HESI basic care and comfort

Which considerations will assist the nurse in prioritizing client assessments? Select all that apply. One, some, or all responses may be correct.

- The most recent assessment of the client - The information from the change-of-shift report - The pertinent information from the medical record

After the nurse teaches a client with varicose veins about prevention of venous thromboembolism (VTE), which client statement indicates the client requires further teaching?

"I will try to keep my legs lower than my heart." To prevent VTE in clients at risk, the legs are elevated above the level of the heart as frequently as possible to promote venous return and prevent venous stasis (blood pooling will form clots)

acute coronary syndrome (ACS)

Any condition brought on by a sudden reduction or blockage of blood flow to the heart.

Which intervention would minimize breast discomfort in a postpartum client who is formula feeding?

Application of covered ice packs to the breasts

A client asks about the difference between cow's milk and breast milk. The nurse would respond that cow's milk differs from human milk in that it contains which?

More protein, more calcium, and fewer carbohydrates

The client is admitted to the emergency department with burns on the anterior part of both arms, from the shoulders to the hands, and the anterior part of the head. Which percentage of total body surface area burned would the nurse document in the client's hospital record using the rule of nines?

13.5% Using the rule of nines, the anterior surface of each arm is 4.5% and the anterior portion of the head is 4.5%. These total 13.5%.

Screening for large bowel abnormalities is accomplished with which procedure?

Colonoscopy. Colonoscopy is used for evaluation of abnormalities of the large intestine, particularly colorectal cancer.

Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? Select all that apply. One, some, or all responses may be correct.

- decreased urine - hypotension - dry mucous membranes - poor skin turgor

A client with severe chronic rheumatoid arthritis reports that pain lasts for 2 to 3 hours after exercising. Which information would the nurse teach the client?

Decrease the time and number of exercise repetitions.

A client at 31 weeks' gestation is admitted in preterm labor. Which class of medications would the nurse anticipate providing education for?

A beta-adrenergic Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily.

Pyridoxine (vitamin B6) and isoniazid (INH) are prescribed as part of the medication protocol for a client with tuberculosis. Which response indicates that vitamin B6 is effective?

Absence of paresthesias One of the most common side effects of INH is peripheral neuritis due to vitamin B6 deficiency, and vitamin B6 will counteract this problem.

how to prevent systemic absorption of eye drops

After instilling eyedrops, gentle pressure would be applied to the inner canthus for 1 to 2 minutes to minimize systemic absorption.

Which is the nurse's primary concern when caring for a pregnant woman with class II cardiac disease and a hemoglobin level of 8 g/dL (80 mmol/L)?

Impending heart failure A hemoglobin of 8 g/dL is anemia, which reduces the capacity of the blood to carry oxygen and thus increases demands on the heart.

On the third postpartum day after a cesarean birth a client tells the nurse that her breasts feel warm, firm, and tender. The skin is shiny and taut. Which condition would the nurse suspect as the cause of the client's breast discomfort?

Physiologic engorgement Physiologic engorgement is characterized by increased circulation in the breasts and increasing milk production. It commonly occurs at about the third day after birth. An oversupply of milk would not be common at this time.

Tidal volume

is the volume of air inhaled and exhaled with each breath.

Which education would the nurse provide the parents of a 4-year-old child about typical sleeping patterns in preschoolers? Select all that apply. One, some, or all responses may be correct.

- Total sleep averages 12 hours at night - In the awake period, the child may sleepwalk - It is common for the child to awaken during the night.

Which assessment findings are associated with Wernicke encephalopathy?

- Altered gait - Confusion - Ocular motility abnormalities Wernicke encephalopathy, a substance-induced persistent dementia, is caused by a prolonged deficiency of vitamin B1 (thiamine). Symptoms include altered gait, vestibular dysfunction, confusion, and ocular motility abnormalities. Sluggish reaction to light and unequal pupil size are also symptoms.

