Rationale HESI 3
What assessment finding places a client at risk for problems associated with impaired skin integrity? A. Capillary refill 5 seconds. B. Smooth nail texture. C. Scattered macular on the face. D. Absence of skin tending.
Answer A. Capillary refill 5 seconds. Rationale (A) Capillary refill > 3 seconds indicates impaired circulation or oxygenation, which places the client at risk for skin breakdown. (B, C, and D) are all normal findings.
As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the plural space. What action should the nurse take first? A. Have the client exhale forcefully, and tape 3 sides of a sterile gauze over insertion site. B. Clamp the tubing with covered hemostats and call for help. C. Place the end of the tubing in a bottle of sterile water. D. Have the client lie on the affected side, and instruct the client to take shallow breaths.
Answer A. Have the client exhale forcefully, and tape 3 sides of a sterile gauze over insertion site. Rationale Forceful exhalation pushes out the air in the intrapleural space while taping three sides of the sterile gauze over the insertion site will prevent a tension pneumothorax (A). The tubing is no longer inside the chest wall so (B or C) will not help the situation. Lying on the affected side (D) would not help, and deep breaths are needed, not shallow.
A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available and 25 mg/ml ampules. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Answer 0.4 Rationale First convert pounds (lbs) to kg, 42 lbs : X kg = 2.2 lbs : 1 kg 2.2X = 42 and X = 19.09 kg Next, calculate to prescribed dose, 0.5 mg x 19.09 kg = 9.535 Then, use Desired dose/dose on Hand x Volume on hand, 9.545 / 25 mg x 1 ml = 0.3818 = 0.4 ml Or use ratio and proportion, 9.545 mg : X ml = 25 mg : 1 ml 25X = 9.545 and X = 0.3818 = 0.4
The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's Disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? A. Affirm that the UAP is using an effective strategy to reduce the clients anxiety. B. Meet with the UAP later to role model more assertive communication techniques. C. Assume care of the client to ensure that effective communication is maintained. D. Tell the UAP to offer more choices during the personal care to prevent anxiety.
Answer A. Affirm that the UAP is using an effective strategy to reduce the clients anxiety. Rationale Redirection is an effective technique and managing the anxiety of clients with Alzheimer's Disease, so the nurse should affirm that the UAP is using an effective strategy (A). More assertive communication (B) and offering more choices (D) may increase anxiety and agitation. (C) is not indicated since the UAP is using redirection, an effective strategy.
The parents of a 4-week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitating and pyloric stenosis, which is most important for the nurse to obtain? A. Degree of forcefulness of vomiting episodes. B. Level of infant's distress after vomiting. C. Odor and texture associated with emesis. D. Position of the infant when vomiting occurs.
Answer A. Degree of forcefulness of vomiting episodes. Rationale The most important information to obtain is a description of the forcefulness of the vomiting episodes (A). Projectile vomiting is a cardinal symptom of pyloric stenosis. (B) is not characteristic of either regurgitation or pyloric stenosis, nor is there any difference in odor or texture of emesis (C). Projectile vomiting occurs with the infant in any position (D), whereas positioning the infant in the upright position may prevent regurgitation. Determination of position at the time of vomiting is not as important as (A).
During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. What action should the nurse implement next? A. Take the blood pressure to more times during the visit and determine the average of the three readings. B. Measure the child's blood pressure three times during the visit and determine the highest of the three readings. C. Refer child to the healthcare provider and schedule evaluation of blood pressure in two weeks. D. Conduct a head to toe assessment and omit repeated blood pressures during the examination.
Answer A. Take the blood pressure to more times during the visit and determine the average of the three readings. Rationale Although one blood pressure reading greater than the 90th percentile may indicate hypertension, blood pressure often decreases on repeat readings. The nurse should confirm the findings by repeating the measurement and averaging the results (A). Using the highest of the three blood pressure readings is not the correct protocol (B). Referral is not indicated until the blood pressure is confirmed (C). A physical assessment may be indicated, but this action does not have the priority of (D).
A client with rheumatoid arthritis (RA) is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care? A. The ability to perform activities of daily living. B. Amount of support provided by family members. C. Measurement of pain using a scale of 0 to 10. D. Nonverbal behaviors exhibited when pain occurs.
Answer A. The ability to perform activities of daily living. Rationale RA is a chronic, inflammatory skeletal disorder that results in distortion, dislocation, and ankylosis of involved joints. The most important information to obtain when planning care is the client's ability to perform self-care during daily activities (A). (B, C, and D) are also worthwhile data to obtain but are not as important as (A) when planning the client's care.
