Funds HESI Practice Questions
A client with a diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? a. Wound infection b. Ischemia of the stoma c. Electrolyte imbalances d. Excoriation of skin around the stoma
C
What should the nurse include in dietary teaching for a client with a colostomy? a. Liquid should be limited to 1 L per day b. Nondigestible fiber and fruit should be eliminated c. A formed stool is an indicator of constipation d. The diet should be adjusted to include foods that result in manageable stools
D
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? a. Face tent b. Venturi mask c. Nasal cannula d. Nonrebreather mask
D
Which step in the nursing process would involve promoting a safe environment for the client? a. Planning b. Diagnosis c. Assessment d. Implementation
D
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease. By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? a. Decrease in red cell formation b. Rupture of emphysematous bullae c. Depression in the respiratory center d. Excessive drawing of the respiratory mucosa
C
An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? a. Oxygen saturation: 89% b. Body temperature: 101 degrees Fahrenheit c. Blood pressure: 130/80 mmHg d. Respiratory rate: 26 beats/minute
A
A client is receiving total parenteral nutrition through a central venous access device. What important nursing intervention should be included? a. Placing the client in the supine position before changing the tubing b. Monitoring the blood pressure frequently to assess for hypovolemia c. Decreasing the infusion rate of blood glucose levels become elevated d. Piggybacking intravenous antibiotics on to the TPN tubing to prevent infection
A
A client with a new diagnosis of type one diabetes is told that lifelong insulin will be needed. The client becomes agitated and says "I am scared of shots. If that is my only option, I'll just have to go into a coma and die!" What is the nurse's best response? a. Injections are not the only option available for insulin. b. It won't be so bad; you will get used to it if you will only try. c. This is one of those times when you need to act like an adult. d. Clients have the right to refuse treatment, but I need you to sign this form that removes us from liability for your decision.
A
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do? A. Increase oral fluid intake to 2 to 3 L/day. B. Maintain bed rest after discharge. C. Limit fluid intake to 1 L/day. D. Void at least every hour.
A
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? a. Wear cotton underpants b. Void at least every six hours c. Increase foods containing alkaline ash in the diet d. Wipe from back to front after toileting
A
A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include? a. Administering water after the feeding is completed b. Maintaining the supine position during the feeding c. Heating the feeding to slightly above body temperature d. Determining tube placement by instilling water before the feeding
A
What are common negligent acts of nurses found in the hospital setting? a. Failure to notify the health care provider of the problems b. Failure to follow the six rights of medication administration c. Failure to ensure the safety of a client with disequilibrium problems d. Failure to notify a family member about a client's current status e. Failure to administer medication during an emergency without consulting with the nursing manager
A,B,C
The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discuss is this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." What does the nurse determine that the client needs to be taught about? a. Need for home delivered meals b. Foods that meet basic nutritional needs c. Effective aging on the need for some foods d. Need for meat at least once per day throughout life
B
The primary healthcare provider instructs the client to increase their intake of seafood and protein in the diet. What could be the reason for this instruction? a. The client has vitiligo b. The client has hypothyroidism c. The client has diabetes mellitus d. The client has urinary infection
B
What action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? a. Assessing the client's ability to understand the nurse's questions b. Evaluating how actively the nurse has been listening to the client c. Reinforcing to the client how important sharing is for successful recovery d. Reviewing how the questioning techniques are being used by the client
B
When providing care for a client who is receiving enteral feedings via a nasogastric tube, the nurse should take measures to prevent what serious complication? a. Skin breakdown b. Aspiration pneumonia c. Retention ileus d. Profuse diarrhea
B
Which statement made by diabetic client shows that dietary teaching by the nurse was effective? a. My diet should be rigidly controlled to avoid emergencies b. My diet can be planned around a wide variety of commonly used foods c. My diet is based on nutritional requirements that are the same for all people d. My diet must not include eating any combination dishes and processed foods
B
Which therapeutic communication technique involves using a coping strategy to help the nurse and client adjust to stress? a. Sharing hope b. Sharing humor c. Sharing empathy d. Sharing observations
B
As a young male client is undergoing a dialysis treatment, the nurse notes that he is not talking with the other clients and that his eyes are lowered, and his jaw clenched. The nurse says you look discouraged. The client replies "I'm a bother. My wife would at least get some insurance money if I died." Which is the most therapeutic response by the nurse? a. I can understand how you feel. b. You feel so bad you wish you were dead. c. We all have days when we feel like that. let's talk about your diet. d. I know it's hard don't let it get you down; you just need time to adjust.
