HESI PLAN A -Reduce Risk Potenital

Which explanation would the nurse provide to a client who asks about the procedure for arthroscopic knee surgery? A) "It is surgical repair of a joint using a device with a tiny video camera." B) "Dye is injected to help diagnose the extent of the injury." C) "The procedure will determine the type of treatments to be prescribed." D) "Anesthesia is used so that you would not remember anything about the procedure."

A) "It is surgical repair of a joint using a device with a tiny video camera." Rationale: The response "It is surgical repair of a joint using a device with a tiny video camera attached" describes the procedure for arthroscopic surgery.

An indirect Coombs' test is performed on a pregnant Rh-negative client to predict fetal risk for which disorder? A) Acute hemolytic anemia B) Respiratory distress syndrome (RDS) C) Protein metabolism deficiency D) Physiological hyperbilirubinemia

A) Acute hemolytic anemia

The registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning? A) Administering sodium polystyrene sulfonate B) Instructing a client to increase potassium and sodium intake C) Monitoring glucose levels hourly D) Providing potassium-sparing diuretics

A) Administering sodium polystyrene sulfonate

When assessing a client's forearm for a potential intravenous (IV) catheter insertion site, the nurse notes that the client has an excessive amount of hair. Which action would the nurse take to properly prepare the site for insertion? A) Clip the hair. B) Shave the area. C) Apply a securement device. D) Prepare the skin with a protectant solution.

A) Clip the hair Rationale: Excessive hair should be clipped. Skin should never be shaved before venipuncture. Shaving can cause microabrasions that can lead to infection. The use of a securement device such as StatLock can be used also; however, it will not adhere if there is excessive hair. Skin protectant can be used; however, with excess hair, the tape or dressing used to cover the insertion will not adhere

Which action would the nurse include in the plan of care for a client after pelvic surgery? A) Encouraging the client to ambulate in the hallway B) Elevating the client's legs by raising the bed's knee support C) Providing passive range of motion to the client's legs D) Maintaining the client on bed rest until the bandages are removed

A) Encouraging the client to ambulate in the hallway

Which would the school nurse's first action be when a child reports a sore throat? A) Examine the throat. B) Have the child sent home. C) Take the child's temperature. D) Secure a prescription for an oral analgesic.

A) Examine the throat. Rationale: The priority is to assess the throat to determine the extent of inflammation. Significant swelling can create the potential for airway obstruction. Assessment of the child's problem must be done before initiating any other actions.

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries? A) Incontinence; inability to move independently. b) Periodic diaphoresis; occasional sliding down in bed. c) Minimal reaction to painful stimuli; receiving tube feedings. d) Spending extensive time in a chair; body mass index (BMI) of 23.

A) Incontinence; inability to move independently. Rationale: Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure injuries.

Which action would the nurse include in the plan of care for a client with ascites who is scheduled to have a paracentesis? A) Instruct the client to urinate before the procedure. B) Shave hair around and 2 to 3 inches (5-7.5 cm) beyond the puncture site. C) Position the client on the side with the hips and knees flexed. D)Measure the abdominal girth two fingerbreadths below the umbilicus.

A) Instruct the client to urinate before the procedure. Rationale: The bladder should be empty to prevent injury during insertion of the trocar. Shaving the hair from the needle insertion site is not necessary.

A client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. Which action would the nurse plan to take? A) Perform a neurovascular assessment of the extremity. B) Reassure the client that these injuries are not that serious. C) Gather equipment needed for the application of skeletal traction. D) Prepare the client for a surgical reduction of the injured extremity.

A) Perform a neurovascular assessment of the extremity.

The nurse is measuring the blood pressure of toddlers. Which blood pressure finding is the nurse most often to find in the toddlers? A) 85/54 mm Hg B) 95/65 mm Hg C) 105/65 mm Hg D) 110/65 mm Hg

B) 95/65 mm Hg

Which client with complications of fracture would the nurse expect may be treated with a fasciotomy?

