hesi lvl 2

Which action puts a client at risk for low back injury and pain?

Smoking tobacco

Which statement by the parents of an infant with Erb palsy would the nurse determine indicates accurate understanding of their infant's prognosis?

"Complete recovery takes a few months."

Which immunization is required between 4 and 6 years of age?

Inactivated poliovirus

Which etiology is associated with intertrigo in clients?

Obesity

Which finding would the nurse expect to identify when assessing a client with a herniated lumbar disk?

Pain radiating to the hip and leg

After 6 hours in labor a client is dilated 5 cm and at -1 station. In the next hour her contractions gradually become irregular and more uncomfortable. Which possibility would the nurse immediately consider?

The client has a full bladder should be emptied

Which intervention would the nurse recommend for post-cesarean gas pain?

Walking around the room

A client with a high cholesterol level says to the nurse, "Why can't I take a medication that will eliminate all of the cholesterol in my body so it isn't a problem?" The nurse explains that some cholesterol is needed to perform which body function?

Cellular membrane structure

which musculoskeletal abnormality would the nurse suspect in a client who exhibits short steps and drags a foot?

Spastic gait

What are the stages of the policy process in correct order?

1.Agenda setting 2.Policy formulation 3.Policy adoption 4.Policy implementation 5.Policy evaluation

According to Freud's developmental theory, which age is considered the phallic stage?

3 to 6 years old According to Freud's developmental theory, 3 to 6 years of age is considered the phallic stage. Birth to 18 months of age is considered the oral stage. Eighteen months to 3 years of age is the anal stage. Six to 12 years of age is the latent stage.

Protein level

6.4-8.3

Which clinical finding in a newly delivered client requires immediate investigation?

A slow trickle of blood from the vagina

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)?

All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed.

Which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis?

Apply an alcohol free, moisturizing lotion several times a day."

A client with Guillain-Barré syndrome has been hospitalized for 3 days. Which assessment data would the nurse plan to monitor frequently for this client?

Ascending weakness

Which nursing intervention is the priority during the first 2 hours after a cesarean birth?

Assessing the lochia to identify the complication of hemorrhage

A client with epilepsy reports diffuse redness and large blisters on the buccal mucosa. Administration of which medication could be a possible reason for the client's condition?

Barbiturates

The nurse notes an older adult's admission orders include gentamicin for the treatment of osteomyelitis. Which laboratory reports will the nurse review before beginning the medication? Select all that apply. One, some, or all responses may be correct.

Blood urea nitrogen (BUN) and creatinine Electrolytes and urinalysis

How would the nurse respond to an alcohol recovery program sponsor requesting to read his or her client's progress record?

By not allowing the sponsor to review the record

Which assessment would the nurse prioritize for a newborn with Down syndrome?

Cardiac irregularities for congenital heart disease

Which iron-rich foods would the nurse recommend for a toddler diagnosed with iron deficiency anemia? Select all that apply. One, some, or all responses may be correct.

Chicken Broccoli Lean steak

The nurse is preparing to teach a group of new parents about factors that have a significant effect on the dosage of medications appropriate to treat pediatric clients. Which factors would the nurse include in the teaching? Select all that apply. One, some, or all responses may be correct.

Children's skin is thinner and more porous. body temperature is less well-regulated among children

A client reports disturbed sleep due to allergic pruritus. Which medication would help the client sleep and treat the allergic symptoms?

Chlorpheniramine

Which would be the consequences if a health care organization follows the guidelines of transparency and allows the free flow of information?

Clients would be able to make informed decisions. Transparency allows the free flow of information that enables clients to make informed choices about their health. A transparent system helps mitigate potential errors. As the number of errors decreases, the number of malpractice suits may also decrease. Transparency may not affect the number of clients visiting the hospital to seek health care.

A pregnant client is prescribed heparin to prevent the risk of thromboembolism. Which adverse effects would the nurse anticipate with this medication? Select all that apply. One, some, or all responses may be correct.

Compression fractures of the spine Osteoporosis

The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. One, some, or all responses may be correct.

Cyanosis Tachypnea Retractions

Which medication is used in the treatment of a client with intervertebral disc disease?

Cyclobenzaprine

Which nursing assessment indicates dehydration in an infant?

Decreased urine output

Which domain of the Nursing Interventions Classification (NIC) taxonomy includes care that supports homeostatic regulation?

Domain 2

When can a primigravida fetal heartbeat be heard for the first time?

Doppler ultrasound at 10 to 12 weeks

A client receiving peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution. Which action would the nurse take?

Drain the fluid from the peritoneal cavity.

Which dietary changes would the nurse suggest to the client with diarrhea associated with human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct.

Eat much less roughage Drink plenty of fluids between meals."

A client with a renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions would the nurse undertake before the procedure? Select all that apply. One, some, or all responses may be correct.

Ensure that the consent form has been signed. Assess the client for iodine sensitivity. Administer an enema or cathartic to the client.

