NR 304 HESI Study Slides

A nurse is caring for a client who had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? 1 Femoral pulse 2 Toes for mobility 3 Condition of the pin 4 Range of motion of the knee

2 Monitoring the mobility of the toes assesses neural integrity distal to the surgical site; this is part of a neurovascular assessment. The femoral artery is not assessed, because it is not distal to the surgical site. No pin is present with an open reduction and internal fixation of a fractured hip. An assessment of range of motion of the knee may cause flexion of the hip, which is contraindicated.

A client who uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. What action should the RN implement first? A. Withhold medication and report any symptoms and vitals to the HCP B. Give PRN meds for nausea and vomiting and evaluate the client in 30 minutes. C. Reassure the client that the ipratropium given will alleviate the symptoms D. Delay administration of ipratropium until next maintance medication is scheduled.

Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately then (B, C, and D) may place the client in imminent danger.

The RN is teaching a client who is being discharged after treatment for TB. Which cultural issues should the RN assess when prepping the patient for discharge? A. Native Language B. Education level C. Type of lifestyle D. Previous medical history E. Financial resources

(A,B,C and D) are correct.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder? 1 Ham sandwich with cheese, whole milk, and potato chips 2 Penne pasta, spinach, banana, and decaffeinated iced tea 3 Baked lasagna with sausage, salad, and milkshake 4 Hamburger, french fries, and cola

2 A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume

What is the function of a client's cranial nerve VI? 1 Movement of the eye with levator muscle 2 Movement of the eye with lateral rectus muscles 3 Movement of the eye with medial rectus muscles 4 Movement of the eye with superior oblique muscles

2 Cranial nerve VI (abducens) helps eye movement with the lateral rectus muscles. Cranial nerve III (oculomotor) helps in the lid elevation with the levator muscle. Cranial nerve III (oculomotor) helps in the eye movement with medial rectus muscles. Cranial nerve IV (trochlear) helps in eye movement with the superior oblique muscles.

An older adult with peripheral vascular disease has stopped smoking, and the client's children want to make the home environment safe. What should the home healthcare nurse emphasize when providing instructions? 1 Observe for evidence of blurred vision 2 Use measures that can prevent thermal injuries 3 Reduce fluid intake to prevent peripheral edema 4 Limit activities to reduce the workload on the heart

2 The ability to perceive extremes in temperature is limited in the presence of peripheral vascular disease. Prevention of thermal injury through avoidance of hot and cold (e.g., hot water, heating pads, ice packs) is advised. Blurred vision is not associated with peripheral vascular disease. Limiting fluid intake may precipitate dehydration, increasing the risk of thrombophlebitis. Limiting fluids may be indicated if a client has heart failure, not peripheral vascular disease. Limiting activities to reduce the workload on the heart may be important for a client with heart failure, not with peripheral vascular disease.

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? Select all that apply. 1 Flatulence 2 Anal itching 3 Blood in stool 4 Rectal bulging 5 Pain when defecating

2,3,4,5 Anal pruritus (itching) occurs as varicosities enlarge and become inflamed. Blood and mucus in the stool occur during bowel movements. Rectal bulging (prolapse) occurs as portal venous pressure increases and varicosities enlarge. Pain occurs when varicosities enlarge and thromboses occur; pain increases on defecation. Flatulence is unrelated to hemorrhoids.

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation

4 Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema.

The RN is caring for a client with a newly placed NG tube. Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NG is not displaced? A. Check pH of aspirated stomach contents obtained from the NG B. Auscultate over the epigastrium while injecting air into the NG. C. Disconnect and place the end of the NG in water to see if bubbles appear. D. Listen for hyperactive bowel sounds in all four quadrants of abdomen.

A Checking the pH of aspirate (A) is he best method to validate that the NG is not displaced and should reveal an acidic pH of 1.5-3.5 due to presence of gastric acid. (B,C and D) are not reliable methods to ensure that the NG placement in the stomach.

The RN is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all) A. Hematemesis B. Gastric pain on empty stomach C. Colic-like pain with fatty good ingestion D. Intolerance of spicy foods E. Diarrhea and steatorrhea

A, B, D (A, B and D) are correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance (D). (C) is consistent with cholecystitis. (E) is not consistent with PUD.

The RN uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7's A. Recall of information B. Orientation to surroundings C. Attention to details D. Ability to follow complex commands

C. Counting by 7's evaluates the ability to do simple calculations and is specific to the client's attention to detail (C). (A,B, and D) are additional parts of the MMSE that evaluate orientation and cognitive function.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1 At the onset of menstruation 2 Every month during ovulation 3 Weekly at the same time of day 4 1 week after menstruation begins

4 -The breast self-examination should be performed monthly, 7 days after the onset of the menstrual cycle.

