HESI mid-circular practice

A client is recently diagnosed with an oral cancerous lesion. Which question should the nurse ask when assessing the client's need for instruction in relation to this condition?

"Have you noticed any change in your appetite?" Problems involving the oral cavity often result in nutritional problems and weight loss needing nursing intervention. The question, "Have you noticed any change in your appetite?" will elicit more information. The nurse needs to determine a client's past and current appetite and nutritional status.

Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply.

Facial and trigeminal

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority?

Institute fall prevention/safety measures. The high ammonia levels contribute to deterioration of mental function and then to hepatic encephalopathy and hepatic coma; safety is the priority.

A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. What nursing action is most important when caring for this client?

Turn the client onto the side The side-lying position promotes drainage of emesis and secretions from the mouth, reducing the risk of aspiration. Although accurate assessment of intake and output is important, prevention of aspiration is the priority. Dehiscence is not probable at this time; it is more common five to seven days after surgery. Although the antiemetic may prevent additional vomiting, the nurse's priority is to prevent aspiration.

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching?

"I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." Although most people defecate after breakfast because ingestion of food on an empty stomach initiates the gastrocolic reflex, not all people defecate at this time. Irrigation should be performed at the time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Irrigations should be performed at the same time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Clients can eat before irrigating the colostomy. An irrigation cannot be postponed until the client accepts the altered body image, because this may take weeks or months.

A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The healthcare provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client?

Antimicrobial administration Preventing infection through the use of prophylactic antibiotics is the priority. Tearing the meninges may have introduced infectious organisms

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take?

Assess the client's airway Ensuring an airway is the first action in an emergency response to any client.

A client who had a gastric resection for cancer of the stomach is admitted to the postanesthesia care unit with a nasogastric (NG) tube. Which symptom should the nurse expect to observe?

Bright red bloody drainage in the suction container Drainage is bright red initially and gradually becomes darker red during the first 24 hours. If the nasogastric tube is functioning correctly, secretions will be removed, and vomiting will not occur. Because the bowel was emptied before surgery and the client is now nothing by mouth, intestinal activity is not expected. If the nasogastric tube is functioning correctly, gastric distention will not occur.

After surgery for cancer of the pancreas, the client's nutrition and fluid regimen are influenced by the remaining amount of functioning pancreatic tissue. The nurse considers both the exocrine and the endocrine functions of the pancreas and expects that, postoperatively, the client's dietary regimen will be focused on the management of what substances?

Fats and carbohydrates Formation of lipase necessary for digestion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism.

The nurse is caring for a client with peritonitis who had surgery two hours ago due to a ruptured appendix. Which clinical findings should the nurse expect to observe when assessing this client? Select all that apply.

Fever, Urinary retention, abdominal muscle rigidity The nurse is assessing a client with peritonitis who is also recovering from surgery that occurred two hours ago for a ruptured appendix. The nurse should expect to observe a fever and abdominal muscle rigidity from peritonitis and urinary retention as a complication of surgical anesthesia. A fever is associated with peritoneal membrane inflammation and a moderate fever is also a common post-surgical assessment finding. Abdominal rigidity over the affected area is a classic sign of peritonitis. Malaise, fatigue (not hyperactivity), and nausea (not hunger) are the expected findings with peritonitis and during surgical recovery.

A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. What is the priority nursing intervention?

Focusing on daily activities while avoiding discussion of the eye discomfort The client's eye problems are a conversion reaction. Avoiding discussion of the physical problems prevents the client from using this topic to avoid an exploration of feelings. Focusing on the safe topic of activities may eventually progress to a discussion of emotion-laden topics such as feelings.

A client with ascites has been scheduled for a paracentesis. What intervention should the nurse implement immediately before the procedure?

Instruct the client to void The bladder should be empty to avoid injury during insertion of the abdominal trocar. The upright position is preferred to allow accumulation of fluid in the lower abdomen by gravity. Although regular monitoring of girth is important, it is not necessary immediately before paracentesis. Having the client drink a glass of water is unrelated to the procedure; however, it is preferable to offer fluids after the procedure if permitted by the healthcare provider.

A client who has been immobilized for an extended period of time questions why the tilt table is being used. What is the nurse's best explanation of the tilt table's function?

It prevents loss of calcium from the long bones Calcium leaves the long bones during periods of prolonged bed rest. The tilt table places the client in an upright position, which provides for weight bearing.

A nurse is assisting a healthcare provider to perform a sigmoidoscopy. In which position should the nurse place the client for this procedure?

Knee-chest position Knee-chest position maximally exposes the rectal area and facilitates entry of the sigmoidoscope.

client with narcolepsy tells the primary healthcare provider, "I often feel drowsy and fall asleep at inappropriate times." Which medication should the nurse anticipate being prescribed by the primary healthcare provider for this client?

Modafinil Drowsiness and an inability to remain awake while performing activities are signs of narcolepsy. Modafinil is a drug used to promote wakefulness and combat narcolepsy.