The nurse would plan to discharge which clients to free up inpatient beds for other disaster victims? Select all that apply. One, some, or all responses may be correct.

- Those who can be treated in long-term care -Those who can be cared for in rehabilitation - Those with no critical change in condition for the past 3 days

Which medications are immunosuppressives prescribed to prevent kidney rejection? Select all that apply. One, some, or all responses may be correct.

- Cyclosporine - Methylprednisolone - Tacrolimus - Mycophenolate mofetil

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. One, some, or all responses may be correct.

- crackles - coughing - orthopnea ( shortness of breath or difficulty breathing when you're lying down)

which action would the nurse take to prevent deformities in a client who has an exacerbation of arthritis? select all that apply. one, some or all responses may be correct

- encourage motion of the joint - maintain joints in functional alignment when resting exercise of involved joints is important to maintain optimal mobility and prevent buildup of calcium deposits. functional alignment places the least strain on joints, muscles, and tendons

a pregnant client has a spontaneous rupture of membranes prior to the onset of labor. what interventions are appropriate for this client?

- keep the client in bedrest - keep vaginal exams to a minimum - follow standard precautions - document the time that the membranes ruptured

Which foods would the nurse teach a client to avoid when diagnosed with calcium oxalate renal calculi? Select all that apply. One, some, or all responses may be correct.

- tea - spinach - rhubarb

Which clinical indicators would the nurse expect for a client who has end-stage renal disease (ESRD)? Select all that apply. One, some, or all responses may be correct.

-Azotemia -Hypertension Azotemia is a type of Nephrotoxicity. Azotemia is an excess of nitrogen compounds in the blood Hypertension occurs as a result of fluid and sodium overload and dysfunction of the renin-angiotensin-aldosterone system

The nurse is presenting a class at the community center about the prevention of colorectal cancer. Which statements should the nurse include in their teaching?

-Decrease the consumption of fat, refined carbohydrates and low in animal fat. -After the age of 50, a colonoscopy should be done every 10 years. - Increase the consumption vegetables such as broccoli, cabbage and sprouts. - Exercise a minimum of three to four times a week.

Which of these assessments leads the nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply. One, some, or all responses may be correct.

-Irritability -High-pitched cry - Ineffective feeding behavior

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply

-Pallor - Agitation -Tachycardia -Narrow pulse pressure

According to Hersey's Situational Leadership Model, which type of leadership behavior should the nurse use when delegating client care activities to recently hired, unlicensed assistive personnel (UAP) who appear competent and motivated?

Participating

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, and fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, which problem would the nurse suspect?

Placenta previa A nontender uterus and bright-red bleeding are classic signs of placenta previa; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed

Which suggestion would the nurse make to a client with rheumatoid arthritis who asks about ways to decrease morning stiffness?

Take a hot bath or shower in the morning.

A client with acute kidney failure reports fatigue and becomes lethargic. Upon reviewing the client's medical record, which finding would the nurse determine is the most likely cause of these clinical manifestations?

An increased blood urea nitrogen (BUN) level An increased BUN level, indicating uremia, is toxic to the central nervous system and causes fatigue and lethargy.

Using the 5-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks.

G4, T1, P1, A1, L3 Four pregnancies = G (gravida) 4. One pregnancy that ended at 38 weeks = T (term) 1. One pregnancy that ended at 32 weeks = P (preterm) 1. One pregnancy that ended at 18 weeks = A (abortion) 1. One set of twins and a singleton = L (living) 3.

The nurse presents a continuing education series focusing on professional appearances and behaviors related to IOM recommendations, inclusive of topics such as writing skills, social media, and interpersonal relationships. These topics are included in order to accomplish which goal?

Improve the opinion of nursing's professional role to increase quality outcomes. The IOM recommends that nurses develop interprofessional relationships in the community. Developing a professional image, as viewed by professionals in other health care disciplines, is crucial to achieving safe, quality care objectives and improving the voice of nursing within the interdisciplinary care team.

