HESI

When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? a. Complete blood cell count b. Serum potassium level c. X-ray film of long bones d. Blood cultures ×3

b. Serum potassium level A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia.

How can the nurse describe heart failure to a client? a. A cardiac condition caused by inadequate circulating blood volume b. An acute state in which the pulmonary circulation pressure decreases c. An inability of the heart to pump blood in proportion to metabolic needs d. A chronic state in which the systolic blood pressure drops below 90 mm Hg

c. An inability of the heart to pump blood in proportion to metabolic needs

Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? a. Maintain muscle strength b. Reduce leg discomfort c. Prevent clot formation d. Improve wound healing

c. Prevent clot formation Active range-of-motion (ROM) exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis.

To check a client's carotid pulse, where would the nurse palpate? a. Below the mandible b. In the lateral neck region c. Along the clavicle at the base of the neck d. At the anterior neck, lateral to the trachea

d. At the anterior neck, lateral to the trachea The carotid artery is located along the anterior edge of the sternocleidomastoid muscle at the level of the lower margin of the thyroid cartilage

Which action would the nurse take when performing external cardiac compression?

Interlock the fingers with the heel of 1 hand on the sternum and the heel of the other on top of it.

The nurse is assessing the needs of a client who just learned that a tumor is malignant and has metastasized to several organs and that the illness is terminal. Which behavior would the nurse expect the client to exhibit during the initial stage of grieving?

Asking for a second opinion (denial)

When calculating a client's heart rate on an electrocardiogram (ECG) strip, which action would the nurse take?

Count the QRS complexes

Which statement made by the student nurse indicates ineffective learning about the disaster triage tag system? a. "I will use a yellow tag for clients with shock." b. "I will use a green tag for clients with closed fractures." c. "I will use a red tag for clients with airway obstruction." d. "I will use a black tag for clients with massive head trauma."

a. "I will use a yellow tag for clients with shock." According to the disaster triage tag system, a yellow tag is used for clients who require treatment within 30 minutes to 2 hours. Clients with shock require immediate attention and a red tag is appropriate. A green tag is used in clients with minor injuries, such as fractures and abrasions, who can be managed with delayed treatment. A red tag is used for the clients who have immediate threats to life, such as an airway obstruction. A black tag is used for clients who are expected to die or require mechanical ventilation in conditions such as massive head trauma and high cervical spinal cord injury.

Which type of shock is associated with a ruptured abdominal aneurysm? a. Vasogenic shock b. Neurogenic shock c. Cardiogenic shock d. Hypovolemic shock

d. Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel.

A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give? a. Compression of the heart muscle b. Release of myocardial isoenzymes c. Rapid vasodilation of the coronary arteries d. Inadequate oxygenation of the myocardium

d. Inadequate oxygenation of the myocardium Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue.

How would the nurse explain the purpose of early ambulation to a client who had surgery the previous day? a. Promote healing of the incision b. Decrease the incidence of urinary tract infections c. Allow nursing staff to change the bedding d. Keep blood from pooling in the legs to prevent clots

d. Keep blood from pooling in the legs to prevent clots The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis.

To ensure accuracy when assessing a client's blood pressure, how would the nurse prevent a parallax error?

Read the manometer at eye level.

In what order does normal cardiac conduction occur through the heart?

Sinoatrial node -> Atrioventricular (AV) node -> Bundle of His -> Bundle branches -> Purkinje fibers

Which action will the nurse take to determine a client's pulse pressure?

Subtract the diastolic from the systolic reading.

Which explanation will the nurse give when a client asks about what causes varicose veins? a. "Abnormal configurations of the veins." b. "Incompetent valves of superficial veins." c. "Decreased pressure within the deep veins." d. "Atherosclerotic plaque formation in the veins."

b. "Incompetent valves of superficial veins." Incompetent valves result in retrograde venous flow and subsequent dilation of veins.

Which method would the nurse use to measure the temperature of a 4-year-old child with leukemia who has mucositis? a. Digital, rectal b. Electronic, oral c. Infrared, tympanic d. Sensor, ear-based e. Temporal artery

c. Infrared, tympanic e. Temporal artery

After measuring a client's PR interval at 0.08 seconds, how would the nurse interpret the finding? a. Normal conduction in the atrioventricular (AV) node b. Slowing of sinoatrial node conduction c. Delayed conduction in the AV node d. Abnormally fast conduction

d. Abnormally fast conduction A short PR interval indicates abnormally fast conduction through the atria and atrioventricular node, such as might happen with a junctional dysrhythmia. Normal AV node conduction would result in a normal PR interval of 0.12 to 0.20 seconds

When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin? a. vitamin K b. vitamin D c. vitamin B1 d. vitamin B12

a. vitamin K Warfarin causes inhibition of vitamin K-dependent clotting factors, and use of vitamin K would affect the therapeutic effect of warfarin.

