Review HESI: Fundamentals
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? "I should sleep on my left side." "I should sleep on my right side." "I should sleep with my head flat." "I should not wear my glasses at any time."
"I should sleep on my left side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.
The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? "I can eat whatever I want." "I will eat rice cereal for breakfast." "I will eat beef barley soup for lunch." "I will eat only wheat bread for a snack."
"I will eat rice cereal for breakfast." Rationale: A client with celiac disease should be instructed to avoid gluten-containing products such as wheat, barley, oats, and rye.
The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made? "It can detect heart disease in my baby." "It will discover the presence of cancer in my baby." "It will check for the presence of a genetic condition in my infant." "It will allow me to institute measures to prevent complications if the level is elevated."
"It will allow me to institute measures to prevent complications if the level is elevated." Rationale: Phenylketonuria is a genetic disorder that is characterized by an inability of the body to use the essential amino acid phenylalanine. The phenylalanine level is checked to screen for this disorder. Newborn screening tests are mandatory in all 50 states and are most reliable if the blood sample is taken after the infant has ingested a source of protein. The objective in diagnosing or treating phenylketonuria is to prevent cognitive impairment. Minimal or absent phenylalanine hydroxylase activity results in profound cognitive impairment if not treated early with dietary restriction of phenylalanine.
The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? Serum electrolytes Urine specific gravity 24-hour fluid intake and output without restricting food or fluid intake Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland
24-hour fluid intake and output without restricting food or fluid intake Rationale: The first step in diagnosing DI is to measure a 24-hour fluid intake and output without restricting food or fluid intake. All of the other options may be done but would not be as definitive as a 24-hour fluid intake and output test.
normal serum potassium level
3.5-5.0 mEq/L
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? Call for help. Extinguish the fire. Activate the fire alarm. Confine the fire by closing the room door.
Activate the fire alarm. Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.
The nurse is caring for a pregnant client who is iron deficient. What groups are vulnerable to this condition? Select all that apply. Diabetics Alcoholics Vegetarians People with hemochromatosis Women of childbearing years Older people who consume poor diets
Alcoholics Vegetarians Women of childbearing years Older people who consume poor di
The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? A normal T4 level An elevated T4 level An elevated TSH level A decreased TSH level
An elevated TSH level Rationale: Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.
The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply. Laxatives Stool softeners Anabolic steroids Oral contraceptives Nonsteroidal antiinflammatory drugs
Anabolic steroids Oral contraceptives Nonsteroidal antiinflammatory drugs
A client's nasogastric feeding tube has become clogged. The nurse should take which action first? Replace the tube. Aspirate the tube. Flush with carbonated liquids. Flush the tube with warm water.
Aspirate the tube. Rationale: The first step in attempting to unclog a feeding tube is gently aspirating the tube. If this is not successful, flushing the tube with warm water can be tried. Carbonated liquids sometimes are used for flushing a clogged tube (depending on agency policy and procedures), but the tube must be rinsed thoroughly afterward to avoid stickiness. Replacement of the tube is the last step if other actions are unsuccessful. Also, the health care provider may prescribe another method of alleviating the obstruction.
The nurse is providing instructions to a client who is scheduled for a hepatobiliary scintigraphy (HIDA) scan. What should the nurse instruct the client to do? Eat a high-fat meal on the evening before the procedure. Eat a high-fat meal for breakfast on the day of the procedure. Avoid oral intake except for water on the day of the procedure. Maintain strict nothing-by-mouth status on the day of the procedure.
Avoid oral intake except for water on the day of the procedure. Rationale: The nurse instructs the client to avoid oral intake except for water on the day of the procedure. The client is injected with a radioactive chemical intravenously during the test to stimulate emptying of the gallbladder.
The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. Buffer Cardiac Nervous Chemical Respiratory Neuromuscular
Cardiac Nervous Neuromuscular Rationale: Most problems of alkalosis are related to increased stimulation of the cardiac, nervous, and neuromuscular systems. Chemical reactions are also called buffer systems and are not related to most problems of alkalosis. The respiratory system is related to respiratory alkalosis and not metabolic alkalosis.
A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside? Intubation tray Morphine sulfate injection Portable chest x-ray machine Chest tube and drainage system
Chest tube and drainage system Rationale: Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse should have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client may be premedicated before the procedure, or a local anesthetic is used. A portable chest x-ray machine would be needed to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure
A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms? Disorientation and dyspnea Decreased respiratory rate and depth Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias
Decreased respiratory rate and depth
A nursing student is assigned to an adult client who is scheduled for bone marrow aspiration. The coassigned nurse asks the nursing student about the possible sites that could be used for obtaining the bone marrow. The student demonstrates understanding of the procedure by identifying what as the correct aspiration site? Ribs Femur Scapula Iliac crest
Iliac crest Rationale: The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing.
The nurse is assisting a female client to collect a midstream urine specimen. How should the nurse implement aseptic technique? Cleansing the meatus with antiseptic pads using upward strokes Letting go of the labia once this tissue is cleansed, to allow the client to urinate Making sure that the fingers avoid touching the inside of the collection container Instructing the client to urinate in the container after the labia have been cleansed
Making sure that the fingers avoid touching the inside of the collection container
The nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? Stop the IV infusion. Obtain a prescription for a chest x-ray. Notify the health care provider. Apply cold compresses to the insertion site.
Stop the IV infusion. Rationale: The assessment indicates that infiltration of the IV solution has occurred, and the infusion must be stopped immediately to prevent further infiltration of the chemotherapy fluid. The nurse next notifies the health care provider (HCP) of the occurrence. The HCP needs to prescribe the treatment for the insertion site.
The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results?
The normal range for urine specific gravity is between 1.005 and 1.030.
intravenous (IV) flow rate formula
Total volume × Drop factor -------------------------- = gtt/min Time in minutes
The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen? Turnips Hard cheese Milk products Cottage cheese
Turnips
The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? Twitching Hypoactive bowel sounds Negative Trousseau's sign Hypoactive deep tendon reflexes
Twitching Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period? Diarrhea Bradycardia Urinary retention Excessive salivation
Urinary retention Rationale: Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.