Funds HESI Questions

A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle?

90

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. • Report any signs of drug addiction to the nurse immediately. • Wait until the client's pain is gone before assisting with personal care. • This client's pain will be difficult to manage, since the cause is unknown.

A

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? a.) Continue gabapentin. b.) Discontinue ibuprofen. c.) Add aspirin to the protocol. d.) Add oral methadone to the protocol.

A

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. • Trigger points identified by palpation and manual pressure of painful areas. • Schedule and total dosages of drugs currently used for breakthrough pain. • Sympathetic responses consistent with onset of acute pain

A

A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? • Encourage the student to associate with non-smokers only while attempting to stop smoking. • Tell the student that he is still young and should continue to try various smoking cessation methods. • Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. • Provide the student with the latest research data describing the long-term effects of tobacco use.

A

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. • Apply dressing to wound area before applying the Unna's paste boot. • Wrap the leg from the knee down towards the foot. • Remove the Unna's paste boot q8h to assess wound healing.

A

What is the most effective way to implement a teaching plan? • Teach the information that the client wants to learn first. • Streamline the teaching plan to include only essential information. • Present to the client all the information necessary to meet the objectives. • Provide the client with written material to review before teaching sessions.

A

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? • Record these findings in the client's record. • Observe closely for possible dehiscence. • Notify the healthcare provider that the client's wound is producing a sanguineous drainage. Incorrect • Increase the IV fluid rate and encourage the client to eat more ice chips.

A

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. • Obtain and place a portable commode by the bed. • Ask the client to push the IV pole to the chair. • Clamp the indwelling catheter. • Assess the client's blood pressure.

A, B, D, F

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? • Check for a blood return. • Reposition the client's arm. • Remove the IV site dressing. • Flush the lock with saline.

B

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? • Help the client to accept the final stage of life. • Assist and support the client in establishing short-term goals. • Encourage the client to make future plans, even if they are unrealistic. • Instruct the client's family to focus on positive aspects of the client's life.

B

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? • Document the client's request in the medical record. • Ask the client if this decision has been discussed with his healthcare provider. • Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. • Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

B

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? • May I ask your daughter to help you with your personal hygiene? • I will ask one of the female nurses to bathe you. • A staff member on the next shift will help you. • I will keep you draped and hand you the supplies as you need them.

B

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? • Page the unit manager to address the situation. • Close the demographic screen on the computer. B • Instruct the UAP to end the phone call immediately. • Send a UAP into the client's room to relieve the nurse.

B

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? • She is almost sure to be less able to adapt than before. • It's highly likely that she will recover and return to her pre-illness state. • If you can interest her in something besides religion, it will help her stay well. • Cultural strains contribute to each woman's tendencies for recurrences of depression.

B

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? • Passive ROM exercises to all joints on all extremities four times a day. • Active ROM exercises to both arms and legs two or three times a day. • Active ROM exercises with weights twice a day with 20 repetitions each. • Passive ROM exercises to the point of resistance and slightly beyond.

B

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? a.) Temperature increases from 98.8° to 99.0° F. b.) Pulse rate decreases from 78 to 52 beats/min. c.) Respiratory rate increases from 16 to 24 breaths/min. d.) Blood pressure increases from 110/84 to 118/88 mm/Hg

B

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? a.) Empty the client's urinary drainage bag. b.) Draw up the irrigating solution into the syringe. c.) Secure the client's catheter to the drainage tubing. d.) Use aseptic technique to instill the irrigating solution.

B

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? • Hand washing prior to preparation of the injection. • Method used to aspirate medication from a vial. • Selection and rotation of injection sites. • Proper disposal of injection equipment.

B

The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? • Use an electronic sphygmomanometer to take the BP every 30 minutes. • Retake the blood pressure in the same arm, deflating the cuff slowly. • Ask another nurse to recheck the blood pressure to compare results. • Obtain another blood pressure cuff and retake the blood pressure.

B

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? • Maintain in a lateral position using protective wrist and vest devices. • Position prone with a small pillow below the diaphragm. • Raise the head and knee gatch when lying in a supine position. • Transfer into a wheelchair close to the nurse's station for observation.

B

What action should the nurse implement when adding sterile liquids to a sterile field? • Use an outdated sterile liquid if the bottle is sealed and has not been opened. • Consider the sterile field contaminated if it becomes wet during the procedure. • Remove the container cap and lay it with the inside facing down on the sterile field. • Hold the container high and pour the solution into a receptacle at the back of the sterile field

B

When caring for an immobile client, what nursing diagnosis has the highest priority? • Risk for fluid volume deficit. • Impaired gas exchange. • Risk for impaired skin integrity. • Altered tissue perfusion.