Which object would the nurse teach the client with a newly implanted pacemaker to avoid? a. Strong magnet b. Microwave oven c. Mobile telephone d. Remote control device

a. Strong magnet The client with a newly implanted pacemaker is taught to avoid strong magnets because they can change the settings and function of the pacemaker.

Which factors would the nurse recognize as increasing the incidence of injury to a school-aged child? Select all that apply. a. The protection offered by adults b. The behavior patterns of the child c. The physical activity level of the child d. Dangers present in the environment e. Participation in extracurricular activities

a. The protection offered by adults b. The behavior patterns of the child d. Dangers present in the environment

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? a. "I have abnormal platelets." b. "I have abnormal hemoglobin." c. "I have abnormal hematocrit." d. "I have abnormal white blood cells."

b. "I have abnormal hemoglobin." The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle.

Which statement by an unlicensed assistive personnel (UAP) who is assisting the nurse in caring for a group of clients indicates a correct understanding of the UAP's role? a. "I will turn off clients' intravenous lines that have infiltrated." b. "I will take clients' vital signs after their procedures are over." c. "I will use unit written materials to teach clients before surgery." d. "I will help by giving medications to clients who are slow in taking pills."

b. "I will take clients' vital signs after their procedures are over."

The nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. Which is the volume of solution the nurse would prepare? a. 150 to 250 mL b. 250 to 350 mL c. 300 to 500 mL d. 500 to 750 mL

b. 250 to 350 mL The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enemain a toddler. The nurse would prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.

After teaching a client about sulfonamide use for a urinary tract infection, which client statement would the nurse review for correction? a. "I will avoid the sunlight." b. "I will increase my fluid intake." c. "I will let my doctor know if I develop a rash." d. "I will stop taking the medication when my symptoms subside."

d. "I will stop taking the medication when my symptoms subside." The nurse instructs the client to complete the entire course of treatment, not stop when symptoms subside. The client on sulfonamide therapy should avoid prolonged exposure to sun, increase fluid intake to support the kidneys, and report a rash to investigate possible hypersensitivity.

A client with type 1 diabetes asks what causes several brown spots on the skin. What would be the best response by the nurse? a. "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." b. "Those spots indicate a high glucose content in the skin that may get infected if left untreated." c. "They are the result of diseased small vessels in the shins and may spread if not treated soon." d. "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

d. "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct.

diuretics low-salt diet daily weight checks fluid restriction intake and output oxygen administration

Which recommendation would the nurse include when a client asks what can be done to remain safe in the hospital? Select all that apply. One, some, or all responses may be correct. a. "Ask questions if you have doubts or concerns." b. "Keep and bring a list of all the medications you take." c. "Be sure to have an attorney in mind just in case you need one." d. "Make sure you understand what will happen if you need surgery." e. "Do not get any test results unless your health care provider approves it."

a. "Ask questions if you have doubts or concerns." b. "Keep and bring a list of all the medications you take." d. "Make sure you understand what will happen if you need surgery."

The nurse teaches a client about the use of tampons. Which statements made by the nurse indicate correct action to teach a client regarding tampon use? Select all that apply. a. "Wash your hands before inserting a tampon." b. "Use a superabsorbent tampon during the daytime." c. "Use sanitary napkins at nighttime." d. "Report any physical changes while using a tampon." e. "Avoid using feminine deodorant sprays and douches during tampon use."

a. "Wash your hands before inserting a tampon." c. "Use sanitary napkins at nighttime." d. "Report any physical changes while using a tampon."

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. a. Fatigue b. Orthopnea c. Pitting edema d. Dry hacking cough e. 4-pound weight gain

a. Fatigue b. Orthopnea c. Pitting edema d. Dry hacking cough e. 4-pound weight gain

How would anxiety affect outcomes for a client with heart failure? a. Increases the cardiac workload b. Interferes with usual respirations c. Produces an elevation in temperature d. Decreases the amount of oxygen used

a. Increases the cardiac workload Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure.o check a client's carotid pulse, where would the nurse palpate?

When a client is diagnosed with Hodgkin disease, which lymph nodes would the nurse expect to be affected first? a. cervical b. axillary c. inguinal d. mediastinal

a. axillary Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows the disease progresses.

When caring for a client with an infection caused by group A beta-hemolytic streptococci, the nurse will monitor for which complication? a. hepatitis A b. rheumatic fever c. spinal meningitis d. rheumatoid arthritis

b. rheumatic fever Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the heart's valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of streptococcal infections have limited the occurrence of rheumatic heart disease. Hepatitis A, an inflammation of the liver, is caused by the hepatitis A virus, not by bacteria

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. Which would the nurse conclude that the client is experiencing? a. Atrial fibrillation b. Sinus tachycardia c. Ventricular fibrillation d. First-degree atrioventricular block

b. sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillationcauses an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

The nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization? a. P wave b. T wave c. PR interval d. QRS complex

d. QRS complex The QRS complex represents ventricular depolarization. The P wave represents atrial depolarization. The T wave represents ventricular repolarization. PR interval and represents depolarization of the sinoatrial node, both atria, and the atrioventricular node.

normal potassium levels

3.5-5.0 mEq/L

When arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH, which factor is the likely cause of the laboratory result?

