Hesi EAQ

Which specialized support skills will the registered nurse (RN) learn during the training process for the Disaster Medical Assistance Team (DMAT)? Select all that apply. One, some, or all responses may be correct.

-Logistics -Security -Communications

Which leukocyte values determine the adequacy of a client's response to inflammation? Select all that apply. One, some, or all responses may be correct.

-Monocytes -Neutrophils -Macrophages

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems?

Correct1 A motor vehicle accident involving five cars

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The nurse would direct the client to call back after taking which action?

Correct1 Drink a glass of orange juice and time 10 fetal movements

Which members of the health care team are under dependent status when a task is delegated by the registered nurse (RN)? Select all that apply. One, some, or all responses may be correct.

Correct2 Unlicensed assistive personnel Correct5 Licensed vocational nurse (LVN)

The nurse is providing care to a toddler admitted to the hospital with symptoms of mercury poisoning. Which assessment question would help the nurse determine the source of the mercury?

Correct3 "Does your child consume fish?"

Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" How would the nurse respond?

Correct3 "You seem very concerned. Tell me what you know about your surgery."

Which action is essential for the nurse to take after a client returns from spinal surgery?

Correct3 Assess the client's feet for sensation

Which nursing action is the priority when providing care to a trauma client?

Correct3 Assessing respiratory effort

The nurse leader sent a team of followers to conduct a community health session that was completed successfully. Which action of the nurse indicates leadership quality?

Correct3 Giving rewards to the followers responsible for the success

For which reason would the nurse caring for clients who were injured in a tornado call the medical command physician?

Correct3 To determine resource needs of clients

A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client has which response?

Correct4 "I may have a sore throat."

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. Which action would the nurse take to promote adequate cerebral blood flow?

Correct4 Monitor serum carbon dioxide levels

When preparing to assess a client with active tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room?

Correct4 N95 respiratory mask

Which staff members will be the first to manage the care of victims from an accident at the nuclear power plant?

Correct4 Prehospital care providers

Which client assessment is triaged to nonurgent status by the emergency department nurse?

Correct4 Teenager with ecchymosis and edema to the ankle The teenager with ecchymosis and edema to the ankle likely has a sprain, which is nonurgent. An older adult male with purulent sputum could have new onset of a respiratory infection such as pneumonia, which is urgent. The toddler with periods of unresponsiveness, which is life threatening, is triaged as emergent. The middle-aged female with right scapular pain has possible gastrointestinal- or gallbladder-related problems, which is urgent.

Which results would be expected when assessing the laboratory values of a client with type 2 diabetes?

Correct4 Urine negative for ketones and positive glucose in the blood

The parents inform the nurse that their school-age child frequently participates in hazardous activities. Which instruction is a priority in this case?

Ensure the child has eye, ear, and mouth protection

A client presents to the emergency department with bruises and a concussion. Which information would the nurse obtain to determine the client's risk for further injury?

Frequency of abuse

Which nursing actions during a focused urinary assessment are used to collect subjective data? Select all that apply. One, some, or all responses may be correct.

Correct1 Inquire about painful urination. Correct2 Ask the client about changes in characteristics of urination.

Which question would the nurse ask first of the witnesses who accompanied a rescued drowning victim to the emergency department?

"How long was the client underwater?

Which response would the nurse make when obtaining a health history from a client who is known to be verbally abusive and says, "You're ugly, and you're probably stupid, too. Why am I stuck with you"?

"You are talking inappropriately, so I'm going to leave and will come back when you stop being verbally abusive."

Which clients are triaged at the nonurgent level by the disaster response nurse after a natural disaster? Select all that apply. One, some, or all responses may be correct. impair

- A client with a sprained ankle -A client with a simple fracture of the forearm

Which nursing actions contribute to a health care facility's emergency preparedness and response before a natural disaster? Select all that apply. One, some, or all responses may be correct.

- Participating in drills - Evaluating outcomes

Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring? Select all that apply. One, some, or all responses may be correct.

- Wearing a medical alert bracelet - Initiating bleeding precuations -refrain frim estrogen therapy - Obtaining routine pt times -Notify providers of anticoagulation

Which findings occur with orthostatic hypotension? Select all that apply. One, some, or all responses may be correct.

