Exit Hesi 100-199
A client is receiving mesalamine 800mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?
Bowel patterns
A client with a chronic health problem has difficulty ambulating short distances due to generalized weakness but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?
Crutches with 4 point gait.
A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?
Determine if she can ask for support from family, friend, or the baby's father
The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?
Elevate the presenting part of the cord
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, no blisters or bleeding and no evidence of watery stools. Best intervention?
Instruct the mother to change the child's diaper more often
The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Report what to HCP?
Jaundice
The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?
Keeps the irrigating container less than 18 inches above the stoma.
The rapid response team detects the return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. the client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral intubation. What action should the nurse implement.
Perform bilateral chest auscultation
The nurse is teaching postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs cigarettes and takes 750mg calcium supplements daily. Teach osteoporosis prevention?
Postmenopausal women need an intake of at least 1,500mg of calcium daily
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Flower position with his arms at his side. What action should the nurse implement?
Raise the head of the bed to a Fowler's position and support his arms with a pillow
A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?
Reduced level of pain
An 18-year-old female client is seen at the health department for the treatment of condylomas acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual Papanicolaou (pap) smears
A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?
Simethicone (Mylicon)
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?
Skills of staff and client acuity
A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important to include in the client's plan of care?
Teach family proper range of motion exercises.
The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel. Which procedures can the nurse delegate to the UAP? SATA
- take postoperative vital signs for a client who has an epidural following knee arthroplasty -collect sputum specimen for a client with a fever of unknown origin -ambulate a client who had a femoral-pop
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)
-a client must be willing to accept palliative care, not curative care - the healthcare provider must project that the client has 6 months or less to live.
After several hours of non-productive coughing, a client presents to the emergency room C/O of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? SATA
-administer PRN nebulizer treatment -obtain 12 lead electrocardiogram -monitor continuous oxygen saturation
A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin for a methicillin resistant Staphylococcus aureus wound infection. Which action should the nurse take? SATA
-collect multiple site screening culture for MRSA -Place the client on contact transmission precautions -continue to monitor client for signs of infection
The nurse is developing an education program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? SATA
-contains a list with definitions of unfamiliar terms uses common words with few syllables - uses pictures to help illustrate complex ideas
The nurse interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? SATA
-interacts with a flat affect -avoids eye contact -has a disheveled appearance
A client with cirrhosis of the liver is admitted with complications related to end-stage liver disease. Which intervention should the nurse implement? SATA
-monitor abdominal girl -report serum albumin and globulin levels -note signs of swelling and edema
Two days after admission, a male client remembers that he is allergic to eggs and informs the nurse of the allergy. Which actions should the nurse implement? (SATA)
-notify the food services department of the allergy -enter the allergy information in the client's record -add egg allergy to the client's allergy armband
An older male resident of LTC facility is hospitalized for a cardiac catherization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. Best actions to take?
-notify the healthcare provider of the client's change in mental status -include q2hr reorientation in the client's plan of care
In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
-place personal religious artifacts on the body -attach identifying name tags to the body -follow cultural beliefs in preparing the body
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
-weigh the client and report any weight gain -report any client complaint of pain or discomfort -note and report the client's food and liquid intake during meals and snacks.
A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
a mother with an infected episiotomy
The charge nurse is making assignments on a psychiatric unit for a practical nurse and a newly licensed registered nurse. Which client should be assigned to the RN?
a young male with schizophrenia who said voices are telling him to kill his psychiatric.
The nurse caring for a 3 month old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
administer a prescribed analgesia for pain
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?
administer the analgesic as requested
The healthcare provider changes a client's medication prescription from IV to PO administration to double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?
administer the medication via the oral route as prescribed
At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?
anxiety
In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?
anxiety related to fear of suffocation
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take
ask the client what he is thinking about at this time.
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take
ask the older brother how he felt during the incident
An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. Which action should the nurse implement first?
assess the surroundings for nose and distractions
While receiving a male postoperative client's stables the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." What actions should you implement?
attempt to distract the client with general conversation
Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?
aural migraine headaches
The nurse should teach the client to observe which precaution while taking dronedarone?
avoid grapefruits and its juice
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?
avoid the nurse of nonsteroidal anti-inflammatory drugs (NSAID)
An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
be alert for possible cross-sensitivity to cephalosporin agents
When evaluating a client's rectal bleeding, which findings should the nurse document?
color characteristics of each stool
A client with Alzheimer's disease is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?
confirm the desired effect of the medication has been achieved
The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?
confirm the necessity for continued use of the CVC
A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing increased intracranial pressure in the plan of care. Which signs indicate to the nurse that ICP has increased.
confusion and papilledema.