B) Compartment syndrome

After reviewing the laboratory hormonal profile for four clients, the nurse anticipates which client will need an evaluation for ovarian cancer? A) Progesterone B) Estradiol C) Prolactin D) Luteinizing Hormone

B) Estradiol

Which findings occur with orthostatic hypotension? Select all that apply. A) Reflex tachycardia B) Feeling of faintness C) Increased cardiac output D) Increased diastolic pressure E) Decreased systolic pressure

B) Feeling of faintness E) Decreased systolic pressure

Early in the ninth month of pregnancy a client experiences painless vaginal bleeding secondary to a placenta previa. Which intervention would the client's plan of care include? A) Giving vitamin K to promote clotting. B) Performing a rectal examination to assess cervical dilation. C) Administering an enema to prevent contamination during birth. D) Placing the client in the semi-Fowler position to increase cervical pressure.

D) Placing the client in the semi-Fowler position to increase cervical pressure. Rationale: Placing the client in the semi-Fowler position forces the heavy uterus to put pressure on the blood vessels at the site of the separating placenta, controlling bleeding to some extent.

A client is admitted to the hospital for a thyroidectomy. In which position should the nurse maintain the client after this surgery? A) Prone B) Supine C) Left Sims D) Semi-Fowler

D) Semi-Fowler

Which is the priority information for the nurse to include in discharge instructions to the parents of a child who has undergone surgical correction of hypospadias? A) Ensuring that the child's privacy is maintained B) Increasing the time that the catheter is clamped C) Maintaining the surgically implanted tension device D) Teaching parents how to care for the catheterization system

D) Teaching parents how to care for the catheterization system

A client had a resection of an aldosterone-secreting tumor of an adrenal gland and says to the nurse, "It will be good for me to return to work soon." Based on an understanding of the problem, how would the nurse respond? A) Caution the client about high expectations because the prognosis is variable; the outcome depends on many factors. B) Advise the client to prepare to apply for permanent disability. C) Advise the client to investigate other occupational alternatives if the client wishes to stay in the workforce. D) Tell the client that returning to work is possible if the client takes prescribed hormone supplements.

D) Tell the client that returning to work is possible if the client takes prescribed hormone supplements. Rationale: Surgery is most often performed by laparoscopic procedure. The body has two adrenal glands; an aldosteronoma is a unilateral tumor. The prognosis usually is excellent. The client should be able to return to normal activities and work; however, the client will be receiving hormone replacement until the remaining adrenal gland can produce an adequate amount of hormone. Hormone therapy could last up to 2 years.

Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma? A) Home oxygen therapy B) Antibiotic treatment c) Incentive spirometer use D) Use of peak flow meter

D) Use of peak flow meter

The nurse is conducting discharge teaching with an adolescent with hemophilia. Which statement by the client indicates a need for further teaching? A) "I'll use a straight razor when I start shaving." B) "I plan on trying out for the swim team next year." C) "If I injure a joint, I'll keep it still, elevate it, and apply ice." D) "If I get a little scratch, I can apply gentle pressure for 10 to 15 minutes."

A) "I'll use a straight razor when I start shaving." Rationale: A straight razor should not be used by the adolescent with hemophilia, so further teaching is required. The adolescent with hemophilia should be taught to use an electric razor for shaving. Contact sports should be avoided, but swimming is a recommended activity, so trying out for the swim team indicates that the adolescent understands the teaching. If a superficial injury occurs, gentle, prolonged pressure should be applied until the bleeding has stopped. If a muscle or joint injury occurs, the area should be immobilized, elevated, and iced. Both statements indicate that the adolescent has understood the teaching.

Which steps would the nurse take to measure the temperature of a 4-year-old child using an electronic infrared thermometer? Select all that apply. A) Pull the pinna up and out. B) Pull the pinna down and back. C) Avoid applying pressure to the ejection button. D) Obtain the temperature from client's right ear if the nurse is right-handed. E) Rapidly remove the probe from the ear canal.

A) Pull the pinna up and out. C) Avoid applying pressure to the ejection button. D) Obtain the temperature from client's right ear if the nurse is right-handed. Rationale: The nurse would pull the pinna up and out for a child of 4 years of age. The nurse would be careful not to apply pressure to the ejection button. If the nurse is right-handed, the temperature is measured from the child's right ear. When obtaining the temperature of a child less than 3 years of age, the nurse would pull the pinna down and back to measure body temperature. The nurse would remove the probe after the temperature measurement is displayed, typically after 1 to 2 seconds

Which dietary choices by a client with iron deficiency anemia indicate that the nurse's dietary teaching has been effective? Select all that apply. A) Scrambled eggs B) Baked potato C) Steamed carrots D) Spinach salad E) Dried apricots F) Sliced oranges

A) Scrambled eggs B) Baked potato D) Spinach salad E) Dried apricots Rationale: Eggs, potatoes, dark green vegetables such as spinach, and dried apricots are high in iron.