While assessing an older adult client before noon, the nurse smells alcohol on the client's breath. Which additional signs and symptoms would the nurse then monitor for? Select all that apply. One, some, or all responses may be correct.

Irritability Poor hygiene Family conflict Excessive mood swings

female athlete triad

disordered eating, amenorrhea and osteoporosis. are the female triad. The female athlete triad involves low caloric intake in combination with amenorrhea and low bone mineral density. Therefore, the nurse would assess for osteopenia and last menstrual cycle and pattern. The nurse would also ask about the student's eating patterns and if the client has experienced any weight loss and over what period of time. - osteopenia - amenorrhea - eating disorder - rapid weight loss - low caloric intake

which action would the nurse take if the weights attached to a 7 year old child in traction are touching the floor?

moving the child toward the head of the bed this will provide sufficient counetrtraction to raise the weights off the floor

a newborn has an elevated immunoglobulin M level upon birth. what action should the nurse implement?

prepare to test for TORCH syndrome elevated levels of immunoglobulin M (IgM) at birth may indicate antigenic stimulation in utero caused to an intrauterine infection such as TORCH syndrome. TORCH syndrome includes toxoplasmosis, rubella, cytomegalovirus, and herpes virus simplex type 2 infections

Which stage incorporating Meaningful Use is achieved by the nurse documenting basic care in the electronic health record using the system's standardized format?

stage 1

Which vitamin supplement should be given to the 1-month-old exclusively breast-fed infant?

vitamin D

A client is admitted with coffee ground emesis. This symptom is indicative of which diagnosis?

Upper GI bleed. Stomach enzymes breaks down any blood from an upper GI bleed, which leads the vomitus to appear as dark coffee ground emesis. Coffee ground emesis is a clinical sign of an upper GI bleed.

Encopresis

a childhood disorder characterized by repeated defecating in inappropriate places, such as one's clothing either voluntarily or involuntarily

After an admission for acute coronary syndrome (ACS), a client is asked to notify the nursing staff before getting out of bed. After finding the client up walking alone in the hallways an hour later, which response by the nurse is best?

"Sometimes after ACS, people feel dizzy and fall. The response "Sometimes after ACS, people feel dizzy and fall" provides the client with the rationale for the activity restriction and is more likely to lead to client compliance.

Which goal would the nurse establish when providing care for a client recovering from a transurethral resection of the prostate (TURP)?

Maintain patency of the indwelling catheter. Indwelling catheter patency promotes bladder decompression, which prevents distention and bleeding; continuous flow of an irrigant limits clot formation and promotes hemostasis.

An adult client reports a five-day history of nausea and vomiting. The client has been taking antacids for symptom relief. Which condition is the client likely to develop?

Metabolic alkalosis. Metabolic alkalosis is a type of acid-base imbalance in which the pH of the tissues becomes elevated. This condition may result from the loss of acid from the gastrointestinal system through vomiting, nasogastric suctioning, and overuse of antacids.

A child with cerebral palsy undergoes a tendon-lengthening procedure. The parents ask why their child must wear braces and shoes for at least 12 hours a day, even while in bed. Which is the best response by the nurse?

"They maintain body alignment and help prevent foot drop."

A client with hyperthyroidism is being treated with propylthiouracil (PTU). Which instruction will the nurse include in the teaching plan regarding this medication? Select all that apply. One, some, or all responses may be correct.

- "Avoid abrupt discontinuation of the medication. - "Monitor your weight, pulse, and mood routinely - "Report side effects, such as sore throat, fever, joint pain, or oral lesions.

Which instructions by the nurse will be beneficial to the client prescribed pyrazinamide for tuberculosis? Select all that apply. One, some, or all responses may be correct.

- "Avoid drinking alcoholic beverages while taking this medication." - "Drink at least 8 ounces of water with each dose of the medication."

Which statements accurately describe nortriptyline? Select all that apply. One, some, or all responses may be correct.

