NURS 210 HESI QUIZ 3

which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident

focused adjuncts

The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury

hyperkalemia and hyponatremia

which finding would the nurse anticipate in the health hx of a client who has open angle glaucoma

impairment of peripheral vision

initially after a stroke, the clients pupils are equal and reactive to light. 4 hours later, the nurse identifies that one pupil reacts more slowly than the other and the clients systolic BP is increasing. for which condition would the nurse prepare to intervene

increased intracranial pressure

how is the magnet reflex elicited in a full term newborn

maintaining the supine position and applying pressure to the soles of the newborns feet

which finding during the assessment of a child after a shunt procedure to correct increased intracranial pressure is of most concern

marked irritability

which area is optimal for the nurse to assess adequate tissue oxygenation in a black neonate

mucous membranes of the mouth

which auditory test is appropriate for infants

otoacoustic emissions (OAE)

which nursing action is most accurate when assessing the chest circumference of a newborn

place measuring tape around the rob cage at the nipple line

the nurse is caring for a client with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurses conclusion

plasma proteins moving out of the intravascular compartment

when assessing a client with a diagnoses "brain attack", the nurse evaluated the baseline vital signs of pulse rate of 78 bpm and bp of 120/80 mm hg. which changes in the baseline vital signs indicate an increasing intracranial pressure

pulse 50 bpm and bp 140/60

which action would the nurse take to obtain subjective data about a clients respiratory status? select all that apply

question the patient about SOB and ask the client about color and quantity of sputum

which description explains striae gravidarum encountered in a client in their 26th week of gestation

reddish streaks on the abdomen and breasts

a client sustains a crushing injury of the spinal cord above the level origin of the phrenic nerve. as a result of this injury, he nurse expects to react to which clinical manifestation

respiratory paralysis and cessation of diaphragmatic contraction

which area of assessment is included in the glasgow coma scale

response to verbal commands

a child comes to the school nurse reporting sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. which illness is of most concern if the sore throat is not treated

rheumatic fever

which term would the nurse use to document observing the characteristic gait associated with parkinson disease

shuffling

how would the nurse describe the clonic phase of a tonic-clonic seizure

spasmodic body jerking

which behaviors would the nurse anticipate when conducting a developmental assessment for a newborn? select all that apply

sucking, grasping, swallowing, and rooting

a newborn receiving medication therapy for an infection has developed jaundice. The newborn has poor sucking and extreme sleepiness. Which medication would the nurse suspect as responsible for the newborns condition

sulfonamide

which phrase decribes how an apgar score recorded 5 mins after birth would assist the nurse in evaluating the care of the newborn

tells the HCP how well the baby is doing outside the mothers womb

which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency?

verify the pulse by using a doppler

soft swishing sounds of breathing are heard when the nurse auscultates a clients chest. which term would the nurse use to document this assessment finding

vesicular breath sounds

during a nonstress test the nurse concludes that if accelerations of the fetal heart rate occur with fetal movement, this would most likely indicate which scenario

fetal well being

which range of respiratory rate would the nurse anticipate in a neonate weighing 5 lb 6oz that is born via cesarean birth and admitted to the newborn nursery

30-60

the nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches which level

5-7

the nurse is assessing an electrocardiogram (ECG) rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization

QRS complex

which type of respiration would the nurse expect to identify in a healthy newborn

abdominal and irregular

which behavior would the nurse identify as the moro reflex response

abduction and then adduction of the arms

after measuring a clients PR interval at 0.08 second, how would the nurse interpret the finding

abnormally fast conduction

during auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest?

apex

which client finding would the nurse document as a pulse deficit

apical pulse 86 and radial pulse 78 indicating pulse deficit of 8

a parent calls the school nurse to ask how to check for head lice. which instruction would the nurse provide

ask the child where it itches

which nursing action is priority when admitting a child to the ED who was bitten by a stray dog and sustained a soft tissue injury on the inner aspect of the left forearm

assessing the injury and the vital signs and health hx

to check a clients carotid pulse, which area would the nurse palpate

at the anterior neck, lateral to the trachea

which area would the fundal height be located for a pregnant client at 16 weeks gestation

between the umbilicus and pubic symphysis

the vital sign assessment of a client who gave borth reveal temp 99.3 (37.4 C) pulse 80 bpm, regular and strong, respirations 16 bpm, slow and even, and bp 148/92 mm hg. which vital sign would the nurse check more freq

blood pressure

the postanesthesia care unit nurse providing care for a client who had a craniotomy for a meningoma would monito for which specific clinical manifestation

blurred vision

a 7 year old child sustains a fractured femur in a bicycle accident. the admission x ray film reveal evidence of fractures of other long bones in various stages of healing. which would the nurse suspect as the case of the fracture

child abuse

while assessing a child who has just has a short arm cast applied to a fractured right wrist, the nurse discovers that the fingers of the right hand are cool. which action would the nurse take first

compare the temp of the 2 hands

which type of emergency assessment is the nurse performing when the nurse uses the "AVPU" mnemonic to assess a group of clients admitted with a neurological injury after hiking at high altitude

disability

a client receiving radiation therapy for neck cancer reports "i feel a lump while swallowing, and foods get stuck." Which term would the nurse document in the clients medical history

dysphagia

which pain scale would the nurse use to measure the intensity of pain in toddlers

faces scale

which assessment finding alerts the nurse to increasing intracranial pressure

widening of pulse pressure

which skin color in a client indicates an increased urochrome level

yellow orange