The parents of a 4-year-old child call and report that their child has a fever of 102.6°F (39.2°C), is complaining of a sore throat, and will not lie down, preferring to sit up and lean forward. The child is drooling and looks ill and agitated. Which guidance would the nurse provide this family? A) The child needs immediate medical attention; call 911. B) The parents should provide cool mist and continue to give fluids to the child. C) The child should receive ibuprofen in an appropriate dose to decrease the fever. D) The parents should call back in several hours and update the health center on the child's condition.

A) The child needs immediate medical attention; call 911.

Which statement describes a client's tidal volume? A) Tidal volume is the volume of air inhaled and exhaled with each breath. B) Tidal volume is the amount of air remaining in the lungs after forced expiration. c) Tidal volume is the additional air forcefully inhaled after normal inhalation. D) Tidal volume is the additional air forcefully exhaled after normal exhalation.

A) Tidal volume is the volume of air inhaled and exhaled with each breath. Rationale: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.

Which blood gas value would the nurse expect in a ventilated client with an air leak and suspected alveolar hypoventilation? A) pH of 7.32 B) Po 2 of 95 mm Hg C) Pco 2 of 30 mm Hg D) HCO 3- of 20 mEq/L (20 mmol/L)

A) pH of 7.32 Rationale: Respiratory acidosis is expected. A pH of 7.32 is below the expected range of 7.35 to 7.45; hypoxia causes hypercapnia, resulting in a decreased pH

A client is admitted to the hospital for the surgical repair of an incarcerated indirect inguinal hernia. Which is the priority preoperative nursing intervention for this client? A) Placing the client in the supine position. B) Observing the client's bowel movements. C) Monitoring the client's serum enzyme levels. D) Teaching the client about the need to cough postoperatively

B) Observing the client's bowel movements. Rationale: A possible complication of a hernia is intestinal obstruction; if an obstruction occurs, there is no passage of flatus or regular bowel movements. The supine position has no effect on an incarcerated hernia. Monitoring serum enzyme levels is done for all clients; it is not specific for a client with a hernia. Coughing is contraindicated because it places stress on the operative site.

Which action would the nurse take when using pulse oximetry to determine a toddler's oxygen saturation? A) Using a single-use (tape-on) probe B) Placing the sensor probe on the finger C) Placing the sensor probe on the bridge of the nose D) Turning on the pulse oximeter before placing the sensor

B) Placing the sensor probe on the finger

When the home health nurse is making a home visit to a client who had laryngectomy 3 weeks previously and the client's laryngectomy tube becomes dislodged, which action would the nurse take? A) Notify the health care provider immediately. B) Reinsert another tube into the stoma. C) Place a sterile gauze pad over the stoma. D) Ventilate the client using a bag-valve-mask system.

B) Reinsert another tube into the stoma.

The school nurse recommends suitable physical activity for a child with exercise-induced asthma. Which statement by a parent indicates the need for additional teaching? A) "I'll sign him up for swimming lessons." B) "She'd really enjoy being on a bowling team." C) "I'll encourage him to join a youth running club." D) "I know she'd enjoy going to the gym and lifting weights."

C) "I'll encourage him to join a youth running club." Rationale: Exercise-induced asthma is triggered by rapid mouth breathing of large volumes of dry, cool air, so running increases the risk for an attack. Recommended exercises for people with asthma include swimming, weight lifting, and similar activities that do not necessitate rapid breathing through the mouth.

At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. Which Apgar score would the nurse assign? A) 6 B) 7 C) 8 D) 9

C) 8 Rationale: The Apgar score is 8; 1 point is deducted for diminished muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which manifests as bluish hands and feet. Scores of 6 and 7 are too low and a score of 9 is too high.

When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? A) CXR B) Thoracic ultrasound C) CT D) MRI

C) CT

Which class of clients during a mass casualty situation would the nurse refer to as the "walking wounded"? A) Class I B) Class II C) Class III D) Class IV

C) Class III

Twenty-four hours after a penile implant, the client's scrotum is edematous and painful. Which action would the nurse take? A) Assist the client with a sitz bath. B) Apply warm soaks to the scrotum. C) Elevate the scrotum using a soft support. D) Prepare for an incision and drainage procedure.

