HESI Practice Exam

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? Tell the student to proceed directly to his regularly scheduled class. Call the parent and suggest re-taking the student's temperature at home. Give the student a glass of cool fluids, then retake his temperature. Send the student to class, but re-verify his temperature after lunch.

Tell the student to proceed directly to his regularly scheduled class. This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100 F is normal for this student at this time. The student should attend class since no further nursing action is required.

Which method of medication administration provides the client with the greatest first-pass effect? Oral. Sublingual. Intravenous. Subcutaneous.

Oral The first-pass effect is a pharmacokinetic phenomenon that is related to the drug's metabolism in the liver. After oral medications are absorbed from the gastrointestinal tract, the drug is carried directly to the liver via the hepatic portal circulation where hepatic inactivation occurs and reduces the bioavailability of the drug. Alternative method of administration, such as sublingual, IV, and subcutaneous routes, avoid this first-pass effect.

A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?"Be sure to have a complete physical examination before beginning your planned exercise program.""Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.""Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.""Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation."

"Be sure to have a complete physical examination before beginning your planned exercise program." A client with obesity who intends to begin a weight loss and exercise program may be at risk for cardiovascular complications. The most important teaching is to encourage the client to have a complete medical evaluation so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. Vigorous exercise may result in chest pain, a heart attack, or stroke.

A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? "It allows you to document your wishes regarding life-sustaining treatment if you can't speak for yourself." "It will identify someone that can make decisions for your health care if you are in a coma or vegetative state." "It is not legally binding, but helps the healthcare provider know exactly what medical treatments you want." "It is a form that all people must sign before admission to the hospital so that individualized treatment plans can be developed."

"It will identify someone that can make decisions for your health care if you are in a coma or vegetative state." This is a legal document that allows individuals to identify someone to make decisions for health care, identifies how aggressive treatment should be if the client should ever be in a coma or persistent vegetative state, and lists any medical treatments they would never want performed. Documents about life sustaining treatments is the definition of the "Living Will"--some states and Canada do not consider Living Wills legal documents. A durable power of attorney is a legal document but is not a hospital form.

During the well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents? The child is attempting to formulate a secondary language. This is an attempt by the child to form an imaginary social base. "Private speech" is normal at this age and serves as a problem-solving tool. Concern for psychological development is warranted so further testing is required.

"Private speech" is normal at this age and serves as a problem-solving tool. Children chatter to themselves between the ages of 4 and 6 years, and this "private speech" serves as a problem-solving tool for the preschoolers as they try new tasks or work through unfamiliar situations.

A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibity for the divorce of parents? 1 year. 4 years. 8 years. 13 years.

4 years. Divorce constitutes a major disruption for children of all ages. Behaviors and feelings differ based on children's developmental stages and cover a wide spectrum, with overlap between stages. A preschool-aged child often feels frightened, confused, and may blame themselves for the divorce, or feel it is their personal punishment.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? The kidneys and renal function are not fully developed. Warmth promotes sleep so the infant will grow quickly. A large body surface area favors heat loss to the environment. The thick layer of subcutaneous fat is inadequate for insulation.

A large body surface area favors heat loss to the environment. Thermoregulation, heat regulation, is critical to the survival of a neonate because the newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B). (A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that results from neonatal heat loss.

The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother? Picking up the infant in the middle of the night fosters dependency on the mother. A sense of trust is developed in an infant when others respond to the infant's cry. An infant is learning to manipulate others when the infant is picked up unnecessarily. A 2-month-old who does not sleep through the night should be evaluated further.

A sense of trust is developed in an infant when others respond to the infant's cry. According to Erikson, a crucial element in the developmental stage of the infant is, "Trust versus mistrust", which is nurtured when the mother or the primary caregiver is responsive and consistent in responding to the infant's needs and cries.

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleeping six to eight hours. Achieve a sense of control. Utilize problem solving skills. Increased focus of attention.

Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan.

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement?Acknowledge that the spouse is supporting the arm correctly.Encourage the spouse to keep the joint covered to maintain warmth.Reinforce the need to grip directly under the joint for better support.Instruct the spouse to grip directly over the joint for better motion.

Acknowledge that the spouse is supporting the arm correctly. The client's spouse is correctly holding the arm above and below the elbow to perform passive range-of motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being exercised should be uncovered while the rest of the body should remain covered for warmth and privacy.

