HESI Practice 2

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain?

A 55-year-old woman who has had moderate low back pain for three months.

What action should the nurse implement when adding sterile liquids to a sterile field?

Consider the sterile field contaminated if it becomes wet during the procedure.

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care?

Fluid volume imbalance.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?

Flush the lumen with the saline solution and administer the medication through the lumen.

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first?

Foods and liquids consumed during the past 24 hours.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?

Generativity.

The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation?

Healthcare provider.

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement?

Identify the break in surgical asepsis and provide another set of sterile supplies.

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?

One-inch pressure sore draining serous fluid.

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair?

Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?

Provide warm prune juice before the client goes to bed at night.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted?

Pulse rate decreases from 78 to 52 beats/min.

What action is most important for the nurse to implement when placing a client in the Sim's position?

Raise the bed to a waist-high working level.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take?

Refuse to perform the task that is beyond the nurse's experience.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first?

Reposition the client's arm.

The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care?

Risk for aspiration.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?

Sensory pattern, area, intensity, and nature of the pain.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.)

Snack of potato chips, and diet soda. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. Breakfast of eggs, bacon, toast, and coffee. Bedtime snack of crackers and milk.

While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs?

Speak initially with the oldest family member to show respect.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

The clamp on the urinary drainage bag is open.

Which statement best describes durable power of attorney for health care?

The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.

The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?

The nurse notes that there are numerous scatter rugs throughout the house.

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client?

Use reflective listening techniques when the client expresses spiritual doubts.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan?

Vitamin B12.

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?

Which activities during a routine day are impacted by your pain?

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?

position prone with a small pillow below the diaphragm.

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond?

"I will ask one of the female nurses to bathe you."

What activity should the nurse use in the evaluation phase of the nursing process?

Examine the effectiveness of nursing interventions toward meeting client outcomes.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide?

"It may hurt but we'll give you medicine to help you feel better."

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide?

"It's highly likely that she will recover and return to her pre-illness state."

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time?

"Tell me what you would like to see happen with your children in the future."

When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond?

"What is concerning you this morning?"

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription?

0800, 1200, 1600, 2000.

What client statement indicates to the nurse that the client requires assistance with bathing?

"I don't understand why I'm so weak and tired."

Which technique is most important for the nurse to implement when performing a physical assessment?

A consistent, systematic approach.

What is the rationale for using the nursing process in planning care for clients?

As a tool to organize thinking and clinical decision making about clients' healthcare needs.

A client is demonstrating a positive Chvostek's sign. What action should the nurse take?

Ask the client about numbness or tingling in the hands.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

Ask the client if this decision has been discussed with his healthcare provider.

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement?

Ask the client to relax and run a small amount of fluid into the rectum.

As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement?

Ask the mother to be present to soothe the child.

What action by the nurse demonstrates culturally sensitive care?

Asks permission before touching a client.

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP?

Bend at the knees when lifting heavy objects.

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide?

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use?

Cassette infusion pump.

In evaluating client care, which action should the nurse take first?

Determine if the expected outcomes of care were achieved.

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention?

Determine who is legally empowered to make decisions.

While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first?

Discontinue the administration of the bolus feeding.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?

Accused of diversion.

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises?

Active ROM exercises to both arms and legs two or three times a day.

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction?

Assault and battery with deliberate intent to deviate from the consent form.

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client?

Assist and support the client in establishing short-term goals.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Check capillary refill of toes on lower extremity with Unna's paste boot.

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?

Combination of plant proteins to provide essential amino acids.

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings?

Complains of inability to empty bladder.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?

Continue gabapentin.

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement?

Continue the planned nursing interventions to restore the client's fluid volume.

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next?

Cradle the client's heel.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate?

Evaluate the client's mental status for competence to refuse treatment.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?

Examine one's own culturally based values, beliefs, attitudes, and practices.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first?

Explain that the records are hospital property and may not be removed.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?

Herbs should be obtained from manufacturers with a history of quality control of their supplements.

When caring for an immobile client, what nursing diagnosis has the highest priority?

Impaired gas exchange.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response?

Increase in pulse rate.

Which statement is an example of a correctly written nursing diagnosis statement?

Ineffective coping related to response to positive biopsy test results.

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?

Instruct the client to take slow deep breaths and stop bearing down.

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action?

Locate the perineum.

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first?

Notify family members of the client's condition.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement?

Notify the surgeon that the consent form has not been signed.

How should the nurse handle linens that are soiled with incontinent feces?

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter?

Obtain a prescription for removal of the catheter as soon as possible.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.)

Pre-medicate the client with an analgesic. Inform the client of the plan for moving to the chair. Ask the client to push the IV pole to the chair. Assess the client's blood pressure.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?

Respiratory rate.

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first?

Slow the IV infusion to keep vein open rate.

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

Take measures to promote as much comfort as possible.

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?

Turn the client q2h.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?

Upon discharge, the client will list three ways to protect the feet from injury.

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first?

Wet to moist dressing.

A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement?

Withhold the administration of the suppository until contacting the healthcare provider.

A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement?

Witness the client's signature on the consent form.

An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

Drape the sheets over the footboard of the bed.

When making the bed of a client who needs a bed cradle, which action should the nurse include?

Drape the top sheet and covers loosely over the bed cradle.

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?

Draw up the irrigating solution into the syringe.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time?

Serum albumin.

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement?

Advise the client to sit on the side of the bed for a few minutes before standing again.

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process?

Analysis.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation?

Document the events that occurred in the nurses' notes.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement?

Document the presence and volume of the pulse palpated.

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?

Eats anything and does not think diet makes a difference in health.

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information?

Elicit specific facts about past hospitalizations with direct questions.

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?

Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority?

Inform the family that death is imminent.