Clinical Judgement HESI

During a routine examination at the prenatal clinic the nurse notes significant increases in the client's blood pressure and edema of the face and hands. The diagnostic criterion for preeclampsia is a blood pressure of 140/90 mm Hg, but what is the lowest blood pressure that should prompt the nurse to monitor the client for other signs and symptoms of preeclampsia?

130/85 mm Hg

A nurse in the birthing room is assessing a newborn. Which characteristic should be assigned an Apgar value of 2?

A strong cry

A client, admitted to the hospital with a fractured hip, is scheduled for surgery for a total hip replacement. In which position should the nurse place the client's affected limb after surgery?

Abduction and extension

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication?

Active phase

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?

An activated partial thromboplastin (APTT) twice the usual value

The nurse is getting a client out of bed to the chair for the first time since surgery 2 days ago. What is the most appropriate assessment the nurse should make first before moving the client?

Assessment of comfort and pain

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of an infratentorial brain tumor. What presenting sign does the nurse anticipate when assessing the child?

Ataxia

A client reports a history of bilateral blanching and pain in the fingers on exposure to cold. When rewarmed, the fingers become bright red and "tingly" with a slow return to their usual color. The client smokes one to two packs of cigarettes per day. The nurse determines that the client has Raynaud's disease and not Raynaud's phenomenon because of the:

Bilateral involvement

What information in a postpartum client's health history should alert the nurse to monitor the client for signs of infection?

Blood loss of 850 mL after a vaginal birth

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. What complication of severe preeclampsia requires diligent monitoring of the blood pressure?

Brain attack

A client is placed into a whirlpool tub for range-of-motion exercises. The nurse should explain that rehabilitating exercises carried out underwater use the water's:

Buoyant force

A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? Select all that apply .

Butterfly facial rash Inflammation of the joints

How should a nurse turn a 10-year-old child in a spica cast?

By log-rolling the body as one unit

A client is admitted after incurring electrical burns to both hands while playing golf during a lightning storm. When assessing the entrance and exit wounds, the nurse considers that electrical injury:

Causes severe nervous tissue destruction along a path of least resistance

After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the health care provider if the client:

Complains of sharp pain in the eye

A client reports urinary frequency and burning. To determine if there is tenderness that indicates the presence of an ascending urinary tract infection, the nurse should palpate which area?

Costovertebral angle

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to health care provider with the mother. Which signs and symptoms require further evaluation by the health care provider? Select all that apply.

Decreased urine output Blurred vision with spots Contractions that are regular and 5 minutes apart

A nurse is assessing a child with leukemia who is undergoing chemotherapy. Which side effect should the nurse anticipate?

Epistaxis

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, what action should the nurse take?

Give oxygen at 2 L per minute via nasal cannula.

A client is admitted to the hospital with a diagnosis of peptic ulcer. The nurse should assess the client for which complication commonly associated with the diagnosis?

Hemorrhage

The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level?

Increased total iron-binding capacity (TIBC)

A client is found unconscious and unresponsive. What should the nurse do first?

Initiate a code

A client had an abdominal cholecystectomy. Postoperatively, the client refuses to deep breathe and cough, saying, "It's too painful." The nurse should:

Medicate the client for pain before coughing and deep breathing

The nurse is caring for a client whose vertebral column at the level of T6 and T7 was completely crushed and whose left leg was amputated traumatically above the knee. The nurse expects what clinical assessment finding?

Pain at the level of compression

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? Select all that apply.

Poor tissue turgor Confusion

A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention?

Rapidly rewarming the toes by placing the feet in warm water

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning.

A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. In light of the fact that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?

Sitting by the crib and bathing the child later when the anxiety decreases

A client has laparoscopic surgery to remove a calculus from the common bile duct. What postoperative client response indicates to the nurse that bile flow into the duodenum is reestablished?

Stools become brown

A dehydrated 5½-month-old infant is admitted to the pediatric unit with a fever and a 48-hour history of vomiting. What assessment will most influence the infant's initial care?

Temperature

What is the nurse's most critical assessment in a client with preeclampsia in the immediate postpartum period?

Vital sign

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T 3 ) and thyroxine (T 4 )? Select all that apply

Weight gain Cold intolerance

Which assessment question will provide the best information regarding a client's risk for interrupted sleep related to lifestyle choices?

"Do you smoke cigarettes, cigars, or a pipe?"