B
The nurse provides care for a Chinese client who is experiencing leg pain. the client states, "I don't want to take any medication that I may get addicted to." What is the best nursing intervention in this situation? a. Give ibuprofen to the client with hot tea b. Give morphine to the client with hot tea c. Give ibuprofen to the client with cold water d. Postpone medication administration to the client
A
The nursing leader is teaching the newly hired nurse about the use of an electronic medication administration record. Which statement of the newly hired nurse indicates effective learning? a. It will identify medication errors b. It will be accessible to a single user c. It will decrease the accuracy of charge capture d. It will decrease the accuracy of pharmacokinetic monitoring
A
Three days after admission to the hospital for a brain attack, a client has a nasogastric tube inserted in his receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed? a. Aspirate for a residual volume b. Evaluate the intake in relation to the output c. Instill air into the client stomach while auscultating d. Compare the clients body weight with the baseline data
A
What instruction regarding sample collection should the nurse give a client who is ordered a clean catch urine specimen? a. Urinate small amount, stop flow, fill half of Cup b. Collect the last urine sample voided in the night c. Keep the urine sample in dry warm area if delays anticipated d. Send The urine sample to the laboratory within six hours of collection
A
Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel
A
Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? a. Tubing luer-lok port b. Distal end of tubing c. Urinary drainage bag d. Catheter insertion site
A
Which step of the nursing process is directly affected if the nurse does not make a diagnosis? a. Planning b. Evaluation c. Assessment d. Implementation
A
While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation? a. 1+ b. 2+ c. 3+ d. 4+
A
The client with emphysema complains of increased shortness of breath and becomes anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? a. High concentrations of oxygen cause alveoli to rupture b. High concentrations of oxygen eliminate the respiratory drive c. The client does not need any more than 1 L/min d. The oxygen at 1 L/mon should be enough to diminish the anxiety
B
The nurse asks questions to an older client about past experiences and listens attentively. Which therapeutic communication strategies involved when the older client is recalling the past? a. Touch b. Reminiscence c. Reality orientation d. Validation therapy
B
A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address? A. Safety B. Self-esteem C. Physiological D. Interpersonal
A
A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? A. Hand washing before and after providing client care B. Cleaning all equipment within an approved disinfectant after use C. Wearing personal protective equipment (PPE) when providing client care D. Using medical and surgical aseptic techniques at all times
A
During discharge teaching, a client with an ileal conduit asks how frequently the urine pouch should be emptied. Which replied with the nurse's best? a. To prevent leakage and pulling of the pouch from the skin, it should be emptied every few hours b. To prevent skin irritation, it should be emptied every hour of any urine has collected in the bag c. To reduce the risk of infection, the system should be opened as little as possible; 2 times a day is adequate d. To reduce the cost of drainage pouches, it should be emptied once the system is switched to a bedside collection bag
A
How can a nurse best evaluate the effectiveness of communication with the client? a. Client feedback b. Medical assessments c. Health care team conferences d. Client's physiologic responses
A
Oxygen given to clients during stage four of chronic obstructive pulmonary disease should be administered in which manner? a. 1 to 2 L Via nasal cannula to keep SaO2 above 90% b. 1 to 2 L via nasal cannula to maintain SaO2 at or above 95% c. 3 L via mask to maintain SaO2 at 95% d. Do not give oxygen because it may suppress hypoxic drive in client
A
The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context? A. Assess the resources available to the family B. Meet the client's family's comfort and nutritional needs C. Meet the clients comfort, hygiene, and nutritional needs D. Determine the family's need for rest and their stage of coping
A
The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention? A. Provide perineal care B. Turn and position the client C. Give a complete bed bath. D. Document the bowel movement
A
The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care? A. Safety B. Self-Esteem C. Self-actualization D. Love and belonging
A
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin. Which other parameter can be determined using this technique? a. Arterial oxygen saturation b. Partial pressure of oxygen in arterial blood c. Partial pressure of arterial carbon dioxide d. Partial pressure of oxygen in venous blood
A
The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the best nursing interventions in this situations? A. The nurse should provide a protective environment B. The nurse should assist with personal hygiene C. The nurse should educate the client about correct body mechanics D. The nurse should promote activities that reinforce reality E. The nurse should teach the client's caregiver proper feeding techniques.