A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline solution infusing at 1 mL/hour through one lumen and Total Parenteral Nutrition (TPN) infusing at 50 mL/hour through one port. The nurse prepared a newly prescribed IV antibiotic that should take 45 minutes to infuse. What intervention should the nurse implement? A. Use a secondary port of the Normal Saline solution to administer the antibiotic. B. Add the antibiotic to the TPN solution, and continue the Normal Saline solution. C. Stop the TPN infusion for the time needed to administer the prescribed antibiotic. D. Add the antibiotic to the Normal Saline solution and continue both infusions.
Answer A. Use a secondary port of the Normal Saline solution to administer the antibiotic. Rationale A client in septic shock needs antibiotics administered in a timely manner to ensure maintenance of therapeutic serum levels, so the nurse should administer the antibiotic by using a secondary port of the Normal Saline solution (A). No other medication (B) should be administered using TPN tubing or solution. TPN should not be placed on hold (C) because sudden cessation will cause rapid change in serum glucose levels. (D) excessively delays the administration of the antibiotic.
The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first? A. Usual bedtime and time of awakenings. B. Urinary frequency and episodes of nocturia. C. History of seasonal allergies and nasal congestion. D. Amount and type of caffeinated drinks before bedtime.
Answer A. Usual bedtime and time of awakenings. Rationale First, the nature of the sleep pattern disturbance (A) should be determined. Further information regarding (B, C, and D) can then be obtained.
A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? A. Provide a bedtime snack to be eaten before taking the medication. B. Administer the medication as prescribed with a glass of water. C. Contact the prescriber about changing the time of administration. D. Check the client's blood pressure prior to administering the med.
Answer B. Administer the medication as prescribed with a glass of water. Rationale Simvastatin (Zocor), a HMG co-enzyme A reductase inhibitor, interferes with cholesterol synthesis pathway. Zocor can be taken at any time (B). (C) is not indicated. Food intake is not an important consideration with the administration of Zocor (A). Zocor does not affect blood pressure (D).
A client with Alzheimer's Disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? A. Urinary incontinence. B. Left forearm hematoma. C. Disorientation to surroundings. D. Dislodged intravenous site.
Answer B. Left forearm hematoma. Rationale The left forearm hematoma (B) may indicate an injury, such as a broken bone, that requires immediate intervention. Urinary incontinence (A) may likely be due to the inability to use the toilet due to the fall. Disorientation (C) is a common symptom of Alzheimer's Disease. The dislodged IV (D) is not an urgent concern.
A client taking clopidogrel (Plavix) reports the onset of diarrhea. Which action should the nurse implement first? A. Assess the elasticity of the client's skin. B. Observe the appearance of the stool. C. Review the clients laboratory values. D. Auscultate the clients bowel sounds.
Answer B. Observe the appearance of the stool. Rationale Clopidogrel can cause GI bleeding, as well as diarrhea, so the nurse should first observe the appearance of any stool for the presence of blood (B). Continued or severe diarrhea may cause fluid volume deficit, electrolyte imbalance, or anemia if GI bleeding is present, so assessment of fluid volume status (A) and review of the clients laboratory values may be indicated (C). The client's over-all GI function should also be assessed (D) for other possible problems causing diarrhea, but (B) is the priority action to be implemented at this time.
The nurse is teaching a mother, who is a RN, care about her 4-year-old child who was recently diagnosed with acute lymphocytic leukemia. Based on this mother's nursing background, how should the nurse introduce the teaching plan? A. "I know you are a registered nurse, so I will skip the pathophysiology." B. "Even though you are a nurse, we need to go over the basics of care." C. "Your nursing education should be helpful to you as we begin care." D. "As a nurse, you know that the staff will need your complete cooperation."
Answer C. "Your nursing education should be helpful to you as we begin care." Rationale Acknowledging the mother's expertise without assuming she knows about her child's disease (C) provides support by building on the mother's unique strength. (A) decides for the mother what she needs to learn. (B) does not acknowledge the mother's expertise. (D) does not empower the mother to care for her child.
The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consist of one registered nurse (RN) with 10 years experience, one RN with 5 years experience, and a new graduate RN who just completed a 12-week internship. Which client should the nurse assign the new graduate RN? A. A client with end-stage liver failure who is experiencing a esophageal bleeding. B. A client with multisystem failure secondary to a motor vehicle collision. C. A client with chest tubes secondary to a stab wound to the chest. D. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
Answer C. A client with chest tubes secondary to a stab wound to the chest. Rationale The charge nurse should assign the least critical client to the RN that just completed the internship and the client with chest tubes is the least critical (C) of these four. The more critically ill clients (A, B, and D) should be assigned to the more experienced nurses because they have life-threatening conditions and high mortality rates.
To help prevent drug interactions, which instruction should the nurse provide an elderly client who is taking many medications? A. Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider. B. Be sure a family member knows the name and use of all medications currently being taken. C. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment. D.Use a medication reminder system to prevent forgetting to take the right medications at the right time.
