info for HESI B EXIT

Which assessment finding on a client who has just had a thoracentesis for a right pleural effusion would require the most rapid action by the nurse? A. Oxygen saturation of 93% B. Blood pressure of 160/94 mm Hg C. Decreased right side breath sounds D. Ecchymosis at the site of the thoracentesis

ANS: C Decreased right breath sounds After thoracentesis the breath sounds should be audible on the affected side and decreased breath sounds may indicate pneumothorax. The nurse would immediately notify the health care provider and expect actions such as a chest x-ray and possible insertion of a chest tube.A. The oxygen saturation of 93% is slightly below normal, but would not be surprising in a client who has a history of lung disease.B. Hypotension after thoracentesis may indicate bleeding or that too much pleural fluid has been removed at once, but mild hypertension may occur due to anxiety or pain.D. Ecchymosis at the thoracentesis site would be monitored, but would be expected after thoracentesis.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. What should be the nurse's first action? Stop the transfusion. Obtain the vital signs. Assess the pain further. Monitor the hourly urinary output.

Stop the transfusion. Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.

A newborn is found to have a diaphragmatic hernia. What is the immediate intervention after the neonate is admitted to the neonatal intensive care unit? Hydrating the infant with isotonic enemas Limiting formula feedings to small amounts Placing the infant in the Trendelenburg position Providing gastric decompression via nasogastric tube

Providing gastric decompression via nasogastric tube When a diaphragmatic hernia is present, intra-abdominal pressure must be minimized; this is accomplished with the use of gastric decompression. Hydrating the infant with isotonic enemas is not beneficial. These infants are not fed orally; intravenous fluids are given with careful measurement of electrolytes and intake and output to guide replacement therapy. The Trendelenburg position is contraindicated; the abdominal organs will increase pressure on the diaphragm.

After the nurse has finished teaching a client who is scheduled for hemilaryngectomy about ways to prevent aspiration during swallowing, which client statement indicates the need for further teaching? "I will eat smaller and more frequent meals." "I should avoid eating meals when I am fatigued." "I should plan to drink more water, milk, and juices." "I will have emergency suctioning equipment nearby."

"I should plan to drink more water, milk, and juices." -Risk for aspiration increases after hemilaryngectomy; water and other thin liquids are more difficult to swallow, increasing aspiration risk. Consuming smaller and more frequent meals is advised because relearning how to swallow requires concentration and is fatiguing. Consuming meals in a fatigued condition may lead to aspiration due to inadequate concentration on swallowing technique. Having suctioning equipment nearby allows rapid suctioning if aspiration occurs.

Which information would the nurse include in the preprocedure teaching for a client who requires emergency cardiac catheterization? - Mild sedation is maintained during the procedure. - The procedure will take approximately 15 minutes to complete. - Ambulation is encouraged shortly after the procedure. - Procedure results will be available after about 24 hours.

A mild sedative is used because the client must be alert enough during the procedure to follow directions . A cardiac catheterization takes approximately 2 hours, not 15 minutes. The client remains on bed rest with the legs extended for 4 to 6 hours after the femoral method of entry. Blockages can be visualized during the procedure and are generally discussed with the client during or immediately after the procedure.

Which clinical indicator would the nurse monitor in a client with end-stage renal disease (ESRD)?

Azotemia

Which type of biopsy is required for removal of entire lesions on the skin?

Excisional biopsy An excisional biopsy is required to remove entire lesions on the skin. A punch biopsy provides full thickness skin for diagnostic purposes. A shave biopsy provides a thin specimen for diagnostic purposes. An incisional biopsy is used along with shave and punch biopsies.

In Hemophilia B, this factor is missing.

Factor IX (9)

When a child is newly diagnosed with hemophilia A, the nurse will teach family members that hemophilia A is linked to a deficiency in which clotting factor?

Factor VIII

Which would the nurse expect to see when reviewing the results of a complete blood count for an infant with tetralogy of Fallot?

Polycythemia

Which intervention would the nurse implement for a 4-month-old infant with tetralogy of Fallot and heart failure?

Providing small, frequent feedings

Which part of the nephron secretes creatinine for elimination?

Proximal tubule

Is measured for about 20 minutes before the CST to determine baseline variability and to detect any FHR alterations without induced stress. The test involves monitoring the fetal heart rate during three to five uterine contractions over a 10-minute period. A urine sample is unnecessary. The semi-Fowler position with a left-sided tilt is the position of choice.

The fetal heart rate (FHR)

inflammation of the gallbladder

cholecystitis

a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure.

status asthmaticus

a congenital malformation of the heart involving four distinct defects

tetralogy of Fallot

A client is being discharged after a first-trimester aspiration abortion. Which statement indicates to the nurse that the client has understood the instructions? "I'll be able to have sex in 4 or 5 days." "I can switch from sanitary pads to tampons after 24 hours." "I can expect my menstrual period to start again in 2 to 3 weeks." "I need to call you if I have to change my pad more than once in 2 hours."

"I need to call you if I have to change my pad more than once in 2 hours."