A, B, D
What is a nurse's responsibility when administering prescribed opioid analgesics? a. Count the client's respirations b. Document the intensity of the client's pain c. Withhold the medication of the client reports pruritus d. Verify the number of doses in the locked cabinet before administering the prescribed dose e. Discard the medication in the client's toilet before leaving the room if the medication is refused
A, B, D
When caring for a client with varicella and disseminated herpes zoster, the nurse implement which types of precautions? A. Airborne B. Contact C. Droplet D. Hazardous wastes E. Standard
A, B, E
Which factor should the nurse consider when administering medications to adolescents? a. Explanation of the medication administration procedure by the nurse to the client b. Interactive communication regarding the procedure of medication administration c. Implementation of comfort measures like holding d. Acceptance of aggressive behavior with certain limitations Encouragement of self-expression, individuality, and self-care
A, B, E
A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? A. Loss of turgor B. Urinary incontinence C. decreased night vision D. decreased mobility of ribs E. Increased sensitivity to odors
A, C, D
Which nursing interventions would be beneficial for providing safe oxygen therapy? a. Check tubing for kinks b. Run wires under carpeting c. Post no smoking signs in the client's rooms d. Place oxygen tanks flat in the carts when not in use Make sure that the client is familiar with the phrase stop drop and roll
A, C, D
A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which food should the nurse include in the teaching? a. Carrots b. oranges c. tomatoes d. green leafy greens e. yellow/orange vegetables
A, D, E
Which features distinguish nursing diagnoses from medical diagnoses? a. Nursing diagnoses involve the client when possible b. Nursing diagnoses are based on the results of diagnostic tests and procedures c. Nursing diagnoses are the identification of disease condition in the client d. Nursing diagnoses involve the sorting of health problems within the nursing domain e. Nursing diagnoses involve clinical judgment about the client's response to health problems
A, D, E
While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicated an understanding of the teaching? A. I will clean my comb in ammonia water. B. I should use lindane-containing shampoo. C. I should shampoo my hair in a tub or shower. D. I should use a dilute vinegar solution to loosen the nits E. I should use a shampoo treatment once every 24 hours.
A, D, E
A nurse is caring for a client who is receiving total parenteral nutrition. The nurse would monitor the client for which complications? a. Hyperglycemia b. Infection c. Hepatitis d. Anorexia e. Dysrhythmias
A,B
The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care? a. Sensory deprivation b. Urinary tract infection c. Frequent use of diuretics d. Inaccessibility of a bathroom
B
The nurse is preparing to administer a nasogastric tube feeding to a client via infusion pump. What is the most important assessment the nurse needs to perform before beginning the pump? a. Checking for the last bowel movement b. Checking for residual stomach contents c. Checking to determine time of last medication for nausea d. Checking to make sure that the head of the bed is elevated at least 15 degrees
B
A visitor in the waiting room of the emergency Department has syncopal episode collapses on the floor. The event is witnessed by a nurse on her way into the hospital for her shift, who provides initial care. The nurse assesses the client, maintain safety of the environment, and gave report to the emergency Department nurse, he will provide ongoing care period which of the nurse who witnessed the event do next? a. Contact the family b. Document the incident c. Report the incident to the nurse manager d. Escort the client to the radiology Department
B
1. A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that the client has a prescription for morphine 2 MG intravenously every three hours for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain on a level 8 on a pain scale 0 to 10. What is the first thing the covering nurse should do? a. Determine the document in time when the pain medication was last given b. Verify that the written prescription matches the administration record c. Encourage nonpharmacological measures initially to relieve the pain d. Explain that the primary nurse will be back from lunch in a few minutes
B
A Client was severe Crohn disease develops a small bowel obstruction. Which clinical findings should the nurse expect the client to report? a. Bloody vomitus b. Projectile vomiting c. Bleeding with defecation d. Pain in the left lower quadrant
B
A client comes to the emergency Department because of minimal urinary output despite drinking adequate fluid, the client's blood pressure is 190/94 mmHg. for what additional clinical manifestation associated with this data should the nurse assess the client? a. Thirst b. Weight gain c. Urinary retention d. Urinary Hesitancy
B
A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. What should the nurse do first? a. Instill normal Saline into the tube to maintain patency b. Obtain an X-Ray to verify that the tube is in the stomach c. Auscultate the epigastric area while instilling 15 mL of air d. Withdraw 30 mL of stomach contents to verify tube placement
