Hesi Prep Wrong Answers
When teaching a client about levodopa-carbidopa therapy for Parkinson's disease, a nurse should include which instruction? "Report any eye spasms." "Take this medication at bedtime." "Stop taking this drug when your symptoms disappear." "Be aware that your urine may appear darker than usual."
"Be aware that your urine may appear darker than usual." Explanation: Levodopa-carbidopa, used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life.
Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia? A client newly admitted to a long-term care facility A client who recently traveled on a cruise ship A client who has had multiple family visitors A client whose spouse recently died
A client newly admitted to a long-term care facility Explanation: The client who is a new resident in a long term care facility is at high risk for community-acquired infections. Traveling is not likely to cause community-acquired pneumonia. Legionnaires' disease is a risk if traveling on a confined cruise ship. Receiving family visits and the death of a spouse are not typically causative factors associated with developing community-acquired pneumonia.
A nurse is teaching a female client with a history of multiple urinary tract infections (UTIs) about prevention. What statement indicates the client understands the teaching? "I should wipe from back to front." "I should take a tub bath at least 3 times per week." "I should take at least 1,000 mg of vitamin C each day." "I should empty my bladder after eating a meal."
"I should take at least 1,000 mg of vitamin C each day." Explanation: The client demonstrates understanding of teaching when she states that she should take vitamin C each day. Increasing vitamin C intake to at least 1,000 mg per day helps acidify the urine, decreasing the amount of bacteria that can grow. The client should wipe from front to back to avoid introducing bacteria from the anal area into the urethra. The client should shower, not bathe, to minimize the amount of bacteria that can enter the urethra. The client should increase her fluid intake, and void every 2 to 3 hours and completely empty her bladder. It is not sufficient to empty the bladder only after eating a meal. Holding urine in the bladder can cause the bladder to become distended, which places the client at further risk for UTIs.
The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best? "This disease is not contagious." "Your other children are as likely to develop this disease." "Medicine is available to prevent this, so check with your primary care provider." "Your other children are girls, so they are less likely to get it."
"This disease is not contagious." Explanation: Usually other children in the family do not get rheumatic fever. The disorder is not contagious.There is no medicine to give the children as prophylactic therapy. They have already been exposed to their sibling's streptococcal infection. If the other children do not have a streptococcal infection, they probably will not develop it.Girls, just like boys, are at risk for developing rheumatic fever.
The client presents at the clinic for a cough and is ordered codeine. What should the nurse include in the client's teaching concerning the administration of codeine? Select all that apply. "Use of codeine can cause muscle impairment." "Use of codeine can cause dizziness." "Use of codeine can cause constipation." "Use of codeine can cause a GI bleed." "Use of codeine can cause nausea."
"Use of codeine can cause dizziness." "Use of codeine can cause constipation." "Use of codeine can cause nausea." Explanation: The nurse should explain that adverse effects of codeine include dizziness, nausea, and constipation. Muscle impairment and GI bleeding are not among the adverse effects of codeine, so these should not be noted to the client..
A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate? "Would you like the chaplain to come visit you?" "Would you like to talk about your concerns for your hospitalized baby?" "Having to be in the hospital is hard. Your baby will be better soon." "You seem upset. Having your child hospitalized must be difficult."
"You seem upset. Having your child hospitalized must be difficult." Explanation: Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Asking the mother if she wants to talk about her concerns only allows a yes or no response; it does not provide an opportunity for the mother to share or vent. The mother may want to speak to a chaplain, but asking does not address the issue of being fearful and angry. Additionally, that action involves the nurse delegating the problem to someone else without seeking out the root of the problem. Saying "your baby will be better soon" only gives false reassurance and does not address the mother's immediate needs.
At the 28th week visit, the prenatal client's hemoglobin is 13 g/dL( 130 g/L). What is the best intervention? Instruct the client on how to increase iron in her diet. Reinforce that the client should continue taking her prenatal vitamins for her entire pregnancy. Request a prescription for ferrous sulfate in addition to the client's prenatal vitamin. Ask the client to keep a 3-day food diary.
At the 28th week visit, the prenatal client's hemoglobin is 13 g/dL( 130 g/L). What is the best intervention? You Selected: Ask the client to keep a 3-day food diary. Correct response: Reinforce that the client should continue taking her prenatal vitamins for her entire pregnancy. Explanation: Pregnant clients with hemoglobin levels less than 11 g/dL or 110 g/L are considered to be anemic.A hemoglobin level of 13 g/L or 130 g/L is considered normal so extra interventions to improve the client's hemoglobin level are not needed.The client should just be encouraged to continue taking her prenatal vitamins for the entire length of her pregnancy to assure she continues to maintain sufficient intake of iron.
A 12-year-old client needs lifesaving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? Send the client to surgery without the consent. Call the family for a consent over the telephone, and have another nurse listen as a witness. No action is necessary in this case because consent is not needed. Have the family sign the consent form as soon as they arrive.