Which site should the nurse assess to obtain the pulse rate for a 1-year-old child? Radial. Apical. Carotid. Femoral.

Apical pulse rates should be obtained in children less than 2 years of age to assess cardiac function.

The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? Ask the child whether he was sexually abused. Ascertain what the child understands about sex. Inquire where the child got this important information. Involve the child in teaching sex information to peers.

Ascertain what the child understands about sex. School-age children often use correct sexual vocabulary, and yet have no real understanding of what the words mean, so the nurse needs to determine the child's understanding of the concepts used in conversation.

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.

Ask the client if this decision has been discussed with his healthcare provider. Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?Assist the ambulating client back to the bed.Encourage the client to ambulate to resolve pneumonia.Obtain a prescription for portable oxygen while ambulating.Move the oximetry probe from the finger to the earlobe.

Assist the ambulating client back to the bed. An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first the client should return to bed to rest.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment.

Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client.

The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? Flush the tube with 50 ml of water q 8 hours. Check for tube placement and residual volume q4 hours. Obtain a daily x- ray to verify tube placement. Position on left side with head of bed elevated 45 degrees.

Check for tube placement and residual volume q4 hours. Tube placement and residual volume should be checked every four hours for clients on continuous feeding. If the gastric residual is more than 200mL for an adult client; stop the feeding and re-check the gastric residual one hour later. If the residual still remains more than 200mL; continue to keep the feeding on hold and contact the client's health care provider.

A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? Children need to retain a sense of initiative without impinging on the rights and privileges of others. Negative feelings of doubt and shame are characteristic of 4-year-old children. Role conflict is a common problem of children this age. She is just wondering where she fits into society. At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.

Children need to retain a sense of initiative without impinging on the rights and privileges of others. Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins.

Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present.

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.

Consider the sterile field contaminated if it becomes wet during the procedure. Wet or damp areas on a sterile field allow organisms to "wick" from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D).

The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition? Cystocele. Bladder infection. Pyelonephritis. Irritable bladder.

Cytocele This constellation of signs in a postmenopausal woman are characteristic of a cystocele. These symptoms are not characteristic of the other options.

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. Auscultate the client's breath sounds bilaterally. Elevate the head of the bed to a high Fowler's position. Administer a PRN dose of a prescribed antiemetic.

Discontinue the administration of the bolus feeding. When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated.

An older client with a decreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process? Absorption. Metabolism. Elimination. Distribution.

Distribution. Rationale A decreased lean body mass in an older adult affects the distribution of drugs which affects the pharmacokinetics of drugs. In contrast, decreased gastric pH, delayed gastric emptying, decreased splanchnic blood flow, decreased gastrointestinal absorption surface areas and motility affect absorption in the older adult population. Decreased hepatic blood flow, decreased hepatic mass, and decreased activity of hepatic enzymes affect metabolism in older adults. Decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons affects elimination in an older adult.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? Immediately after exhalation. During the inhalation. At the end of three inhalations. Immediately after inhalation.

During the inhalation. The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication.

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? Solicit information on hospitalization from the insurance company. Look up previous medical records from archived hospital documents. Ask the client to discuss previous hospitalizations in the last 5 years. Elicit specific facts about past hospitalizations with direct questions.

Elicit specific facts about past hospitalizations with direct questions. Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems.

Which family-centered care concept(s) should the nurse encourage family members to use to promote child growth, development, and independence? Tough love. Therapeutic care. Enabling and empowerment. Teaching and care provision.

Enabling and empowerment. Family-centered care includes enabling and empowering the child with opportunities that build on identified strengths, enhance self-efficacy, and promote growth within the collaborative family unit.

The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan? Do not allow those with influenza to be admitted to the unit. Require that all clients receive a pneumonia vaccine prior to admission. Ensure that sterile technique is followed when changing surgical dressings. Encourage clients to drink water to prevent urinary tract infections.

Ensure that sterile technique is followed when changing surgical dressings. A nosocomial infection is one that was not present or incubating at the time of admission, and using appropriate sterile technique and medical asepsis helps to prevent this type of infection from occurring. The other options are infection preventive techniques, but are not specific to the prevention of nosocomial infections.

Which intervention demonstrates the nurse's accountability in a specific decision-making process? Selecting the best medication administration schedule for a client. Evaluating a client's outcomes after implementation of care. Promoting participation of all staff members in unit meetings. Implementing discharge teaching plans that meet individual needs.