B
After surgery for creation of an ileostomy, a client is to be discharged. Before discharge, what is the primary nursing intervention? a. Emphasizing that it is essential that the client can care for the ileostomy without assistance b. Evaluating the client's ability to care for the ileostomy c. Ensuring that the client understands the dietary limitations that must be followed d. Ensuring that the client is competent at changing the dry sterile dressing on the incision
B
A client has arrived on the nursing unit and a scheduled for a cholecystectomy. There is one registered nurse, a licensed practical nurse, and a certified nursing assistant institution policy is that all admissions must have an initial comprehensive assessment completed by the registered nurse. The registered nurse is currently caring for an acutely ill client having a transfusion reaction. What is the best decision? a. Delegate to the practical nurse admission of the client, performance of the initial comprehensive assessment, and completion of the admission documentation b. Have the practical nurse perform a focused assessment and the registered nurse will complete the admission process after the transfusion client is stable c. Instruct the certified nursing assistant to obtain the acute clients vitals every 15 minutes, as this is within the scope of practice d. Tell the admission clerk to put the client in the designated room and explain that the nurses are busy with an emergency and will get to the client as soon as possible
B
A client is admitted for a biopsy of a tumor in her left breast. The client states, "I know it can be cancer, because it doesn't hurt." What is the nurses most therapeutic response? a. Let's hope that it isn't malignant. b. What do you know about breast cancer? c. Most lumps in the breast are not malignant d. Has your Primary Health care provider told you that it wasn't cancer?
B
A client who is scheduled for a muscle biopsy tells the nurse; they better give me a general anesthetic. I don't want to feel anything. Which is the most therapeutic initial response by the nurse? a. You seem to be worried about the test b. This test is done under local anesthesia c. Tell them when you have pain so they can take care of it d. You probably will not have pain so try not to think about it
B
A client with a diagnosis of stomach cancer expresses a lack of interest in food and consumes only small amounts. What is the best intervention the nurse should offer to this client? a. Smaller portions more frequently b. Nutritional supplements between meals c. Supplementary vitamins to stimulate appetite d. Only foods the client likes in small portions at mealtimes
B
A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? A. No specials precautions are required. B. Cover the infected site with a dressing. C. Drape the client with a covering labeled biohazardous D. Place a surgical mask on the client
B
A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? a. Has an upper respiratory infection b. Has many visitors while sitting in a chair c. Has a nasogastric tube for gastric decompression d. Has dry oral mucous membranes from mouth breathing
B
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? a. Procedures used to implement client care b. Sequence of steps used to meet the client's needs c. Activities employed to identify a client's problem d. Mechanisms applied to determine nursing goals for the client
B
A nurse is assessing different situations on the basis of Maslow's hierarchy of needs. Which situation will the nurse address first on priority basis? A. A client feels that he/she leads a completely worthless life B. A client has multiple fainting episodes due to lack of proper nutrition C. A client shows signs of lack of interest in carrying out social interactions D. A client conveys to the nurse that he/she is estranged from all family members
B
A nurse is caring for a client who has a urinary incontinence as a result of a cerebrovascular accident. What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? a. Insert a urinary retention catheter b. Institute measures to prevent constipation c. Encourage an increase in the intake of caffeine d. Suggest that a carbonated beverage may be ingested daily
B
A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease. The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? a. The client may need up to 60% oxygen flow via venturi mask b. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula c. The client should receive humidified oxygen delivered by a face mask The clients respiratory treatment plan should have oxygen eliminated from it
B
A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding? a. Passage of flatus b. Rise of formula in the tube c. Rapid inflow of the feeding d. Tenderness of epigastric area
B
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? a. Evaluation b. Assessment c. Nursing interventions d. Proposed nursing care
B
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of COPD. What is the priority nursing intervention when the client becomes short of breath during the care? A. Obtain a pulse oximeter to determine the client's oxygen saturation level. B. Put the client in a high Fowler position. C. Darken the lights and provide a rest period of at least 15 minutes. D. Continue the hygiene activities while reassuring the client.