While reviewing the patient's EMR the RN assesses a patient who is at risk for a possible med interaction with an OTC decongestant. Which patient health history should the RN report to the HCP concerning the OTC med? (Select all that apply) A. Type I DM B. Closed angle glaucoma C. Chronic Hypertension D, Rheumatoid arthritis E. Chron's Disease

B, C (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with close angle glaucoma (B). Decongestants can increase heart rate and elevate blood pressure which can impact the client's management of chronic hypertension (C). Although the HCP should be informed of all medications taken, (A, D and E) are not directly affected by a decongestant.

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination. 1 Sims 2 Supine with head/feet flat 3 Supine with the head raised slightly and knees slightly flexed 4 Semi-Fowler's position with the head raised 45 degrees and the knees flat

3 This position relaxes the abdominal muscles. *This is according to the powerpoint sent by CAS for HESI*

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which of the following is the best time to perform this exam? 1 After a shower or bath 2 While standing to void 3 After having a bowel movement 4 While lying in bed before getting up in the morning

1 The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct that the best time to perform TSE is after or during a shower or bath when the hands are warm and soapy, and the scrotum is warm.

The nurse is instructing a patient in BSE. The nurse tells the patient to lie down and examine the left breast. The nurse should instruct the patient that while examining the left breast she should place a pillow under which area? 1 Left Shoulder 2 Right Scapula 3 Right shoulder 4 Small of the back

1 The nurse should instruct the patient to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow should be placed under the left shoulder.

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which intervention by the nurse promotes identification of the cause of this incontinence? 1 Abdominal percussion 2 Digital rectal examination 3 Urine culture and sensitivity test 4 Pelvic and abdominal ultrasound

2 Fecal impaction is the primary cause of liquid fecal incontinence. A digital rectal examination will determine the presence of a fecal impaction. Abdominal percussion will not assist in the diagnosis of impaction. Urine culture and sensitivity test will identify urinary tract infection; urinary, not fecal, incontinence is associated with urinary tract infection. Pelvic and abdominal ultrasound might be done if earlier assessments are inconclusive and additional evaluations are required

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1 Decreased blood supply 2 Impaired neural functioning 3 Perforation of the bowel wall 4 Obstruction of the bowel lumen

2 Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply. 1 Eggs 2 Liver 3 Cheese 4 Salmon 5 Shellfish

2,5 Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are also high-purine foods and should be avoided. Eggs and cheese have insignificant amounts of purine and are unrestricted. Foods that contain a moderate amount of purine (50 to 150 mg/dL), such as salmon, may be eaten four times a week.

A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis? 1 Rectal examination 2 Serum phosphatase level 3 Biopsy of prostatic tissue 4 Massage of prostatic fluid

3 A definitive diagnosis of the cellular changes associated with benign prostatic hyperplasia [1] [2] (BPH) is made by biopsy, with subsequent microscopic evaluation. Palpation of the prostate gland through rectal examination is not a definitive diagnosis; this only reveals size and configuration of the prostate. The serum phosphatase level will provide information for prostatic cancer; a definitive diagnosis cannot be made with this test for BPH. A sample of prostatic fluid helps to diagnosis prostatitis.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the HCP? 1 Absence of bruit 2 Concave, midline umbilicus 3 Pulsations between the umbilicus and the pubis 4 Bowel sound frequency of 15 sounds per minute

3 The presence of pulsation between umbilicus and pubis could indicate an abdominal aortic aneurysm, and should be reported to the HCP -Bruis normally are not present -THe umbilicus should be in the midline with a concave appearance -Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5-35 per minute.

THe RN palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply) A. Diminished hair on legs B. Bruising on extremities C. Skin cool to touch D. Capillary refill less than 3 seconds E. Darkened skin on extremities

A, C Diminished hair on the legs (A) and skin that's cool to touch (C) are symptoms of decreased arterial blood flow. (B,D, and E) are not indicators for impaired peripheral circulation.

A client with progressive hearing loss appears distressed when the RN asks open-ended questions about the client's health history. Which forms of communication should the RN use? (Select All) A. Face the patient so he/she can see the RN's mouth. B. Increase one's speech volume C. Repeat information to the patient if misunderstood. D. Check if the patient's hearing aides are working properly E. Reduce environmental noise surrounding the patient.

A, D, E, A patient with hearing loss can deelop the ability to read "lips" so facing the patient during a conversation (A) allows visualization of the lips and directs the sound toward them. Inspection of the hearing aide device's functionality is a vital step in communication (D). Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process (E). Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech (B). If a client shows signs of confusion, rephrasing the question instead of repeating (C) should be done to increase client anxiety and facilitate understanding.

A Muslim male client refuses to let a female registered RN listen to his breath sounds during an examination. How should the RN respond? A. Explain how the nursing skill would be performed before proceeding. B. Examine client with an additional healthcare provider for support. C. Request a male nurse or healthcare provider to perform the exam. D. Avoid any skills that involve touching the client during the exam.

C Modesty is an important value in the Muslim community and Muslims are reluctant to expose any part of their body to healthcare members. Muslim clients are accustomed to being examined by same sex healthcare providers so (C) is the best solution for the client. (A and B) will not alleviate the isue for the Muslim client (D) does not allow a thorough exam of the client.