Evaluating a client's outcomes after implementation of care. Accountability is being responsible, professionally and legally, for the delivery of nursing care, which includes competency in nursing, scientific knowledge, technical skills, and maintaining standards of practice in the nursing profession. Accountability involves follow-up and a reflective analysis of implementation of care and client outcomes.

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? Amount of liquid protein supplements consumed daily. Foods and liquids consumed during the past 24 hours. Usual weekly intake of milk products and red meats. Grains and legume combinations used by the client.

Foods and liquids consumed during the past 24 hours. A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be elicited after confirming the client's dietary history.

What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? Instruct the client to look at examiner's nose and not move his/her eyes during the exam. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and then direct it at the client's pupil.

When assessing a preschooler, which finding warrants further assessment by the nurse? Able to ride a tricycle. Talks about an imaginary friend. Dresses independently. Gains 2 pounds (0.9kg) in 12 months.

Gains 2 pounds (0.9kg) in 12 months. Preschool children gain an average of 5 pounds (2.7kg) per year, so a gain of 2 pounds (0.9kg) is less than half of the expected weight gain and should be investigated further.

Which change in sleep patterns is most likely to occur in an older adult? Becomes more difficult to arouse from sleep. Takes less time to fall asleep. Has a decline in stage 4 sleep. Requires more sleep than a younger adult.

Has a decline in stage 4 sleep. Rationale With aging, a progressive decrease in the amount of non-rapid eye movement (NREM) sleep occurs during stage 3 and 4, and some older adults have minimal amounts of stage 4, or deep sleep. As people age, they do not become more difficult to arouse. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep. The older adult does not require more sleep than a younger adult.

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.

Identify the break in surgical asepsis and provide another set of sterile supplies. Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? Bradycardia. Increase in pulse rate. Peripheral vasodilation. Increase in cardiac output.

Increase in pulse rate. Rationale When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs when orthostatic hypotension occurs.

The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? Loss of independence. Increased self-understanding. Isolation from society. Development of intimate relationships.

Increased self-understanding. Middle adulthood is characterized by self-reflection, understanding, acceptance, and generativity or guidance of children. The other developmental tasks are not specific to middle adulthood.

Which statement is an example of a correctly written nursing diagnosis statement? Altered tissue perfusion related to congestive heart failure. Altered urinary elimination related to urinary tract infection. Risk for impaired tissue integrity related to client's refusal to turn. Ineffective coping related to response to positive biopsy test results.

Ineffective coping related to response to positive biopsy test results. The first part of the nursing diagnosis statement is the "diagnostic label" and is followed by "related to" the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's "response," which the nurse can provide support, reflection, and dialogue.

What is the best action for the nurse to take when initiating contact with a toddler for the first time? Ask the toddler to point to where it hurts. Tell the child your name and that you are the nurse. Call the child by name while picking up the toddler. Kneel in front of the toddler and speak softly to the child.

Kneel in front of the toddler and speak softly to the child. The toddler perceives the nurse as a stranger, so a more positive interaction occurs when the toddler perceives the meeting in a nonthreatening way. Placing oneself at the toddler's eye level and speaking softly can be less threatening for the child. Asking direct questions, giving your name and telling the toddler you are the nurse or picking a toddler up at an initial meeting are perceived as threatening actions by the child and will more likely result in a negative response from the child.

The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective? A decrease in number of calls to the technology department. Less time for nursing staff to complete the daily charting. An increase in staff acceptance of computerized charting. An improvement from pretest scores of the training session

Less time for nursing staff to complete the daily charting. Being able to use the system to accomplish charting more efficiently and in less time compared to previous documentation techniques indicates the staff has learned how to use the system effectively. The other options are not indicative of effective education.

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. Transfer to a commode. Attach the catheter to a drainage bag. Manipulate a syringe to inflate the balloon.

Locate the perineum. Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D).

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Move the chair parallel to the right side of the bed, and stand the client on the right foot. When positioning a client for transfer from bed to chair when the client has left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer.

A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? Milk allergy. Failure to thrive. Inadequate milk supply in mother. Normal growth curve of a breast-fed infant.

Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C).

The nurse must prevent a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? Obtain gloves for the child's hands. Apply finger cots on the child's fingers. Place elbow restraints on the child's arms. Apply soft restraints to the child's wrists.