- feeling of faintness - decreased systolic pressure

The nurse is caring for a client with dysphagia. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct.

-Keep suction equipment nearby -Provide thickened liquids -Sit in high fowler position

Which are the specific functions of the nurse practitioner as an advanced practice registered nurse in a health care setting? Select all that apply. One, some, or all responses may be correct.

-Possesses knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions -Provides comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions -Establishes a collaborative provider-client relationship, working with a specific group of clients or with clients of all ages and health care needs

Which are the best ways for the nurse to be protected legally? Select all that apply. One, some, or all responses may be correct.

-Provide care within the parameters of the standards for nursing practice set by the state or province. -Document consistently and objectively. -Clearly document a client's nonadherence to the medical regimen

What is the Glasgow coma score for a client who opens the eyes when his or her name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus.? Record your answer using a whole number.

11

A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary health care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action would the nurse take?

Correct1 Refuse to suture wounds

A client has a leaking thoracic duct after a radical neck surgery. The nurse expects that the postoperative plan of care will include which prescriptions?

A chest tube, total parenteral nutrition (TPN), and bed rest

Which information would the nurse's teaching plan include for a client scheduled for an elective vacuum aspiration abortion in the first trimester of pregnancy?

A temp of 100.4 or higher should be reported immediately

The nurse reviews the medical record of a client with terminal cancer and notes the presence of a do-not-resuscitate (DNR) order. The order was written with the client's admission orders. The nurse recalls that which factor is relevant to the legal aspects of the DNR order?

Correct1 The policies of the agency establish the status of DNR orders

Which question would the nurse ask a client who has developed pneumonia when assessing risk factors?

Are you a diabetic

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. Which nursing intervention is correct regarding restraints?

Assess the clients condition per hospital protocol

Which parent teaching would the nurse provide to minimize regurgitation in an infant with a cleft lip?

Burp frequently during a feeding.

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

Correct4 "Your infection occurred because of exposure to a health care facility.

The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. Which sounds would the nurse document in the client's assessment record?

Coarse Crackles

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media?

Complete the entire course of antibiotic therapy

The nurse witnesses a client collapse during a home care visit. In which order would the basic life support actions be performed by the nurse?

Correct 1. Use physical and auditory stimulation to attempt to elicit a response Correct 2. Direct the client's spouse to call the emergency management system. 3. observe for pontaneous breaths 4. palpate to determine the presence of a pulse 5. chest compressions 6. breaths

The nurse is teaching skin and basic care to the parent of a 6-month-old infant with eczema. Which statement indicates that the parent needs further teaching

Correct1 "I'll have to be careful not to cut my baby's nails short."

Which health care team member would be responsible for evaluating the acuity of clients from a mass casualty and identifying the need for immediate transfer to the orthopedic care unit?

Correct1 Triage officer

Which instruction would the nurse provide to a group of parents with small children to promote safety and prevent injury? Select all that apply. One, some, or all responses may be correct.

Correct1 Turn pot handles away from edges. Correct2 Install smoke detectors in the house. Correct3 Lock medication away in a safe place. Correct4 Place child safety latches on cabinets. Correct5 Verify water temperature before baths.

The nurse manager reviews the performance report of a direct care nurse and asks the nurse to focus on "emotional intelligence" to be promoted to a nurse leader. Which statement would the nurse leader most likely use while advising the nurse on areas for improvement?

Correct2 "Try to be more sensitive to the experiences of others."

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. Which nursing action is important when suctioning the endotracheal tube?

Correct2 Hyperoxygenating with 100% oxygen before and after suctioning

A client who is having her labor induced with oxytocin has internal fetal monitoring in place. Her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. The baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. The nurse notices that with the past two contractions the fetal heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. Which type of pattern is this?

Correct2 Late decelerations

The primary health care provider instructs the nurse to place a client with burns in the supine position with the affected arm over the head to reduce the risk of contractures. Which part of the client is affected due to burns?

Correct2 Lateral trunk

Which gauge size is appropriate for a peripheral catheter to administer saline to an infant?

Correct3 24 gauge

A client with renal failure wants to go back home, but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. Which role does the nurse play here?