C) Elevate the scrotum using a soft support.

Which is the priority nursing action for a school-aged child admitted for surgery? A) Allowing a favorite toy to remain with the child. B) Documenting the child's antistreptolysin O (ASO) titer and C-reactive protein (CRP) level. C) Inspecting the child's mouth for loose teeth and reporting the findings. D) Encouraging a parent to stay until the child leaves for the operating room

C) Inspecting the child's mouth for loose teeth and reporting the findings. Rationale: School-aged children lose their primary teeth, which may be aspirated during surgery. Special precautions must be taken to maintain safety. Allowing a favorite toy to remain with the child is a comforting gesture, but it is not essential. There is no reason to obtain an ASO titer or a CRP level. Encouraging a parent to stay until the child leaves for the operating room is important but not always possible

When the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take? A) Administer the scheduled dose of warfarin. B) Offer the client foods that are high in vitamin K. C) Notify the health care provider of the laboratory results. D) Warn the client about risk for spontaneous hemorrhage.

C) Notify the health care provider of the laboratory results. Rationale: The therapeutic level for INR when treating a venous thrombosis is 2 to 3, so the nurse would notify the health care provider and anticipate a decrease in warfarin dosage. Administration of a scheduled warfarin dose would further increase the INR. Although vitamin K can decrease warfarin effectiveness, dietary vitamin K is not used to reverse high INR levels. Although higher INR levels may lead to spontaneous bleeding, an INR of 4.6 would not cause hemorrhage.

The nurse teaches a client who is about to undergo an amniocentesis that ultrasonography will be performed just before the procedure to determine which? A) Gestational age of the fetus B) Amount of fluid in the amniotic sac C) Position of the fetus and the placenta D) Location of the umbilical cord and placenta

C) Position of the fetus and the placenta

Which area of assessment is included in the Glasgow Coma Scale? A) Breathing patterns B) Deep tendon reflexes C) Eye accommodation to light D) Response to verbal commands

C) Response to verbal commands

The nurse finds the orders from the primary health care provider inappropriate. Clarification from the health care provider does not resolve the nurse's doubts. Whom would the nurse contact and inform next? A) Risk manager B) Nursing student C) Supervising nurse D) Nurse administrator

C) Supervising Nurse

The primary health care provider instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving? A) Palliative care B) Comfort care C) Supportive care D) End-of-life care

C) Supportive care

To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply. A) Monitor for signs of alopecia. B) Encourage an increase in fluids. C) Wash hands before entering the client's room. D) Advise use of a soft toothbrush for oral hygiene. E) Report an elevation in temperature immediately. F) Teach the client to avoid eating raw fruits and vegs.

C) Wash hands before entering the client's room. D) Advise use of a soft toothbrush for oral hygiene. E) Report an elevation in temperature immediately. Rationale: Bone marrow depression causes neutropenia; it is essential to prevent infection in this client by thorough hand washing before touching the client or client's belongings. Thrombocytopenia occurs with chemotherapy-induced bone marrow depression; using a soft toothbrush helps prevent bleeding gums. Any temperature elevation in a client with neutropenia must be reported to the primary health care provider immediately because it may be a sign of infection

Client 1 Creatine 0.1mg/dl BUN 16mg/dl Client 2 Creatine 0.8mg/dl BUN 18mg/dl Client 3 Creatine 1.2mg/dl BUN 20mg/dl Client 4 Creatine 1.9mg/dl BUN 22mg/dl

Client 4 Rationale: Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys. If the kidneys are not able to remove urea from the blood normally, the blood urea nitrogen (BUN) level rise

Which urine specific gravity level is abnormal? A) 1.006 B) 1.012 C) 1.028 D) 1.041

D) 1.041 Rationale: The normal specific gravity of urine lies between 1.005 and 1.030. A specific gravity value of 1.041 is higher than the normal range; therefore it's abnormal. The specific gravity values of urine such as 1.006, 1.012, and 1.028 lie in the normal range.