B
A nurse obtains daily stool specimens for a client with chronic bowel inflammation. What does the nurse determine is the reason these stool examinations were prescribed? a. Fat content b. Occult blood c. Ova and parasites d. Culture and sensitivity
B
A nurse teaches a client about wearing thigh-high anti embolism elastic stockings. What would be appropriate to include in the instructions? A. You do not need to wear the while you are awake, but it is important to wear them at night. B. You will need to apply them in the morning before you lower your legs from the bed to the floor. C. If they bother you, you can roll them down to your knees while you are resting or sitting down. D. You can apply them either in the morning or at bedtime, but only after the legs are lowered to the floor.
B
While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness? A. Applying moisturizing lotion between toes B. Cutting nails after soaking them for 10 minutes in warm water C. Cutting nails straight across and even with the tops of the fingers or toes D. Using sharp objects to poke or dig under the toenail or around the cuticle
B
While entering data for a client in the electronic health record, the nurse uses North American nursing diagnosis Association international terminology to document which part of the nursing process? a. Planning b. Diagnosis c. Outcomes Interventions
B
The registered nurse is teaching new nurses had to obtain information when introducing themselves to clients suspected of having nervous system disorders. Which statement made by a new nurse indicates the need for further learning? a. I should ask clients about their medical history. b. I should wait to assess the speech of a client until later. c. I should observe the client's ability to perform hand hygiene. d. I should ask whether the client is right-handed or left-handed. I should inquire about the client's ability to perform daily activities
B, C
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicator should the nurse closely observe in the client? a. Anxiety b. Oxygenation c. Drowsiness d. Mental confusion e. Increased respirations
B, C, D
A registered nurse is educating a nursing student about risk management methods to ensure that appropriate nursing care is provided to a client by identifying and eliminating potential hazards. What information should the registered nurse provide? a. If an incident occurs, document in the client's medical record that an occurrence report has been filed. b. Ensure that the three principles of the joint commission's universal protocol are adhered to before starting surgery on a client. c. Refrain from depending on the use of electronic monitoring devices completely because they're not always reliable. d. File an occurrence report in case of an error and technique when administering medication intravenously. e. Document that the health care provider was contacted, the information was conveyed, and the response in the occurrence report.
B, C, D
Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? a. Elevated levels of partial arterial oxygen b. Elevated levels of eosinophils c. Elevated levels of neutrophils d. Elevated levels of red blood cells e. Elevated levels of peripheral capillary oxygen saturation
B, C, D
A nurse is caring for a community-dwelling older adult with dementia. What interventions should the nurse take to ensure the client's well-being? A. Obtain the client's drug history and educate the older adult about safe medication storage. B. Foster human dignity and maintain the best possible functioning, protection, and safety C. Teach the client to be cautious of false advertisements that promise cure for the disease D. Show the caregiver techniques to dress, feed, and toilet the older adult E. Protect and clients client's rights and provide support to maintain the physical and mental health of family members
B, D, E
A nurse provides education to a client about how to prevent Constipation. The nurse concludes that the teaching is understood when the client makes switch statements? a. I may eat potatoes at dinner daily b. I should drink at least 6 glasses of water every day c. I must eat eggs for breakfast three times a week d. I can include bran muffins in my breakfast daily e. I will walk every day as part of my exercise regimen
B, D, E
What are the best ways for a nurse to be protected legally? a. Ensure that a therapeutic relationship with all clients has been established b. Provide care within the parameters of the state or provinces standards for nursing practice c. Carry at least $100,000 worth of liability insurance d. Document consistently and objectively e. Clearly documented client's nonadherence to the medical regimen
B, D, E
Which nursing action is a part of the evaluation phase of the critical thinking process? a. Collecting all the data in order b. Looking at all the situations objectively c. Support the findings in drawing conclusions d. Be open minded to information about a client e. Using several criteria to determine the effectiveness of a nursing intervention
B, E
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? a. Respiratory rate b. Amount of oxygen in the blood c. Percentage of oxygen carrying hemoglobin d. Amount of carbon dioxide in the blood
C
A client has a surgically created colostomy. What is the most effective nursing intervention initially to help the client accept the colostomy? a. Provide literature containing factual data about colostomies b. Ask a number of a support group to come speak with the client c. Begin to teach self-care of the colostomy by introducing equipment d. Point out the number of important people who have had colostomies
C
A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client? a. Prevent dyspnea b. Prevent cyanosis c. Increase oxygen concentration to heart cells d. Increase oxygen tension in the circulating blood
C
A client with pneumonia now requires use of a non re breathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? a. The client's pneumonia is continually improving b. Oxygen concentrations up to 44% can be obtained c. Mechanical ventilation may be required next d. Nasal cannula may be used while the client is eating
C
A nurse is caring for a client who has been admitted to a healthcare facility for the treatment of sinus disorders. The nurse discovers that the client is a cocaine addict. What task followed by the nurse is the best way to deal with the situation? A. Teach the client about safe medication storage and the danger of polypharmacy B. Educate the client about his or her correct body mechanics promote stress management C. Assess the client's drug intake and ensure that the individual does not leave the healthcare facility D. Assist with adequate persons hygiene, nutrition, and hydration and provide emotional support to the family.