- Constipation and urinary retention may occur. - Weight gain is a common side effect

A client takes oxycodone every 3 hours for pain after surgery. Which actions would the nurse take before administering each dose of oxycodone? Select all that apply. One, some, or all responses may be correct.

- Count the client's respiratory rate - Ask the client to rate the level of pain. - Assess the client's level of consciousness. Oxycodone is an opioid that depresses the central nervous system, resulting in a decreased level of consciousness and depressed respirations. The medication should be administered, delayed, or held, depending on the client's status. It is important to have the client rate the pain level as a basis for comparison when checking to see if the medication relieved the pain.

Which information would be included in the discharge planning for a client who has had a new permanent pacemaker implanted above the left clavicle? Select all that apply.

- Take your pulse daily and report changes to the health care provider. - Notify the health care provider about swelling or drainage at the incision. - Inform airport security about the presence of a pacemaker if you are traveling.

A client who is 5 feet 8 inches tall (173 cm) and weighs 220 lb (99.8 kg) has ureteral colic, blood in the urine, and a blood pressure (BP) of 150/90 mm Hg. Which objective is has the highest priority and directs the nursing interventions for this client?

Decrease pain Ureteral colic clinical manifestations include sharp, severe pain (renal colic) radiating toward the genitalia and thigh.

The client reports screaming hysterically whenever a spider comes close to her. Which defense mechanism is the client using?

Displacement The defense mechanism of displacement is related to phobias; displacement is the release of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings

The nurse and the nutritionist are discussing the needs of a client who practices the Russian Orthodox faith. Which would the nurse and the nutritionist consider when planning meals for this client?

No meat on Wednesdays and Fridays

When a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital, which finding will the nurse expect during the assessment?

Left upper quadrant tenderness The spleen is normally not palpable, but splenomegaly usually accompanies chronic myelogenous leukemia, leading to a palpable and tender mass in the left upper abdomen.

The nurse develops a teaching plan for a client with rheumatoid arthritis. Which information would the nurse include in the plan about ways to reduce joint stress?

"If experiencing pain after 1 to 2 hours of activity, actively take measures to address the pain."

Clonus

Clonus is a type of neurological condition that creates involuntary muscle contractions. This results in uncontrollable, rhythmic, shaking movements. People who experience clonus report repeated contractions that occur rapidly.

Which medication would the nurse identify as aiding in uterine evacuation in cases of miscarriage?

Dinoprostone Dinoprostone is a prostaglandin E2 abortifacient that causes uterine evacuation in cases of miscarriage.

The nurse would counsel a pregnant client to take her iron supplement at which time of the day for efficient absorption?

before breakfast iron should be taken before breakfast on an empty stomach to permit maximal absorption.

a new mother is unable to latch her infant due to severe engorgement. what instruction should the nurse provide to the mother?

us the reverse pressure softening technique then latch baby engorgement can cause inflammation of the breast tissue, which is very painful and can cause milk stasis. if breast milk is not removed well plugged ducts or mastitis can occur. engorgement can cause the infant to have difficulties latching to the breast and therefore the reverse pressure softening (RPS) technique should be taught to the mother

Which finding indicates a complication of the labor process in a client with a history of T5 spinal cord injury?

Increased blood pressure A client with a spinal cord injury at T6 or higher is at risk for autonomic dysreflexia, marked by increased blood pressure and bradycardia.

When a client is admitted with dehydration, which clinical manifestations would the nurse expect to find? Select all that apply.

- Oliguria - hypotension - Tenting skin turgor

A client has a diagnosis of hemorrhoids. Which signs and symptoms would the nurse expect the client to report? Select all that apply. One, some, or all responses may be correct.

- Anal itching - Blood in stool - Rectal bulging - Pain when defecating

Which responses indicate that the client receiving total parenteral nutrition is experiencing hyperglycemia? Select all that apply. One, some, or all responses may be correct.