Answer C. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment. Rationale Having the client supply the medications, supplements, and herbals that are currently being taken enables the nurse to make an accurate medication assessment (C) and determine the risk for drug interactions. (A, B, and D) are worthwhile instructions, but do not address prevention of drug interactions.
The nurse is completing an admission assessment for a male client with paranoid schizophrenia. When the client tells the nurse that the staff dislikes him, what action should the nurse take? A. Ask the client if he has a plan to harm himself. B. Assess the client's speech pattern for flight of ideas. C. Determine if the client has formulated any plans regarding the staff. D. Observe the client for obsessive activities such as repeated handwashing.
Answer C. Determine if the client has formulated any plans regarding the staff. Rationale Symptoms of schizophrenia include delusions, hallucinations, and disorganized speech. Paranoid schizophrenia is characterized by distrust of others (C) and it is most important to determine if the client plans to act on this distrust, which could present a safety issue for the staff. Assessing for plan for self-harm (A) is important for those with depression. A flight of ideas (B) is characteristic of those with bipolar disorder. Obsessive handwashing (D) is characteristic of those with obsessive compulsive disorder.
After receiving a positive HIV blood test result, the mail client tells the nurse not to tell his partner the results. What action should the nurse take? A. Respect the client's wishes and keep the results confidential from the partner. B. Try to convince the client of the importance in notifying his sexual partners. C. Explain that federal guidelines require that all sexual partners are notified. D. Ask the client when he plans to tell his sexual partner(s) about his HIV status.
Answer C. Explain that federal guidelines require that all sexual partners are notified. Rationale Confidentiality is important, but in cases involving HIV positive test results, partner notification laws require the disclosure of HIV positive results (C) to affected partners. Confidentiality can be breached in this legal and ethical case(A), which is based on the nurse's duty to warn. Attempting to convince the client to disclose his HIV status (B) and asking the client when he plans to tell his sexual partners about his positive HIV status (D) do not address the legal and ethical considerations with regard to his positive HIV status.
A client who has a history of long-standing back pain is treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client's pain management during the post operative period? A. Consult with surgeon about increasing methadone in lieu of parenteral opioids. B. Use minimal parenteral opioids for surgical pain, in addition to oral methadone. C. Maintain client's methadone, and medicate surgical pain based on pain rating. D. Make no changes in standard pain management for the surgery and hold methadone.
Answer C. Maintain client's methadone, and medicate surgical pain based on pain rating. Rationale When acute pain is superimposed on chronic pain, both types of pain need to be managed. The client's acute surgical pain should be managed with parenteral opioids based on pain rating, while continuing the chronic pain medication regimen (C). Disrupting chronic pain management by increasing (A) or omitting (D) the client's usual medications is not indicated. Pain tolerance is decreased in those with chronic pain, and clients who take opioids for chronic pain often develop a tolerance to pain medications, so it is likely that a higher rather than a lower (B) dosage of parenteral opioids will be needed.
A registered nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for and acutely ill client requiring immediate bedside insertion of a chest tube. Which assignment is the best use of each person's skills? A. The RN inserts the chest tube immediately after the PN cleanses the skin at the insertion site. B. The UAP listens to breath sounds while the RN witnesses the informed consent. C. The UAP obtains an oxygen saturation level while the RN reports findings to the healthcare provider. D. The PN instructs the family about the need for chest tube insertion while the RN obtains vital signs.
Answer C. The UAP obtains an oxygen saturation level while the RN reports findings to the healthcare provider. Rationale (C) reflects the best use of the available nursing personnel. The UAP may obtain oxygen saturation levels, which is a noninvasive procedure. The RN has expertise to report the necessary findings to the healthcare provider. (A) is not within the scope of nursing practice. Lung auscultation requires assessment skills beyond the scope of the UAP (B). (D) should be performed by the RN, with reinforcement of that teaching performed by the PN.
When conducting discharge teaching for a client who has had a mechanical valve replacement, which information should the nurse plan to include? A. It will no longer be necessary to take daily doses of anticoagulants. B. Heparin injections will be required to decrease the incidence of clot formation. C. The client will need to take an antibiotic before dental procedures. D. Mechanical valves usually must be replaced within 7 to 10 years after insertion.
Answer C. The client will need to take an antibiotic before dental procedures. Rationale Clients with mechanical valves require education regarding the need for antibiotic prophylaxis prior to all dental procedures to prevent bacterial endocarditis (C). The client should be on daily doses (A) of coumadin, not heparin (B) for the rest of his/her life. If complications do not occur, the mechanical valve should last in definitely (D), but homo/heterografts may have to be replaced.
