Review HESI Practice Questions 290
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 ***Cantaloupe is high in potassium
Which action will the nurse take when a client's chest x-ray shows atelectasis? A) Administer O2 B) Suction the upper airway C) Position for postural drainage D) Encourage incentive spirometer
D) Encourage incentive spirometer ***atelectasis signifies alveolar collapse and indicates a need for the client to take deep breaths that will expand the alveoli
sodium polystyrene sulfonate
given to treat hyperkalemia
A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates administering which IV solution? A) 3% sodium chloride B) 0.9% sodium chloride C) 5% dextrose and 0.9% sodium chloride D) 5% dextrose and lactated Ringer solution
B) 0.9% sodium chloride ***it is an isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological stabilization
Which finding would be of MOST concern when the nurse assesses a client with emphysema? A) barrel chest B) oral cyanosis C) pursed-lip breathing D) respirations 26 bpm
B) oral cyanosis ***central cyanosis indicates hypoxemia and requires further assessment and actions such as checking O2 saturation and administration of O2
The nurse instructs a client that, in addition to building bones/teeth, calcium is also important for what? A) Bile production B) Blood production C) Blood clotting D) Digestion of fats
C) Blood clotting **when tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors
A client is hospitalized after 4 days of epigastric pain, nausea, and vomiting. The nurse reviews the lab test results: plasma pH 7.51, pCO2 50 mmHg, bicarbonate 58 mEq/L, chloride 55 mEq/L, sodium 132 mEq/L, and potassium 3.8 mEq/L. Which condition does the nurse determine the results indicate? A) Hypernatremia B) Hyperchloremia C) Metabolic alkalosis D) Respiratory acidosis
C) Metabolic alkalosis
Which describes the purpose of restricting sodium for a client with hypertension? A) to chemically stimulate the loop of Henle B) to diminish the thirst response of the client C) to prevent re-absorption of water in the distal tubules D) to cause fluid to move towards the interstitial compartment
C) to prevent re-absorption of water in the distal tubules
When a client in the clinic is offered the influenza vaccine and states, "I had the vaccine already last year so I won't need it now", which response will the nurse give? A) "The flu vaccine is recommended for everyone B) "You only need 1 flu shot in your lifetime to achieve immunity" C) "As long as you are younger than 50 years old, you will not really need vaccination" D) "The immunization changes, so you need to get vaccine annually to stay protected"
D) "The immunization changes, so you need to get vaccine annually to stay protected"
When a client with a history of heart failure arrives for a scheduled clinic appointment and has gained 6 lb, which nursing action has the HIGHEST priority? A) Check for lower leg swelling B) Notify the healthcare provider C) Take the client's pulse rate D) Listen to the client's breath sounds
D) Listen to the client's breath sounds ***weigh gain may indicate fluid retention in this client, the nurse needs to further assess for fluid overload
Assessment findings of a client who is admitted to the ER including cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low-grade fever. The nurse suspects which condition? A) pancreatitis B) appendicitis C) cholecystitis D) diverticulitis
D) diverticulitis
The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which is appropriate to include in the client's dietary plan? A) soft-textured foods to reduce the digestive burden B) low-cholesterol foods to avoid further formation of gallstones C) increased protein to promote tissue healing and improve energy reserves D) reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release
D) reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release
Which clinical manifestations indicate to the nurse that the client has an inadequate fluid volume? SELECT ALL THAT APPLY. - decreased urine - hypotension - dyspnea - dry mucous membranes - lung crackles - poor skin turgor
- decreased urine - hypotension - dry mucous membranes - poor skin turgor ***all symptomatic of dehydration
The nurse is caring for a client with cholelithiasis and obstructive jaundice. When assessing this client, the nurse would be alert for which findings that are consistent with these conditions? SELECT ALL THAT APPLY. - ecchymosis - yellow sclera - dark brown stool - straw-colored urine - pain in right upper quadrant
- ecchymosis - yellow sclera - pain in right upper quadrant
Normal creatinine levels
0.6-1.2 mg/dL
Normal BUN levels
10-20 mg/dL
Which topic will the nurse include in teaching for a client with Raynaud disease? A) tobacco avoidance B) dietary salt reduction C) Need for increased exercise D) low fat, low cholesterol diet
A) tobacco avoidance ***tobacco use causes arterial vasoconstriction which worsens symptoms of Raynaud disease
After obtaining client BP of 172/104 mmHg and 164/98 mmHg during a BP screening, which action would the nurse take NEXT? A) Provide health teaching about a low-sodium diet B) Call the paramedics for transport to the hospital C) Suggest ways to decrease the client's stress level D) Refer the client to a primary health care provider
D) Refer the client to a primary health care provider ***these readings indicate hypertension and thus require further evaluation by a health care provider
Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? A) productive cough B) clubbing of the fingertips C) low-pitched expiratory rhonchi D) diminished breath sounds on auscultation
D) diminished breath sounds on auscultation *** atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished
When caring for a client who has heart failure, with blood pressure of 102/70 mmHG, pulse 106 bpm, and bilateral lung crackles which prescribed action would the nurse question? A) Infuse normal saline at 100 mL/hr B) give furosemide 40 mg IV now C) administer potassium chloride 10 mEq orally now D) titrate o2 by mask to keep o2 93% or higher
A) Infuse normal saline at 100 mL/hr ***infusing normal saline would worsen the symptoms of fluid overload and should be questioned by the nurse
A client with COPD exacerbation is receiving O2 at 2L/minute per nasal cannula and has an O2 saturation of 88%. Which action would the nurse anticipate taking next? A) increasing O2 flow rate to 3L/minute B) Preparing for intubation and assisted ventilation C) administration of an inhaled rapid-acting bronchodilator D) continuing to monitor the client with no therapy change