- Polyuria - Polydipsia - Respiratory rate of 26 breaths/min

Which sleep disorders are examples of dyssomnias? Select all that apply. One, some, or all responses may be correct.

- insomnia - restless leg syndrome - obstructive sleep apnea

After surgery, a client is prescribed a clear liquid diet. Which items would the nurse offer to the client? Select all that apply. One, some, or all responses may be correct.

- jell-o -broth - ginger ale

During a procedure, the client's heart rate drops to 38 beats/min. Which medication is indicated to treat bradycardia?

Atropine sulfate Atropine blocks vagal stimulation of the sinoatrial (SA) node, resulting in an increased heart rate.

Which intervention would the nurse provide a 3-month-old infant hospitalized with respiratory syncytial virus (RSV)?

Clustering care to conserve energy Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest

Which diet would the nurse anticipate for a 4-week-old infant after surgical repair for hypertrophic pyloric stenosis (HPS)?

Electrolyte solution After surgery, initial feedings consist of an electrolyte solution such as Pedialyte until the infant's tolerance of progressive feedings is determined.

After treatment with propylthiouracil for hyperthyroidism, a client has the thyroid ablated with 131I. On a visit to the endocrine clinic, the client exhibits signs and symptoms of thyrotoxic crisis (thyroid storm). Which alteration is the likely cause of thyrotoxic crisis?

Excessive hormone replacement Thyrotoxic crisis (thyroid storm) is the body's response to excessive circulating thyroid hormones.

In providing pain medication for a client who suffered serious injuries after a motor vehicle accident, which theory is the nurse using?

Kolcaba's theory of comfort Kolcaba's theory of comfort states that nurses seek to relieve physical, emotional, spiritual, and social pain.

The nurse will anticipate the need to administer which type of medication when a client with cardiogenic shock has an increased pulmonary artery wedge pressure reading of 30 mm Hg?

Loop diuretic Increased pulmonary artery wedge pressure indicates increased left ventricular preload; the nurse will anticipate the need to decrease preload by administration of a loop diuretic.

A client is receiving total parenteral nutrition (TPN) through a central venous access device. Which important nursing intervention will be included?

Placing the client in the supine position before changing the tubing Placing the client in the supine position before changing the tubing decreases pressure in the vena cava, which helps prevent an air embolus when the catheter is disconnected.

A client being treated for depression is sharing a story with an assigned counselor regarding his divorce. He smiles and states that he is not really hurt about her leaving him for a coworker because he knows that she really loves him and is just trying to make him jealous. Which defense mechanism is the client displaying?

Reaction formation. Reaction formation is the defense mechanism an individual displays in an attempt to deal with unacceptable feelings. Clients using this defense mechanism displays opposite feelings, such as insisting that they are happy when they are actually hurting.

Which description of pain would the nurse expect a client with a ureteral calculus to report?

Spasmodic and radiating from the side to the suprapubic area

A health care provider in the emergency department identifies that a client is in cardiogenic shock. Which type of medication is indicated for management of this condition?

Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output.

An older client is prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which resource should the nurse use to help identify medications that represent a potential health risk for older clients?

The Beers Criteria. The Beers Criteria is a list of medications that should typically be avoided by older adults. The newest version includes lists of medications that have been demonstrated to cause harm, specific drug-to-drug interactions that are known to cause harm, medications that should only be used with caution, and medications that require dosage adjustments.

The nurse notes in the history of the client in labor that she is a gravida 5 para 2112. Which statement would be true based on this information?

The client has two living children Gravida refers to all pregnancies a woman has had, including the present one. The four-digit para terminology lists in order: full-term deliveries, preterm deliveries, pregnancies that ended before 20 weeks (including elective abortions), spontaneous abortions, ectopic pregnancies, molar pregnancies, and the last digit refers to living children. Option 3 is correct in that the client has two living children.

Whole milk cannot be substituted for formula because it does not meet an infant's requirements for which nutrients?

Vitamin C and iron