A mother brings her 2-month-old infant to the clinic for a well baby appointment. The nurse obtains a history and conducts a physical assessment. Which finding requires the most immediate intervention? A. History of poor feeding and vomiting. B. A positive Ortolani maneuver. C. Mother describes infant as irritable. D. Bilateral retinal hemorrhages.
Answer D. Bilateral retinal hemorrhages. Rationale Bilateral retinal hemorrhages (D) are evidence of shaken baby syndrome and a shearing brain injury, which require immediate intervention. (A, B, and C) also require intervention by the nurse but are of less urgency than (D).
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool? A. Consumption, liver enzyme, gastrointestinal complaints and bleeding. B. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Efforts to cut down, annoyance with questions, guilt, drinking as an "eye-opener".
Answer D. Efforts to cut down, annoyance with questions, guilt, drinking as an "eye-opener". Rationale Cutting down, annoyance, guilt, and eye-opener drinking are represented with the acronym of CAGE. Based on the four CAGE questions (Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had an eye-opener first thing in the morning because of a hangover or just to get the day started?), the nurse should further explore the client's behaviors related to his drinking history. (A, B, and C) are not included in the CAGE questionnaire.
In evaluating the effectiveness of a post operative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Evaluate the clients ability to use an incentive spirometer. D. Observe both lower extremities for redness and swelling.
Answer D. Observe both lower extremities for redness and swelling. Rationale Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in immobile and postoperative clients, and it's effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis (D). (A, B, and C) are not the most important interventions.
A 78-year-old male client is admitted with complications related to Chronic Obstructive Pulmonary Disease (COPD). He reports progressive dyspnea worsening on exertion, weakness, and dependent edema. Which instruction should the nurse include in the client's teaching plan? A. Limit high calorie foods. B. Replace sodium with salt. C. Eat a low protein diet. D. Restrict daily fluid intake.
Answer D. Restrict daily fluid intake. Rationale This client is manifesting signs and symptoms related to Cor Pulmonale, a complication of COPD, which is characterized by right heart failure caused by long term high blood pressure in the pulmonary arteries and right and right ventricle of the heart. To limit edema and decrease workload on the right heart, the client should be instructed to restrict fluid intake to between 1,000 and 2,000 ml/day (D) and to eat a high-calorie (A), low sodium (B), and high protein (C) diet.
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity. B. Palpable cervical lymph node. C. Jugular vein distention. D. Carotid bruit.
Answer D. Carotid bruit. Rationale A bruit is a swooshing sound auscultated at the site of turbulent bloodflow. A bruit heard over the carotid artery (D) indicates an increased risk for stroke, generally as the result of arthrosclerosis. (A) is typically manifested in meningitis. (B) does not increase the risk for stroke. (C) reflects a problem with fluid volume excess, not typically an indicator of increased risk for stroke.
In assessing a 70-year-old female client with Alzheimer's disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this clients plan of care? A. Scrub the lesions with warm soapy water. B. Encourage the client to drink orange juice for added vitamin C. C. Notify the healthcare provider of the need for oral antibiotics. D. Ensure that the client gets adequate B vitamins in foods or supplements.
Answer D. Ensure that the client gets adequate B vitamins in foods or supplements. Rationale Angular stomatitis at the corners of the mouth is caused by poor dietary intake of vitamin B12 (riboflavin) and B6 (pyridoxine) (D). (A) Would irritate them. Although a vitamin C supplement would be beneficial, (B) would burn the client's mouth and make her less likely to eat. The client is not likely to have an infection, but if the cracks at the corners of her mouth do become infected, antibiotics in the form of a cream would be more appropriate (C).
The healthcare provider prescribes the nonsteroidal anti-inflammatory drug (NSAID) naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow up visit one month later, the client tells the nurse, "The pills don't seem to be working. They are not helping the pain at all." Which factor should influence the nurses response? A. Noncompliance is probably impacting optimum medication effectiveness. B. Drug dosage is in adequate and needs to be increased to four times a day. C. The drug needs 4 to 6 weeks to reach therapeutic levels in the blood stream. D. NSAID response is variable and another NSAID may be more effective.
Answer D. NSAID response is variable and another NSAID may be more effective. Rationale Response to particular NSAIDs is highly individual (D), so switching to another NSAID may provide better pain relief. There is no indication of (A). Drug effects are immediate (C). Recommended doses (B) for adults are 250 to 500 mg twice a day. If the dosage is increased it is not done by increasing dose frequency.
A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? A. Bounding erratic pulse. B. Regularly irregular pulse. C. Thready irregular pulse. D. No palpable pulse.
Answer D. No palpable pulse. Rationale The client should have no palpable pulse (D) because ventricular fibrillation produces a chaotic electrical activity which does not produce cardiac output. This is a medical emergency which requires immediate treatment to prevent death. (A, B, and C) are not typical of pulses in ventricular fibrillation.