The nurse is reviewing the plan of care to prevent contractures of the joints of the lower extremities in a client with paraplegia. The nurse should question which item that is listed on the plan?

Provide the client with active lower-extremity exercise instructions The paraplegic client is unable to exercise the lower extremities actively because the client is paralyzed from the waist down

A nurse is caring for a client who recently is diagnosed with a gastric ulcer. The nurse expects that the plan of care will include a prescription for which type of diet?

Regular diet with foods that are tolerated No specific diet is recommended; the client is encouraged to avoid meals that overdistend the stomach and foods that cause gastrointestinal (GI) distress. There is no need for a soft diet; a soft diet is appropriate for those who have difficulty with chewing and swallowing. The client does not require a liquid diet. High-fat dairy products increase GI secretions and may not be tolerated by some clients.

The nurse is caring for a client one hour after the client had esophageal surgery. Which assessment is the priority for this client?

Respiratory assessment Because of the trauma of surgery and the proximity of the esophagus to the trachea, respiratory assessments become the priority. Although assessment of the incision, determining the level of pain, and monitoring the client's nasogastric tube are important, an adequate airway is the priority.

A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. What should the nurse identify is the function of the gallbladder when providing preoperative teaching?

Stores and concentrates bile The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.

A client who is having presurgical testing before a colon resection and possible colostomy says to the nurse, "If I have to have this surgery, I know my partner will never come near me." What would be the nurse's best initial response?

"You seem worried that the surgery will change how your partner sees you." "You seem worried that the surgery will change how your partner sees you" is an open-ended response that encourages further discussion.

A client has a mean arterial blood pressure (MAP) of 97 mmHg and an intracranial pressure (ICP) of 12 mmHg. What is the cerebral perfusion pressure (CPP) for this client? Record your answer using a whole number.__________ mmHg

85 mmHg The cerebral perfusion pressure (CPP) can be calculated by the following equation: CPP=MAP - ICP. If the mean arterial blood pressure (MAP) is 97 mmHg and intracranial pressure (ICP) is 12 mmHg, the CPP is 85 mmHg.

After a subtotal gastrectomy a client demonstrates signs of dumping syndrome. About 90 minutes after the initial attack, the client reports feeling shaky. What does the nurse determine is the cause of the latter effect?

An overproduction of insulin that occurs in response to the rise in blood glucose The rapid absorption of carbohydrates from the food mass causes an elevation of blood glucose, and the insulin response often causes transient hypoglycemic symptoms. The elevation in insulin usually occurs 90 minutes to 3 hours after eating and is known as late dumping syndrome. The physiological adaptations related to late dumping syndrome are caused by an increase in insulin, not glucose. The insulin-adjusting mechanism is not overwhelmed but responds vigorously, causing rebound hypoglycemia. Dumping syndrome is related to the high glucose content of food, not the amount of food, entering the duodenum.

A nurse is caring for a client who had a subtotal gastrectomy. Which assessment finding indicates the client is ready for postoperative oral feedings?

Presence of flatulence Bowel sounds and flatulence indicate the return of intestinal peristalsis; peristalsis is necessary for movement of nutrients through the gastrointestinal (GI) tract. Incisional pain is unrelated to intestinal peristalsis. Hematocrit levels indicate blood loss, not peristalsis. Dumping syndrome occurs after, not before, the ingestion of food and does not indicate readiness to ingest food.

The nurse is performing an abdominal assessment on a client. Where on the abdomen should the nurse assess for McBurney point?

Right lower quadrant (RLQ) McBurney point is an area of extreme sensitivity in acute appendicitis and located about halfway between the umbilicus and the right iliac crest. Inflammation of the vermiform appendix occurs most often among young adults and is the most common cause of right lower quadrant (RLQ) pain. The appendix usually extends off the proximal cecum of the colon just below the ileocecal valve. Inflammation occurs when the lumen (opening) of the appendix is obstructed (blocked), leading to infection as bacteria invade the wall of the appendix. The point is not located in the RUQ, LUQ, or LLQ.za

The nurse is caring for a client with a 25-year history of excessive alcohol use. Which assessment finding is consistent with the client's history?

A small liver with a rough surface Scar tissue that forms as cirrhosis progresses causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points. The client has cirrhosis, not a liver infection. The liver converts ammonia to urea; therefore, the blood ammonia level increases, not decreases, when the liver fails. A high fever and a generalized rash are adaptations of an infection, not cirrhosis of the liver.

After an acute episode of upper gastrointestinal (GI) bleeding, a client vomits undigested antacids and reports having severe epigastric pain. The nursing assessment reveals an absence of bowel sounds, a pulse rate of 134, and shallow respirations of 32 per minute. In addition to calling the healthcare provider, what is the priority nursing action?

Prepare the client for surgery These symptoms are classic indicators of a perforated ulcer, for which immediate surgery is indicated; this should be anticipated. Although oxygen may be helpful, it is not the priority. The symptoms are more indicative of perforation than of shock, so placing the client in the supine position with legs elevated is not appropriate at this time. Black, tarry stools indicate bleeding, not perforation.