While in the medical records department, the nurse observes several old medical records with names visible in the waste container. What action should the nurse implement?
contact the medical records department supervisor
the nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
convey to the client that birth is imminent
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries
decrease the prevalence of glaucoma in the population
A client with hyperthyroidism is being treated with radioactive iodine. Which explanation should be included in preparing this client for this treatment?
describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?
determine client's pulse, blood pressure, and respirations
A client arrives on the surgical floor after major abdominal surgery. Best first interventions?
determine the client's vital signs
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?
digoxin
An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?
document the ongoing wound healing
The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class, the nurse should emphasize the need to check glucose levels when?
during acute illness
A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?
encourage the client to eat finger foods
After administering an antipyretic medication. Which intervention should the nurse implement?
encouraging liberal fluid intake
An elderly female is admitted because of a change in her level of sensorium. During the evening shift the client attempts to get out of bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
ensure proper alignment of the leg in traction
In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?
ensure that no dependent loops are present in the tubing
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
establish a structured routine for the client to follow
An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?
explain the reason for using only non-narcotics
Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?
fall prevention measures
The nurse is evaluating a client's symptoms and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?
fever and dysuria
After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
hold oral intake until swallow evaluation is done
A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Most important to consider when analyzing the cost benefit?
how many departments can use this equipment
When implementing a disaster intervention plan, which intervention should the nurse implement first?
identify a command center where activities are coordinated
An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
identify pills in the bag
A client presents in the emergency room with right sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experienced a Bell's palsy rather than a stroke?
inability to close the affected eye, raise brow, or smile
A client experience withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?
initiate seizure precautions
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?
large amounts of fluid and electrolyte replacement
A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. Client complains that antiembolic stockings are constricting, intervention to implement?
maintain both lower extremities elevated on pillows
A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?
maternal pulse rate of 162 beats per min.
Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?
medicate as needed for pain and anxiety
Which intervention should the nurse include in the plan of care for a child with tetanus?
minimize the amount of stimuli in the room
An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temp 96, HR 122/min, RR 36/min, MAP 64 mmhg and CVP 7. Serum laboratory findings include hemoglobin 6.5, platelets 60,000, and WBC 3,000. Based on these findings this client is at greatest risk for which pathophysiological condition?
multiple organ dysfunction syndrome (MODS)
A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?
new onset of purple skin lesions
A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should be reported to HCP?
no wheezing upon auscultation of the chest
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
observe aspiration site
A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?
palpate at the radial pulse site with the pads of two or three fingers
A client with a cervical spine cord injury (SCI) has Cruthchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's plan of care?
provide daily care of tong insertion sites using saline and antibiotic ointment
A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take
provide the man and his mother with a copy of the patient's bill of rights
A client had a right hip replacement 3 days ago, is pale with diminished breath sounds over the left lower lung fields, temp of 100.2, o2 at 90%. Recommendation for HCP
reassess readiness for SNF transfer
To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?
remind the client to keep his appointments to have his cholesterol level checked
Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?
remove cigarettes from the client's room
During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
repeated fasting blood sugar is 132 mg/dl or 7.4 mmol/L
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
report weight gain of 2lbs in 24hours
A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the UAP encourages the child to stay in bed in supine position. What should the nurse implement?
reposition the client with the head of the bed elevated.
When assessing an adult male who presents as the community health clinic with a history of hypertension, the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Best action to implement?
review the client's use of over the counter medications
A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include :blood pressure 85/45 mm Hg, temp 98.6, pulse 124 beats/min, and resp 22 breaths/min. Based on these data, the nurse formulates the first portion of nursing diagnosis as "risk of injury related to" what?
shock
A client who was admitted yesterday with severe dehydration is complaining of pain with a 24 gauge IV with normal saline infusing at a rate of 150ml/hour. Which intervention should the nurse implement first?
stop the normal saline infusion
While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
submit a referral for an evaluation by a physical therapist.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?
supervise a newly hired graduate nurse during an admission assessment.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)
take Glucophage with the morning and evening meal.
A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAP's working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAP's?
tell all their assigned clients to stay in their rooms
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
the client's need for pain medication should be determined
A client in the post anesthesia care unit (PACU) has an eight (8) on the Aldrete post anesthesia scoring system. What intervention should the nurse implement?
transfer the client to the surgical floor
A client with a history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. which assessment finding warrants immediate intervention by the nurse?
ventricular arrhythmias
The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?
vitamin supplements for high-risk pregnant women
The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 hr for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?
yogurt and/or buttermilk