C
A nurse is caring for a client who is receiving total parenteral nutrition after extensive: surgery. The nurse concludes that the client understands teaching about the purpose of TPN when the client makes which statement? a. TPN provides supplemental nutrition. b. TPN provides short-term nutrition after surgery. c. TPN provides total nutrition when gastrointestinal function is questionable. d. TPN assess people who are unable to eat but have active gastrointestinal function.
C
A nurse is hired to work in a health care facility that has a completely computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says what? a. More medication errors are made when the system is used b. It is disappointing that nurses are not allowed to use the system c. Client information is immediately available when the system is used d. I will have less time to provide direct care to my clients with the system
C
For a client with difficulty swallowing, the nurse should crush which medication? a. Metoprolol extended release b. Felodipine sustained release c. Acetaminophen extra strength d. Potassium chloride extended release
C
The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? a. Start urinating in the Cup and then finish urinating in the toilet b. If you can't fill the cup then leave it on the toilet and use it again when you void next c. With the enclosed towelettes, wipe your labia from front to back before collecting the specimen d. When you finish, leave the cup on the back of the toilet and the aide will get it when making rounds
C
The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? a. Except with rare blood disorders, hemoglobin seldom affects oxygenation status b. There are many other factors that affect oxygenation status more than hemoglobin does c. A low hemoglobin level causes reduced oxygen carrying capacity d. Hemoglobin reflects the body's clotting ability and may or may not affect oxygenation status
C
The nurse observes a client with chronic obstructive pulmonary disease breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take next? a. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula b. Place the client in a sideline position and perform chest physiotherapy using clapping and vibration c. Raise the head of the bed to a high Fowler position and administer 2 L/min oxygen per nasal cannula d. Assist the client and assuming a position of comfort and perform postural drainage
C
The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? A. Airborne B. Droplet C. Contact D. Protective
C
The nurse should instruct the client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what? a. Force urine to back up into the kidneys b. Suppress production of urine c. Cause the device to pull away from the skin d. Tear the ileal conduit
C
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? A. Increase fluid intake B. Restrict fluids C. Encourage early mobility D. Elevate the knee gatch of the bed
C
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? a. Colitis b. Stomatitis c. Paralytic ileus d. Gastrocolic reflux
C
Which nursing intervention helps to prevent medication errors in children? a. Encouraging the use of brand names b. Promoting the use of abbreviations and acronyms c. Minimizing the use of verbal and telephone orders d. Carefully reading all labels for accuracy and checking expiration dates e. Recording the client's weight before carrying out the medication order
C, D, E
A nurse is caring for a client with a venturi mask who is receiving 40% oxygen. What nursing actions are indicated? a. Keep the oxygen source higher than the client's airway. b. Adjust the leader flow according to the oxygen saturation c. Prevent the clients blanket from covering the adapters orifices d. Ensure that the bag does not deflate completely during inspiration e. Check that the appropriate adapter to deliver the prescribed FiO2 is attached to the mask
C, E
A Hospice nurse visits the home of a female client in the terminal stage of cancer three days each week to provide physical care and emotional support. The nurse observes that the client's adolescent children are having difficulty talking with their mother. The nurse suggests a family meeting, knowing what? a. It's important to solve family problems before death occurs b. They will be unable to deal with their feelings until after their mother dies. c. A deeper level of knowledge will help the client understand what their mother is going through. d. The opening of communication increases the ability of family members to work through their reactions to the terminal illness.
