.

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do

• Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.

The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, "Why? Everything was going well. How could they do this to me?" What response by the staff nurse reflects an understanding of the client's borderline disorder?

• "Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety."

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?

• "If a wound heals on the surface but infection remains, it will open and drain."

A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client:

• "It's frightening to have new people on the unit. We're here to talk about things like being afraid."

Which client statement indicates an understanding of the risk of alcohol relapse?

• "Stopping support groups and not expressing feelings can lead to relapse."

A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status?

• "What did your child eat for breakfast?"

A client with Parkinson's disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the mostappropriate action by the nurse?

• Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment.

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?

cool, pale fingers

A nurse is conducting an educational program about advanced directives for a group of adults at a local community center. The nurse explains what the directives entail and how they are used. After explaining this topic, the nurse determines that the teaching was successful based on which statement by the group?

• "The document allows us to choose what we want to have happen."

A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next?

• Administer the acetaminophen with codeine.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital?

• Decrease the client's feelings of isolation and loneliness.

A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first?

The client admitted after a head injury in a motor vehicle who reports nausea

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

Massages the clients legs