A health care provider prescribes bed rest, loperamide, and esomeprazole for a client who just had major surgery. After several days of this regimen, the client complains of diarrhea. Which treatment strategy would the nurse conclude is the cause of the diarrhea?

Esomeprazole

During a regular checkup, a pregnant client reports constipation. Which strategies would the nurse recommend? Select all that apply. One, some, or all responses may be correct.

Exercise regularly Add a few tablespoons of wheat bran to cereal at breakfast. Increase the intake of whole grains

The nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be cool, tender to touch, with edema of 15.2 cm (1-6 inches) at the site of catheterization. Which condition would the nurse suspect?

Infiltration

Which serum blood level would the nurse expect to be decreased in a client with a diagnosis of hyperparathyroidism?

Phosphorus

A registered nurse is teaching a nursing student about the third heart sound (S3). Which statement given by the nursing student is incorrect?

S3 is normal in pregnant women. The third heart sound (S3) can be heard when the heart attempts to fill an already distended ventricle. This sound may be common and normal in the last stages of pregnancy but not in all stages. This sound may be heard in heart failure clients. The S3 sound is abnormal in adults over the age of 31. This sound is normally heard in children and young adults.

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?

Saline irrigation

Which is a sensory simulation strategy a laboring client can use as a nonpharmacological strategy for pain management?

Selecting a focal point and beginning breathing techniques

Which information would the nurse include in response to a client's questioning a protein-restricted dietary change required for his or her acute kidney injury?

This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys."

Which medication increases the risk of hematuria?

Warfarin

Which is the recommended size of the urinary catheter that can be used in a 3-year-old child?

the recommended size of a urinary catheter that can be used in a 3-year-old child is 8 to 10 Fr. A urinary catheter of 5 to 6 Fr is generally used in infants. A length of 14 to 16 Fr is recommended for most adult clients. A length of 16 to 18 Fr is commonly used in adult males.

Celsius is converted (39 C)

to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.

Which nursing theory is the inspiration for self-care?

Orem's theory

A primigravida who is at 40 weeks' gestation arrives at the birthing center with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal heart rate and maternal vital signs?

Provide the client with comfort measures for relaxation

Which statement regarding Roy's theory of nursing needs correction?

The Roy adaptation model views the environment as an adaptive system. The Roy adaptation model views the client as an adaptive system. The need for nursing care occurs when a client cannot adapt to internal and external environmental demands. Roy's model believes the goal of nursing is to help a client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. All individuals must adapt to the following demands: meeting basic physiological needs, developing a positive self-concept, performing social roles, and achieving a balance between dependence and independence.

Which characteristic of a comminuted fracture would the nurse consider when planning care for a client with a fractured arm?

The bone has broken into fragments, and the skin is intact.

Which represents a significant shift in U.S. health policy in recent years?

There is a focus on better managing clients with multiple chronic conditions.

Which rational supports administering the medication pregabalin to a client with acquired immunodeficiency syndrome (AIDS)?

To reduce neuropathic pain

While assessing a client who sustained a road traffic accident, the nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected?

Trigeminal nerve

During an assessment, the nurse suspects a client is in the primary stage of syphilis. Which findings support the nurse's conclusion? Select all that apply. One, some, or all responses may be correct.

Ulcers on the hands and lips Firm and enlarged lymph nodes

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

Urine negative for ketones and positive glucose in the blood

Which food would the nurse recommend for a child who is at risk for developing rickets?

Yogurt for vitamin D

A client develops steatorrhea with malabsorption syndrome. How will the nurse document this finding in the client's medical record?

bulky foul smelling

Which suggestion would the nurse make to a client with morning sickness?

"Eat dry crackers before you get out of bed."

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which medication will the nurse expect the health care provider to prescribe?

Calcium

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and has hypovolemic shock. Which site(s) would be used to obtain the client's pulse rate? Select all that apply. One, some, or all responses may be correct.

Carotid Femoral

Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction?

Effleurage

Which action would the nurse take to prevent knee deformities in a client who has an exacerbation of arthritis? Select all that apply. One, some, or all responses may be correct.

Encourage motion of the joint Maintain joints in functional alignment when resting

When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client?

Heart muscle ischemia

A teenager with a diagnosis of osteosarcoma is to have the affected leg amputated. Which should promote psychological adjustment and early function immediately after surgery?

Help the client adjust to the temporary prosthesis.

Which action is characteristic of the hormone vasopressin?

Helps produce concentrated urine

Which manifestations are exhibited with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)?

Hyponatremia and decreased urine output

Which category would the error fall when the nurse makes a nursing diagnosis without validating data obtained from the client?

Labeling

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding?

"I should apply powders or talc on a perineum wound."

The nurse is assessing a school-age child who suffers from encopresis. Which advice provides effective treatment for this condition? Select all that apply. One, some, or all responses may be correct.

"You should drink lots of fluid. You should include cereals in your diet." "You should eat fresh fruit for breakfast."

The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning?

Banana

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction?