Place elbow restraints on the child's arms. Elbow restraints prevent arm flexion and the ability to reach to scratch the involved areas, but do not inhibit use of the hands for play activities.

How should the nurse handle linens that are soiled with incontinent feces? Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. Place an isolation hamper in the client's room and discard the linens in it. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated.

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.

Position prone with a small pillow below the diaphragm. Rationale The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point.

A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? Notify the healthcare provider of the measurement. Quiet the child and retake the blood pressure. Ask the parent if the child has a history of hypertension. Document the finding and recheck in 4 hours.

Quiet the child and retake the blood pressure. When a child is crying, intra-thoracic and abdominal pressures increase and are reflected in an elevation of systemic blood pressure, so the nurse should quiet the child before retaking the blood pressure.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first?Irrigate the nasogastric tube with sterile normal saline.Reposition the client on her side.Advance the nasogastric tube an additional five centimeters.Administer an intravenous antiemetic prescribed for PRN use.

Reposition the client on her side. The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? Use a laryngoscope to check for a foreign body lodged in the esophagus. Reposition the head to validate that the head is in the proper position to open the airway. Turn the client to the side and administer three back blows. Perform a finger sweep of the mouth to remove any vomitus.

Reposition the head to validate that the head is in the proper position to open the airway. The most frequent cause of inadequate aeration of the client's lungs during CPR is the improper positioning of the head resulting in occlusion of the airway. The nurse should reposition the client's head and attempt to ventilate again, looking for the rise and fall of the chest.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? Respiratory rate. Wound location. Pedal pulses. Pain rating.

Respiratory rate. Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A) before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A).

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. Realize that Southeast Asians may not take Western medications. Ask the husband to step out during the mother's pelvic examination. Tell the family that planning health care is provided in private with the client.

Speak initially with the oldest family member to show respect. Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct.

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? Stage 1. Stage 2. Stage 3. Stage 4.

Stage 3 Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 because it is a full-thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. Stage 1 is a nonblanchable pressure point over intact skin. Stage 2 is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. Stage 4 is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.

The scope of professional nursing practice is determined by rules promulgated by which organization? State's Board of Nursing. State Nursing Associations. American Nurses Association (ANA). National Labor Relations Board (NLRB).

State's Board of Nursing. Each state's Board of Nursing is authorized to promulgate rules and regulations that carry the weight of law. The State Legislature delegates its law-making authority to this administrative law body. State nursing organizations and the ANA are influential in defining and describing nursing standards of care, but neither have the authority to pass laws that legally define the professional scope of nursing practice. Although NLRB may rule on issues important to nursing practice, the scope of professional nursing practice is determined by the laws, rules, and regulations promulgated by state Boards of Nursing.

The nurse is using the Ages and Stages Questionnaire (ASQ) to screen a 12-month-old infant during a well-child visit. When the parents ask the nurse the reason for this procedure, which response provides the best explanation? This tool identifies achievement of development milestones in infants and young children. The procedure tests cognitive, physical, and psychological areas of development. The examination screens for early speech difficulties so early treatment can begin. This test measures intellectual ability and screens for possible learning difficulties later in school.

The ASQ is a screening tool for children one month to 5.5 years of age to identify strengths and developmental- social-emotional delays in normal early developmental milestones. The other choices are not the focus of the ASQ.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? The drainage tubing is secured over the siderail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame.

The clamp on the urinary drainage bag is open. Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? The client voluntarily signed the form. The client fully understands the procedure. The client agrees with the procedure to be done. The client authorizes continued treatment.

The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure that the client fully understands the procedure. The nurse's signature does not indicate that the client agrees to or authorizes treatment.

What should the nurse assess last when examining a 5-year-old child? Heart. Lungs. Throat. Abdomen.

Throat; most invasive

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. Turn the client q2h.

Turn the client q2h (D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (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 in the dietary plan? Fiber. Folate. Ascorbic acid. Vitamin B12.

Vitamin B12. Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegetables and fruits.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room.

Wash hands after caring for the client. The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.

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.

Wet to moist dressing. To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface.

The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? Kyphosis with a reduction in height. Dilated superficial veins on both legs. External hemorrhoids with itching. Yellowish discoloration of the sclerae.

Yellowish discoloration of the sclerae. In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment.