HESI

Which assessment would the nurse determine is the priority in a client who just returned to the floor after a right total knee replacement?

Circulation and sensation in right leg

Which sign of hypokalemia would the nurse monitor for in a client who is taking furosemide?

Flabby muscles

Which action would be taken by the nurse caring for a hospice client who is unconscious with irregular breathing, has a blood pressure of 70/40 mmHg, and a pulse rate of 120 beats per minute?

Inform the family that these changes are normal and the client is not suffering Rational: The priority intervention for a dying hospice client with falling blood pressure and increasing pulse is to inform the family that these changes are normal and expected and are not uncomfortable for the client.

Which action would the nurse complete when caring for a client with severe dyspnea receiving oxygen through a Venturi mask?

Monitor oxygen saturation levels when eating

Which clinical findings indicates that a postoperative client who has a nasogastric tube attached to low continuous suction may be experiencing hypokalemia?

Muscle weakness and cardiac dysrhythmias

Which goal would the nurse expect to see in the nursing plan of care for a client who is taking a diuretic and a beta blocker for hypertension?

No injury caused by falls rationale: A client with hypertension who is taking a diuretic and a beta blocker is at risk for injury from falls caused by orthostatic hypotension.

Where should the nurse stand when assisting a client to ambulate after surgery to repair a fractured right hip

On the client's left side

Which initial sign would the nurse find when assessing a client with hyp-ocalcemia?

Paresthesia (burning/prinkling sensation found usually in the hands, arms, legs, or feet)

Which priority during a focused assessment of the client admitted to the emergency department with a stab wound to the chest?

Quality and depth of respiration

A nurse cares for a client with terminal pancreatic cancer. The client tells the nurse, "I am afraid of what will happen to me after I die and I would like to talk with someone." Which member of the core interdisciplinary hospice team should be contacted?

Spiritual coordinator

Which action by a 70-year-old female would limit further progression of osteoporosis?

Taking supplemental calcium and vitamin D

In clients who all have low oxygen saturation levels, which client will benefit the most from receiving oxygen via a nasal cannula?

The client with an increase in visitors while sitting in a chair

Which food would the nurse suggest that is rich in calcium and digested easily by clients with osteoporosis who do not tolerate milk?

Yogurt

An infant is admitted to the pediatric unit with gastroenteritis and dehydration. The nurse determines that the parents understand the teaching about contact precautions when they make which statement?

"Our gloves must be changed each time we change the baby's diaper."

The father of a child who is dying of cancer asks the nurse whether he should tell his 7-year-old son that his sister is dying. Which response by the nurse is the most appropriate?

"Your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's possible death."

The registered nurse is explaining basic rules for documentation to a licensed practical nurse (LPN). Which statement made by the LPN indicates understanding?

- "I will document the details when observed." - "I will record in the chart using black ink pen."

A family member of a dying client states, "My father is staring at an empty corner of the room talking to someone who is not there." Which suggestion by the nurse would provide comfort to the family member during this time? Select all that apply.

- "You can reassure him this is part of the transition from life." - "It is important that you provide him reassurance at this time." - "This is a good time to encourage your father to verbalize his feelings."

Which would the nurse do to prevent complications from a common, serious side effect of morphine?

- Assess for altered breathing patterns

Which nursing intervention would help prevent sepsis in an older adult client who has an indwelling urinary catheter? Select all that apply.

- Empty the urinary drainage bad when it is one-half full - Wash hands and wear clean gloves when performing catheter care - Use alcohol to clean the drainage port before reconnecting it to the bad - Consult the health care provider to have the catheter removed as soon as possible

Which intervention would the nurse implement when caring for a dying client and family? Select all that apply.

- Help the family set up hospice if desired - Plan care using the client and family's strengths and weaknesses - Arrange for church or community support for the family

Which manifestation would indicate a hospice client may be approaching death? Select all that apply.

- Irregular breathing with periods of apnea Rationale: signs or symptoms that indicate approaching death include an irregular breathing pattern with 10- to 30- second periods of absence of breathing (apnea).

Which food would the nurse offer to a client who is prescribed a clear-liquid diet after surgery? Select all that apply.

- Jell- O - Broth - Ginger ale

Which priority assessment would be completed while evaluating breathing? Select all that apply.

- Observe for chest wall trauma - Assess breath sounds and respiratory effort

An emergency tracheotomy is performed on a toddler. Which early sign of respiratory distress indicates that it is necessary for the nurse to suction the tracheotomy? Select all that apply.

- Restlessness - Increased pulse rate

Which factor would the nurse confirm before discharging a client with an infected abdominal wound? Select all that apply.

- The client and family caregiver can perform proper hand hygiene techniques - The client and family members state the need and process for contact precautions - Accurate wound cleansing and dressing change are demonstrated by a family caregiver - The client and family state the importance of taking antibiotic medication exactly as prescribed - The client and family can identify signs and symptoms of infection to report to the health care provider

Which nursing action is acceptable to the family members of a Muslim client who has just died, considering their cultural beliefs? Select all that apply.

- Washing the client's body with gloves - Positioning the client with the face toward Mecca

Which skin disease requires the use of contact precautions? Select all that apply.

- scabies - impetigo - pediculosis - herpes zoster - neonatal herpes simplex

The mother of a preschool-age child tells the nurse that her husband is dying of cancer and that she is worried about how her child will cope. Which describes how preschool-age children view death?

A form of sleep

Which information would the nurse collect and document when performing a focused abdominal assessment on a client with peritonitis?

Abdominal girth