Correct4 Advocate

Which is the most appropriate nursing intervention to prevent further injury in the client who was injured in a tornado and is disoriented?

Correct4 Asking a family member to remain with the client

As the nurse prepares to have a client sign her abdominal hysterectomy with a bilateral oophorectomy surgical consent, the client asks the nurse how long she should wait to become pregnant after the surgery. Which action would the nurse take at this time?

Correct4 Call the primary health care provider immediately and hold preoperative medications.

How long would the nurse maintain isolation of a child with bacterial meningitis?

Correct4 For 48 hours after antibiotic therapy begins

Which is the priority intervention for the unconscious client in ventricular fibrillation?

Defib

The nurse is providing care in the postanesthesia care unit to a client who underwent a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness?

Encouraging deep breathing

When caring for a client in the third trimester of pregnancy with a history of myocardial infarction, which statement made by the client would concern the nurse the most?

I have been using cough drops to try and get rid of my cough

Which are the important points to be considered when imparting practical knowledge to nursing students about preventing complications in the hospital? Select all that apply. One, some, or all responses may be correct.

If a client is harmed, the nursing student is accountable. Nursing students would never be assigned any tasks they are unprepared for It is recommended for a nursing student to work as a nursing assistant or nurse's aide when not attending classes. The nursing supervisor would be notified in case the nursing student is delegated tasks that he or she is not prepared for.

Which intervention would the nurse question when caring for a client who has tested positive for human immunodeficiency virus (HIV)?

Internal fetal scalp electrode

Which finding would the nurse expect in a client with left-side phrenic nerve paralysis?

Left base dullness to percussion

Which trauma center level is appropriate for the client who survived an earthquake and is found to have multiple injuries and requiring stabilization?

Level III

Which prehospital intervention is the priority for a client bitten by a snake?

Moving the victim to safe area away from the snake and encouraging rest

Which priority interventions would the nurse implement for a client with neutropenia in an emergency department? Select all that apply. One, some, or all responses may be correct.

Obtain blood cultures immediately Administer antibiotic STAT as prescribed

A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, which education would the nurse provide the parents?

Offer crushed ice chips

Which agents of bioterrorism can be treated effectively with antibiotics? Select all that apply. One, some, or all responses may be correct.

Plague Anthrax Tularemia

While performing a respiratory assessment of a client with pneumonia, the nurse hears these sounds. Which assessment finding would the nurse document in the client's medical record? (sounds like walking on a creeking floor or a coffee pot)

Pleural friction rubs

Which intervention is the nurse's priority when caring for a child with human immunodeficiency virus (HIV)?

Prevent infection

How can the nurse best manage a common side effect of chemotherapy?

Provide meticulous oral hygiene

Which assessment finding for a client with pneumonia would be most important for the nurse to communicate to the health care provider?

RR of 38

The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client lost only 3 lbs (1.4 kg). Which response by the nurse is correct?

Reevaluate the plan of care for appropriateness

Which response would the nurse take when a client comes up and shouts, "I hate you! You're talking about me again!" and throws a glass of juice at the nurse who is talking to another client?

Removing the client from the room because limits must be places on such behavior

The nurse is caring for a client who was brought to the emergency department after binge drinking at a party. Which interventions would the nurse include in the plan of care to prevent a suicide attempt? Select all that apply. One, some, or all responses may be correct.

Require sitter in room at all times Verify medications are swallowed use plastic utensils and paper cups

Which topics will the nurse include when educating adolescents about injury prevention? Select all that apply. One, some, or all responses may be correct.

Suicide Seat belt use Firearm safety

Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter?

Take the deepest breath you can, then blow out hard and fast

Which is the best resource for hospital administrators to use when formulating a fire evacuation plan as part of the organizational disaster plan for a new facility?

The Life Safety Code

6. A client with tuberculosis asks the nurse about the communicability of the disease. Which response would the nurse use?

Untreated active tb is communicable

Which would be included when educating daycare workers on the sanitization of bathroom and diaper-changing areas?

Use fresh 1:64 bleach solution

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct.

Use sterile technique when cleaning the inner cannula Don sterile gloves before removing the inner cannula

Transmission-based precautions are implemented for a client with salmonellosis and would include which component?

wearing a gown if soiling is likely