A) increasing O2 flow rate to 3L/minute
When a client has difficulty swallowing after a stroke, which action by the nurse would be MOST important in preventing pneumonia? A) Giving influenza vaccine to the client B) Having suction available during meals C) Assisting the client to take deep breaths D) Teaching about incentive spirometer use
B) Having suction available during meals ***Because the client with difficulty swallowing is at risk for aspiration, having suction available will be most effective intervention in preventing aspiration pneumonia
When palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia? A) Bilateral decreased chest expansion B) Increased fremitus over the affected area C) Tracheal deviation away from the affected side D) Decreased chest expansion on the affected side
B) Increased fremitus over the affected area *** fremitus is the vibration that can be felt on the chest wall when the client talks; increased fremitus is felt when palpating over the area of pneumonia
A client with known peripheral arterial disease calls the clinic and tells the nurse about experiencing several symptoms. Which symptom requires the MOST rapid action by the nurse? A) anxiety B) chest pain C) weak pulse quality D) cool/pale lower legs
B) chest pain *** because atherosclerosis is a systemic disease, clients with PAD are likely to have coronary artery disease as well
The nurse teaches a client about the dangers of using sodium bicarbonate regularly. Which effect of sodium bicarbonate is the nurse trying to prevent? A) gastric distention B) metabolic alkalosis C) chronic constipation D) cardiac dysrhythmias
B) metabolic alkalosis ***also causes retention of sodium and water
Which result would the nurse expect to see on the EKG tracing monitor when a client has diabetic ketoacidosis and a potassium level of 5.4? A) abnormal P waves and depressed T waves B) peaked T waves and widened QRS complexes C) Abnormal Q waves and prolonged ST segments D) peaked P waves and an increased number of T waves
B) peaked T waves and widened QRS complexes
On admission to an intensive care unit, a client is diagnosed with compensated metabolic acidosis. The nurse expects which assessment finding? A) Muscle twitching B) Mental instability C) Deep/rapid respirations D) Tachycardia and cardiac dysrhythmias
C) Deep/rapid respirations
Which diet choice by a client who has been prescribed a 2-g sodium diet indicates that diet teaching has been effective? A) Mac n cheese B) Sausage and scrambled eggs C) Hamburger with bun, lettuce, and tomato D) Canned chicken noodle soup with fruit plate
C) Hamburger with bun, lettuce, and tomato
What is ecchymosis?
bruising
The nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the client's history MOST likely played a role in the development of hemorrhoids? SELECT ALL THAT APPLY. - constipation - hypertension - eating spicy foods - bowel incontinence - numerous pregnancies
- constipation - numerous pregnancies
Which action is MOST appropriate for the nurse to take for a client who began receiving furosemide 2 days ago and has a serum potassium level of 2.8 mEq/L? A) hold the morning dose of the diuretic and have the lab repeat the test B) continue to monitor the level to ensure that it stays within the normal limits C) notify the primary health care provider of the critically low result D) anticipate a prescription of an increase in the dosage of the furosemide
C) notify the primary health care provider of the critically low result
A primary health care provider diagnoses a client with acute cholecystitis with biliary colic. Which clinical findings would the nurse expect when performing a health history and physical assessment? SELECT ALL THAT APPLY. - diarrhea with black feces - intolerance to foods high in fat - vomiting of coffee-ground emesis - gnawing pain when stomach is empty - pain that radiates to the right shoulder
- intolerance to foods high in fat - pain that radiates to the right shoulder
Which clinical manifestations will the nurse assess for in a client with a serum potassium level of 6.4 mEq/L? SELECT ALL THAT APPLY. - anorexia - constipation - muscle weakness - irregular heart rhythm - hyperactive bowel tones
- muscle weakness - irregular heart rhythm - hyperactive bowel tones **an increase in potassium interferes with muscle contractions and dysrhythmias
A client develops hyponatremia. Which factors are likely causes of hyponatremia? SELECT ALL THAT APPLY. - diabetes insipidus - profuse diaphoresis - excess sodium intake - removal of the parathyroid glands - rapid IV infusion of 5% dextrose in water (D5W)
- rapid IV infusion of 5% dextrose in water (D5W) - profuse diaphoresis
The nurse is caring for a client with GERD. Which information would the nurse provide the client to prevent worsening of the disorder? SELECT ALL THAT APPLY. - eat a snack before bed - include vigorous exercise - wear loose-fitting clothing - begin a weight-loss program - sleep with the head of bed elevated
- wear loose-fitting clothing - begin a weight-loss program - sleep with the head of bed elevated
The RN teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? A) Administering sodium polystyrene sulfonate B) Instructing a client to increase potassium and sodium intake C) Monitoring glucose levels hourly D) Providing potassium-sparing diuretics
A) Administering sodium polystyrene sulfonate ***Increased potassium levels indicate hyperkalemia and are observed in clients with adrenal insufficiency. Administering potassium binding and excreting resin, such as sodium polystryne sulfonate, can reduce the potassium levels
The ABG for a 3-month-old infant with diarrhea showed that the pH is 7.30, PCO2 is 35 mmHg, and HCO3- is 17 mEq/L. Which would the nurse conclude has developed? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
A) Metabolic acidosis
Which clinical sign is the MOST important indication of an accurate degree of dehydration? A) Dry skin B) weigh loss C) Sunken fontanel D) decreased urine output
B) weigh loss
When the nurse is reviewing a client's ABG results, which finding is consistent with respiratory alkalosis? A) An elevated pH, elevated PCO2 B) A decreased pH, elevated PCO2 C) An elevated pH, decreased PCO2 D) A decreased pH, decreased PCO2
C) An elevated pH, decreased PCO2