A client is admitted to the hospital after 2 days of painful abdominal spasms and severe diarrhea. Which appropriate sequence does the nurse use to examine the client's abdomen starting with inspection? A) Percussion, palpation, auscultation B) Palpation, percussion, auscultation C) Auscultation, palpation, percussion D) Auscultation, percussion, palpation

D) Auscultation, percussion, palpation Rationale: Auscultation must be performed before percussion and palpation because they may influence intestinal peristalsis and give inaccurate results. Percussion is performed before palpation because palpation can cause pain. Percussion or palpation performed before auscultation may result in an inaccurate assessment of bowel sounds

Which instruction is important for the nurse to provide to the client after cataract surgery? A) Remain flat for 3 hours B) Eat a soft diet for 2 days C) Breathe and cough deeply D) Avoid bending from the waist

D) Avoid bending from the waist

Which arterial blood gas (ABG) value would indicate diabetic ketoacidosis? A) Increased pH B) Decreased Po 2 C) Increased Pco 2 D) Decreased HCO 3

D) Decreased HCO 3 Rationale: The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids; in metabolic acidosis, there is a decrease in bicarbonate because of an increase of metabolic acids. The pH is decreased. The Po 2 is not decreased in diabetic acidosis. The Pco 2 may be decreased by the body's attempt to eliminate CO 2 to compensate for a decreased pH.

A client with palpitations who is admitted to telemetry for observation, asks the nurse for a cup of coffee. Which is the nurse's best response? A) Bring the client a cup of decaffeinated coffee. B) Offer to bring the client a cup of hot tea instead. C) Tell the client that caffeinated drinks are not permitted on the telemetry unit. D) Educate the client about the effect of caffeine on the heart's conduction system.

D) Educate the client about the effect of caffeine on the heart's conduction system

A client with palpitations who is admitted to telemetry for observation, asks the nurse for a cup of coffee. Which is the nurse's best response? A) Bring the client a cup of decaffeinated coffee. B) Offer to bring the client a cup of hot tea instead. C) Tell the client that caffeinated drinks are not permitted on the telemetry unit. D) Educate the client about the effect of caffeine on the heart's conduction system.

D) Educate the client about the effect of caffeine on the heart's conduction system.

When checking the reflexes of a newborn born vaginally in the breech presentation, the nurse is unable to elicit a specific reflex response. The absence of this reflex is not uncommon in neonates born with this presentation. How would the nurse attempt to elicit this response? A) Moving the thumb along the sole of the foot B) Stroking the ulnar surface of the hand and fifth finger lightly C) Touching the skinfold of the mouth and cheek on the same side D) Holding the infant in the upright position while pressing the feet flat on the crib mattress

D) Holding the infant in the upright position while pressing the feet flat on the crib mattress Rationale: Holding the infant in the upright position while pressing the feet flat on the crib mattress elicits the stepping response, which is absent when paresis is present and in neonates born vaginally in the breech presentation.

A client fears pregnancy despite the use of oral contraceptives. The nurse anticipates that which blood test will be prescribed? A) Prolactin test B) Testosterone test C) Progesterone test D) Human chorionic gonadotropin (hCG) test

D) Human chorionic gonadotropin (hCG) test Rationale: A human chorionic gonadotropin (hCG) test is used to detect pregnancy; therefore the primary health care provider orders an hCG test for the client. A prolactin test is used to detect amenorrhea. A testosterone test is used to determine ovarian dysfunction. A progesterone test is used to determine the occurrence of ovulation.

Under which conditions would the nurse cut away all the client's clothing? Select all that apply. A) When ambulating a client B) When cervical spine protection is needed C) If client is suffering from a simple fracture D) It fabric may fuse to the client's skin because of burns E) If rapid access to the client's body is critical for resuscitation

D) It fabric may fuse to the client's skin because of burns E) If rapid access to the client's body is critical for resuscitation Rationale: The nurse would cut away clothing with scissors when the fabric is fused to the client's body as a result of thermal or chemical burns. The nurse would cut the clothing when there is a requirement to access the client's body rapidly to begin the resuscitation process. There is no requirement to cut away clothing when ambulation is required or protection of cervical spine is needed. The nurse does not have to cut away clothing in case of a simple fracture.

Which expected surgical outcome would the nurse include in the preoperative teaching for a client scheduled for a labyrinthectomy to treat Meniere syndrome? A) Absence of pain B) Decreased cerumen C) Loss of sense of smell D) Permanent irreversible deafness

D) Permanent irreversible deafness