B

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? • Hydrogel. • Exudate absorber. • Wet to moist dressing. • Transparent adhesive film.

C

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? • Most herbs are toxic or carcinogenic and should be used only when proven effective. • There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. • Herbs should be obtained from manufacturers with a history of quality control of their supplements. • Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

C

A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? • Use disposable plates and utensils. • Stay in a room with the door closed. • Dispose of soiled dressings in plastic bags that are securely closed. • Others who are in the same room with the client should wear a mask.

C

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? • Notify the charge nurse that a medication error occurred. • Submit a medication variance report to the supervisor. • Document the events that occurred in the nurses' notes. • Discard the original medication administration record.

C

The home health nurse visits an elderly female client who had a brain attack 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? a.) The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. b.) The client tells the nurse that she does not have much of an appetite today. c.) The nurse notes that there are numerous scatter rugs throughout the house. d. ) The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

C

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? • Confirm the finding by further assessing the client for jugular vein distention. • Offer the client high protein snacks between regularly scheduled mealtimes. • Continue the planned nursing interventions to restore the client's fluid volume. • Change the plan of care to include a nursing diagnosis of impaired skin integrity.

C

When culturing a wound, the nurse should obtain the sample from which part of the wound? • The outer edges of the wound. • All necrotic sections of the wound. • Areas containing purulent or pooled exudates. • Any particularly painful area of the wound.

C

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? • Review the client's medical record for an advance directive. • Determine if a do-not-resuscitate prescription has been obtained. • Document that the client is being discharged against medical advice. • Evaluate the client's mental status for competence to refuse treatment.

D

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? • Encourage the client to take several slow, deep breaths while ambulating. • Help the client to remain standing by the bedside until the dizziness is relieved. • Instruct the client to remain on bedrest until the healthcare provider is contacted. • Advise the client to sit on the side of the bed for a few minutes before standing again.

D

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? • Report the healthcare provider for the violation in aseptic technique. • Allow the completion of the procedure. • Ask if the glove and sterile field are contaminated. • Identify the break in surgical asepsis and provide another set of sterile supplies.

D

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 distraction techniques during times of spiritual stress and crisis. • Reassure the client that his faith will be regained with time and support. • Consult with the staff chaplain and ask that the chaplain visit with the client. • Use reflective listening techniques when the client expresses spiritual doubts.

D

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? • Ask the nursing supervisor to meet with the students. • Notify the student's clinical instructor of the situation. • Ask the student if permission was obtained from the client. • Explain that the records are hospital property and may not be removed.

D

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? • Use a mechanical lift to transfer from the bed to a chair. • Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. • Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. • 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.

D

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? • Apply flannel pajamas to provide warmth. • Administer a PRN dose of ibuprofen. • Perform range of motion exercises in a warm tub. • Drape the sheets over the footboard of the bed.

D

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? • Administer a PRN antihypertensive prescription. • Provide the client with an additional blanket. • Encourage additional fluid intake. Incorrect • Turn the client q2h.

D

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 the dietary plan? • Fiber. • Folate. • Ascorbic acid. • Vitamin B12.

D

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? a.) Raise the bed to a comfortable working level. b.) Bend the client's knee. c.) Move the knee toward the chest as far as it will go. d.) Cradle the client's heel.

D

When making the bed of a client who needs a bed cradle, which action should the nurse include? • Teach the client to call for help before getting out of bed. • Keep both the upper and lower side rails in a raised position. • Keep the bed in the lowest position while changing the sheets. • Drape the top sheet and covers loosely over the bed cradle.

D

When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? • Place a sterile drape under the client's buttocks. • Instruct the client to inhale and then exhale slowly. • Discard the gloves and apply new sterile gloves. • Apply a sterile lubricant to the end of the catheter.

D

Which action should the nurse implement when using the confrontation technique during a vision exam? • Use an ophthalmoscope to watch the client's pupil constrict when a strong light is shown on it. Incorrect • Stand behind the client and direct the client to tell the nurse when an object enters the peripheral field of vision. • Show the client a series of four cards with printing of varying sizes and ask which card the client sees most clearly. • Sit facing the client and while look directly at the client's face, move an object inward from the periphery.

D

Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? • Removing the empty food tray from a client with a urinary catheter. • Washing and combing the hair of a client with a fractured leg in traction. • Administering oral medications to a cooperative client with a wound infection. • Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

D