Call the family for a consent over the telephone, and have another nurse listen as a witness. Explanation: While laws in states and provinces may vary, generally, when the client cannot sign the operative consent and it is a true life-saving emergency, consent may be obtained over the telephone from the client's next-of-kin or guardian. The surgeon must obtain the telephone consent, but if it is a true life-saving emergency the surgeon often is already in surgery, so the nurse makes the telephone call and another nurse witnesses the call. Some institutions have a special consent form for emergency surgery. Consent can be waived in situations in which no family is available; however, if the family can be reached by telephone before surgery, verbal consent is legally
The nurse is assessing an adult client with spina bifida to determine if the client has obtained the recommended preventive health screenings. The client states, "I have not had a pelvic exam for more than 15 years." What is the most appropriate nursing intervention to facilitate this screening examination for the client? Perform further assessment to establish if the client is experiencing menopausal symptoms. Contact health care practitioners who provide the screening examination in an accessible environment. Communicate with the primary care provider to determine if the client can participate in the examination. Obtain for the client a copy of The Americans with Disabilities Act, which explains access to care.
Contact health care practitioners who provide the screening examination in an accessible environment. Explanation: Clients with disabilities have the right of access to care, and the nurse must assist clients to find health care practitioners who provide the needed health screening examinations in an accessible environment. Other assessments of the client and documentation of health information and the client's physical limitations are important to share with the screening practitioner. Educating clients about their rights under the Americans with Disabilities Act would be a later nursing intervention.
When instructing a pregnant client diagnosed with a chlamydial infection at 28 weeks' gestation, what should the nurse include about this infection during pregnancy? This infection could indicate a central nervous system disorder in the fetus. She will likely receive a 5-day course of azithromycin. A cesarean birth is most likely necessary. There could be fetal death.
She will likely receive a 5-day course of azithromycin. Explanation: Chlamydial infection during pregnancy has been associated with preterm labor, resulting in a low birthweight infant and with preterm rupture of the membranes. Chlamydial infection is usually treated with azithromycin or doxycycline.
The nurse is providing follow-up care to a client 10 days after the birth. The nurse would anticipate what outcomes from the new mother? Select all that apply. The client feels tired but can care for herself and her new infant. The family has adequate support from one another and others. Lochia is changing from red to pink and is smaller in amount. The client feeds the baby every 6 to 8 hours without difficulty. The client has positive comments about her new infant.
The client feels tired but can care for herself and her new infant. The family has adequate support from one another and others. Lochia is changing from red to pink and is smaller in amount. The client has positive comments about her new infant. Explanation: Outcome evaluation for a family about 7 days after childbirth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 7-day old infant feeds every 3 to 4 hours if bottle-feeding and every 1½ to 3 hours if breastfeeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first checkup? It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment
A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The student can practice as an employee during clinical experiences. The student nurse is not responsible for knowing the facility's policy and procedures. The nursing instructor can be liable if the assignment is above the student's competency.
The student nurse is responsible for the student nurse's actions. The student nurse is held to the same standard of care as a nurse. The nursing instructor can be liable if the assignment is above the student's competency. Explanation: Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students can practice as employees during an educational clinical experience. Students are responsible to be familiar with hospital policy and procedures.
The nurse is teaching the parents of a 5-month-old infant who has been prescribed digoxin. What teaching will the nurse include in the infant's plan of care? Select all that apply. assessing the infant's apical pulse monitoring the infant's urinary output administering medication with food giving the medication at different times in the day monitoring the infant for signs of toxicity
assessing the infant's apical pulse monitoring the infant's urinary output monitoring the infant for signs of toxicity Explanation: Monitoring the heart rate is necessary prior to administration. Monitoring the client's urinary output will assist in assessment of the client's renal status. Digoxin should be given on an empty stomach. Monitoring for signs of toxicity is important and includes assessing for nausea, vomiting, anorexia, diarrhea, restlessness, drowsiness, fatigue, and visual disturbances. The medication should be given at the same time every day.
The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing's syndrome. The nurse reviews the history and physical (see chart). The nurse should develop a plan with the client to manage which effects? Select all that apply. low blood volume risk for injury slow healing changes in physical appearance risk for infection
risk for injury slow healing changes in physical appearance risk for infection Explanation: Cushing's syndrome results from excessive levels of cortisol. Some effects of excessive adrenocortical activity include musculoskeletal changes, and the client may be at risk for injury and falls. There is excessive protein catabolism causing muscle wasting, decreased inflammatory response, and potential for delayed healing and infection. The increased cortisol levels cause a moon-faced appearance to which clients must adjust. The skin becomes thin and fragile, and the client is also at risk for infection. Increased cortisol levels do not cause deficient fluid volume.
A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client expresses concerns about insurance coverage and financial needs. Based on this information, to whom would the nurse initiate a referral? hospice financial advisor social services case management
social services Explanation: A social worker can be extremely beneficial in helping clients identify additional personal and community funding resources and support groups. A hospice referral is not appropriate for a client with a new diagnosis who is seeking treatment. The nurse would not refer the client to a financial advisor as these advisors typically focus on wealth management, not the identification of resources. A referral to case management would be contingent on the client's insurance requirements and would not address the immediate concern.