Circulating nurse

A client who has severe back pain is found to have a vertebral compression fracture. Which cause of fracture would the nurse consider when planning interventions?

Collapse of the vertebral bodies

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietitian and walking for 45 minutes daily for the past 8 months. Which would the nurse document the client's stage based on the transtheoretical model of health behavior change?

Maintenance (after 6 months) *Action is before 6 months

Which assessment finding by the nurse indicates that the treatment for a client with cor pulmonale has been effective?

Decreased peripheral edema

A client is admitted to the postanesthesia care unit after abdominal hysterectomy. Which assessment would the nurse report to the primary health care provider immediately?

Decreased urine output

A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give?

Inadequate oxygenation of the myocardium

After a newborn has skin-to-skin contact with the mother, the nurse places the newborn under a radiant warmer. Which complication is the nurse attempting to prevent?

Metabolic acidosis

The nurse is obtaining a health history from a client with endometriosis. Which consequences can occur as a result of this disorder? Select all that apply. One, some, or all responses may be correct.

Metrorrhagia Impaired fertility Bowel strictures Voiding difficulties *Not MENOPAUSE

The nurse caring for a client with a nasogastric tube after gastric surgery would anticipate performing which action?

Monitor for signs of electrolyte imbalance

The nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor

The nurse understands that megestrol is most often used to treat which issue?

Palliative management of cancer

The nurse suspects that a client has a distended bladder. Which method is correct to assess for this condition?

Percuss and palpate in the hypogastric region.

hich position would help the client who has an above-the-knee amputation prevent a contracture?

Prone

Which verbalization by the parents of a child who has cystic fibrosis (CF) provides evidence that they understand the child's dietary needs?

Provide high-calorie foods between meals

A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and having experienced 10 liquid bowel movements in the past 24 hours. The nurse suspects that the client is dehydrated based on which assessment findings? Select all that apply. One, some, or all responses may be correct.

Sunken eyes Dry mucous membranes

Which statement will the nurse include when teaching the family of a child with asthma about peak flow meters (PFMs)?

"A PFM can help you identify when asthma is getting worse even before your child has symptoms."

The registered nurse (RN) is teaching new nurses how to obtain assessment information while introducing themselves to clients who have nervous system disorders. Which statement made by a new nurse indicates the need for further learning about this assessment? Select all that apply. One, some, or all responses may be correct.

"I should wait to assess the speech of the client until later." "I should ask to observe the client's ability to perform hand hygiene."

The nurse is performing a skin assessment of a client. Which findings may indicate a risk of skin cancer? Select all that apply. One, some, or all responses may be correct.

Lesion Lumps Rashes

The nurse assessed a client who experienced a recent brain attack (stroke) and has a residual right-sided hemiplegia. Which rationale explains the importance of the nurse identifying mobility restrictions or neuromuscular abnormalities when assessing this client?

Shortening and eventual atrophy of the affected muscles will occur.

Which surgery is used as a prophylactic measure and as a palliative treatment for clients with rheumatoid arthritis (RA)?

Synovectomy

While assessing a newborn, the nurse notes that the infant's skin is mottled. Which would the nurse's primary intervention be?

Warm the environment Mottling results from hypothermia; the newborn should be wrapped, placed under a radiant warmer, or given to the mother for skin-to-skin contact. Mottling is a phenomenon that usually indicates a decreasing temperature; the newborn requires warming, not oxygenation or medical attention. Feeding will not increase the newborn's temperature.

Which interventions are appropriate for the client brought to the hospital with heat exhaustion? Select all that apply. One, some, or all responses may be correct.

0.9% normal saline intravenously (IV) Placing a moist sheet over the client Initial fluid bolus to correct hypotension Placing in a cold area and removing constrictive clothing

Which assessment finding would the nurse recognize as needing further evaluation during a head-to-toe assessment of a newborn?

Head circumference 30 cm, chest circumference 34 cm the head circumference should exceed the chest circumference. This could be an indication of microcephaly. When the nurse evaluates the eye with an ophthalmoscope, the retina should appear as a red circle, called the red reflex. Vital signs are normal, and the ear placement is normal.

Which etiologies would the nurse associate with a client who has the skin disorder telangiectasia? Select all that apply. One, some, or all responses may be correct.

Liver failure Sun exposure

Which clients would be eligible for Medicare coverage? Select all that apply. One, some, or all responses may be correct. One, some, or all responses may be correct.

A 67-year-old man with pneumonia A 40-year-old physically handicapped man A 75-year-old woman with end-stage renal failure Medicare is a federal health insurance program that provides health care coverage for all people who are 65 years of age and older, people who are permanently disabled, and individuals with end-stage renal disease. The 67-year-old man with pneumonia, the 40-year-old physically handicapped man, and the 75-year-old woman with end-stage renal failure would be eligible for Medicare coverage. The 50-year-old sales executive with a leg fracture and the 30-year-old irregularly employed woman with appendicitis do not fall into the Medicare category because of their ages and the nature of their conditions.