Lactic acid production

When the nurse is analyzing an electrocardiogram (ECG), which waveform illustrates atrial depolarization?

P wave (a)

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. a. Providing oxygen b. Assessing vital signs c. Obtaining a 12-lead EKG d. Drawing blood for cardiac enzymes e. Auscultating heart sounds f. Administering nitroglycerin

a. Providing oxygen b. Assessing vital signs c. Obtaining a 12-lead EKG d. Drawing blood for cardiac enzymes e. Auscultating heart sounds f. Administering nitroglycerin

How is hemophilia A inherited? a. X-linked recessive trait b. Y-linked recessive trait c. X-linked dominant trait d. Y-linked dominant trait

a. X-linked recessive trait Hemophilia A is an X-linked recessive trait, not a dominant trait, meaning daughters who have the gene are carriers, and sons with the gene have the condition.

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? a. sodium b. calcium c. potassium d. magnesium

a. sodium Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.

The nurse is assessing a client with a history of aggression and inappropriate anger issues. Which findings indicate the client is escalating and requires immediate intervention to prevent harm to others? Select all that apply. One, some, or all responses may be correct. a. Feeling depressed b. Mumbling to oneself c. Pacing back and forth d. Discussing issues with staff e. Maintaining strong eye contact

b. Mumbling to oneself c. Pacing back and forth e. Maintaining strong eye contact Behaviors that would require the nurse to intervene include the client mumbling to him- or herself, pacing back and forth, and maintaining strong eye contact. These are signs that precede violence. Feeling depressed may be a precursor to suicide. Discussing issues with the staff would not indicate aggressive behavior that warrants immediate intervention.

Which group of clients would the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas? a. Children b. Older adults c. Young adults d. Middle-aged persons

b. Older adults The incidence of non-Hodgkin lymphoma increases with age; the disease is more common in men and older adults. Younger individuals have a lower incidence of non-Hodgkin lymphomas.

When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest? a. Apples b. Grapes c. Cantaloupe d. Cranberries

c. Cantaloupe

When assessing a client with heart failure for activity tolerance, which activity would the nurse expect to cause the most distress for the client? a. Getting up from bed in the morning b. Walking to visit the next-door neighbor c. Climbing a flight of stairs to the bedroom d. Leaving the table immediately after a meal

c. Climbing a flight of stairs to the bedroom Stair climbing increases oxygen consumption and increases the workload of the heart; this results in dyspnea and fatigue.

Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? a. Increased blood pH b. Decreased hematocrit c. Increased blood viscosity d. Decreased immune response

c. Increased blood viscosity Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis The pH indicates acidosis; the PCO2 level is the parameter for respiratory function. The expected PCO2 is 40 mm Hg.

When a client with angina is scheduled to have a cardiac catheterization, which explanation would the nurse give about the purpose of the procedure? a. To obtain the pressures in the heart chambers b. To determine the existence of congenital heart disease c. To visualize the disease process in the coronary arteries d. To measure the oxygen content of various heart chamber

c. To visualize the disease process in the coronary arteries

When a child is newly diagnosed with hemophilia A, the nurse will teach family members that hemophilia A is linked to a deficiency in which clotting factor? a. Factor II b. Factor XII c. Factor IX d. Factor VIII

d. Factor VIII Hemophilia type A, the most common type of hemophilia, is from a deficiency of Factor VIII. Factors II and XII are part of the clotting cascade, but they are not associated with hemophilia. Factor IX is associated with hemophilia type B.

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? a. P wave b. T wave c. PR interval d. QRS interval

d. QRS interval The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and of the atrioventricular node.

A client has an open reduction and internal fixation (ORIF) of a fractured hip. The nurse monitors this client for signs and symptoms of a fat embolism. Which client assessment finding reflects this complication? a. Fever and chest pain b. Positive Homans sign c. Loss of sensation in the operative leg d. Tachycardia and petechiae over the chest

d. Tachycardia and petechiae over the chest Tachycardia occurs because of an impaired gas exchange; petechiae are caused by occlusion of small vessels within the skin.

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? a. Count the pulse at another site b. Notify the primary health care provider. c. Lower the legs to increase blood flow. d. Verify the pulse by using a Doppler.

d. Verify the pulse by using a Doppler. Clients with venous insufficiency often have edema, which may make palpation of an arterial pulse difficult. A Doppler uses sound waves so that the pulse can be heard.