D
A client has surgery for an abdominal cholecystectomy Ann returns from surgery with a nasogastric tube to low continuous suction, a T-tube, and an indwelling catheter. Which intervention should the nurse perform first? a. Fasten each tube to the bed sheets b. Irrigate each tube with normal Saline c. Measure the drainage in the collection devices d. Ensure that all tubes are attached to collection devices
D
A client who has been caring for a colostomy on the left side of the abdomen for several years is admitted to the hospital for an unrelated health problem. Which type of stool should the nurse expect? a. Pencil shaped b. Mucus coated c. Loose and liquid d. Moist and formed
D
A client who has intermittently been having painful, swollen knee and wrist joints during the past three months is diagnosed with rheumatoid arthritis. What type of diet should the nurse expect the Primary Health care provider to prescribe? a. Salt-free, low-fiber diet b. High-calorie, low-cholesterol diet c. High-protein diet with minimal calcium d. Regular diet with vitamins and minerals
D
A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. 4 hours after admission, the client has increased restlessness in confusion followed by a decreased respiratory rate and lethargy. What should the nurse do next? a. Question the client about the confusion b. Change the method of oxygen delivery c. Percuss and vibrate the client's chest wall d. Discontinue or decrease the oxygen flow rate
D
A health care provider prescribes intermittent nasogastric tube feedings to supplement a client's oral nutritional intake. Which hazard associated with a nasogastric tube feeding will be reduced if the nurse administers this feeding over 30 to 60 minutes? a. Distention b. Flatulence c. Indigestion d. Regurgitation
D
A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis? What is the category of the diagnostic error? a. Labeling b. Collecting c. Clustering Interpreting
D
A nurse instructs the client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? a. The alveoli need oxygen to live b. The alveoli have no direct effect on oxygenation c. Collapsed alveoli increase oxygen demand d. Oxygen is exchanged for carbon dioxide in the alveolar membrane
D
A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? a. 1+ b. 2+ c. 3+ d. 4+
D
A nurse is assessing several clients. Which client will require parenteral nutrition? a. A client with brain neoplasm b. A client with anorexia nervosa c. A client with inflammatory bowel disease A client with severe malabsorption disorder
D
A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication? a. Asking for explanations b. Showing sympathy to the client c. Asking personal questions of the client d. Providing relevant information to the client
D
A school nurse is asked to develop a program for teachers about infection control, especially focusing on hand washing technique. What is the most effective way for the nurse to evaluate what the teachers have learned? a. Observe the teachers lectured the children about hand hygiene b. Give an objective written final examination to the teachers c. Schedule a seminar for the teachers to share their knowledge d. Watch the teachers demonstrate infection control techniques
D
After a resection of the colon, a client returns to the surgical unit from the post anesthesia care unit with a nasogastric tube to negative pressure. What does the nurse explain is the purpose of this tube? a. Monitoring the acidity of gastric secretions b. Providing a route for liquid tube feedings when possible c. Permitting continuous decompression of the large intestine d. Removing fluids and gas from the upper gastrointestinal tract
D
One day a nurse sits down by depressed clients bedside and says, "I'll be spending some time with you today." The client responds, "Go talk to someone else. They all need you more." What is the most therapeutic response by the nurse? a. Why do you want me to go? b. I'll go, but I'll be back tomorrow. c. Don't you think that you're important too? d. I'll be spending the next half hour with you.
D
The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? A. All nursing functions will be completed by discharge. B. All invasive intravenous lines will remain patent. C. The client will remain awake, alert, and oriented at all times. D. The client will be free of signs and symptoms of infection by discharge
D
The nurse is administering medication through an implanted port. What nursing safety priority should the nurse follow in this scenario? a. The nurse should use barrel syringes to flush any central line. b. The nurse should use 20ML of sterile Saline to flush the port after drawing blood c. The nurse should use 10 milliliters of sterile Saline to flush the port before and after Med administration d. The nurse should withhold the drug until patency and adequate noncoring needle placement of the port are established
D
What does a nurse need to do during the third accuracy check before administering air drops in a 5-year-old child? a. Prepare the medication b. Perform hand hygiene c. Teach the parents about medication d. Check the label of medication at child's bedside
D
Which is an abnormal finding of the urinary system? a. Nonpalpable left kidney b. Presence of bowel sounds c. Nonpalpable urinary bladder d. Pain in the flank region upon hitting
D