When providing care for a client who had a nephrectomy secondary to renal cancer, which factor affects the client's ability to perform his or her postoperative deep breathing and coughing requirements? 1. Location of the client's surgical incision 2. Increased anxiety about the prognosis 3. Inflammatory process associated with surgery 4. Pulmonary congestion from preoperative medications

1. Location of the client's surgical incision Rationale:The location of the surgical site in relation to the diaphragm increases incisional pain when deep breathing or coughing. Anxiety about the prognosis should not interfere with the ability to deep breathe and cough, especially when encouraged by the nurse. Inflammatory changes will cause discomfort in the area of any incision but are not necessarily the prime factor preventing deep breathing after a nephrectomy. The client will need to cough and deep breathe if there is congestion in the lungs.

is an increase in nitrogenous waste (particularly urea) in the blood, which is common with end-stage renal disease.

Azotemia

Which action would the nurse take to assess a client for a fungal infection of the toenails?

Determining the rate of toenail growth

Damage to alveolar and renal glomerular basement membranes by cytotoxic antibody.

Goodpasture syndrome

Which change in blood pressure (BP) would the nurse anticipate after a client has an aldosteronoma surgically removed?

Gradually return to expected levels for an adult

Immediately after a liver biopsy the nurse places the client onto the right side. Which reason explains the use of the right side-lying position?

Helps stop bleeding if any should occur

Diagnostic test that is performed on the section of bowel that functions in place of the urinary bladder

Loopogram

use of a small piece of intestine to convey urine to the ureters and to a stoma in the abdomen

ileal conduit

The T lymphocytes in a healthy older adult client are 120 cells/mm3 (120 cells/uL). The chest x-ray reveals shrinkage of the thymus gland. What might have led to the client's condition?

immunosenescence primary cause of thymic shrinking.

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

myasthenia gravis

An older adult client undergoing cancer therapy reports diffused redness and large blisters on the skin with evident systemic toxicity. Which intervention would be a priority to include in the plan of care for this client?

1 - Discontinue the drug Toxic epidermal necrolysis (TEN) is a rare acute drug reaction that manifests as diffused redness and large blisters on the skin. Elderly clients on chemotherapy are at greater risk for TEN. Therefore the drug should be immediately discontinued to reduce further damage to the skin. Monitoring the body temperature is not a priority intervention in this client. The client should be monitored for hypothermia and fluid and electrolyte balance to provide systemic support and prevent secondary infections. Topical antibacterial drugs are administered to suppress the bacterial growth until healing occurs.

Which body system should the nurse focus on when assessing a client with suspected Goodpasture's syndrome? 1. Renal 2. Neurologic 3. Cardiovascular 4. Musculoskeletal

1) renal Goodpasture's syndrome is an autoimmune disorder in which autoantibodies attack the glomerular basement membrane and neutrophils. One organ with the most damage is the kidneys. A person with the disorder may have kidney problems which manifests as glomerulonephritis that may rapidly progress to complete kidney failure. Goodpasture's syndrome does not affect the neurologic, cardiovascular, or musculoskeletal systems.

Which clinical indicator should the nurse identify before scheduling a client for an endoscopic retrograde cholangiopancreatography (ERCP)?

Bilirubin level

The nurse is caring for an infant with tetralogy of Fallot. Which clinical finding would the nurse expect when assessing the child?

Clubbing of the fingers

The nurse in the clinic is obtaining the health history of a 16-year-old boy with a complaint of a thick urethral discharge. Which is the mostappropriate nursing action to help confirm a tentative diagnosis of gonorrhea?

Obtaining a urethral specimen for a culture Gonorrhea is present in the urinary tract of a male, a culture would provide a definitive diagnosis.Fever- not a specific diagnostic toolUrine sample- can dilute the organismsCBC- won't provide the right information

Which outcome is the main focus of treatment for a client with Addison disease?

Restoration of electrolyte balance Lack of mineralocorticoids causes hyponatremia, hypovolemia, and hyperkalemia. Dietary modification and administration of cortical hormones are aimed at correcting these electrolyte imbalances, which can be life threatening. There is no disturbance in the eosinophil count. Lymphoid tissue does not change. Although glucocorticoids are involved in metabolic activities, including carbohydrate metabolism, the primary aim of therapy is to restore electrolyte imbalance.

A client who experiences severe anaphylactic reactions to insect venom arrives to begin allergen therapy. Which action would the nurse use when administering the allergen?

Rotating the sites for each injection (The allergen extract should always be administered in an extremity away from a joint so that a tourniquet can be applied for a severe reaction. The injection sites should be rotated for each injection to prevent skin damage. Current evidenced-based practice states nurses would not aspirate for blood before administering the subcutaneous injection because the subcutaneous tissues do not contain vessels large enough to affect the client. Systemic reactions may occur immediately. The nurse would observe the client for 20 minutes after receiving the injection .Test-Taking Tip: Understand the nurse is injecting allergen. The nursing intervention should result in the positive outcome towards the health of the client.)

A rare, chronic endocrine disorder in which the adrenal glands do not produce sufficient steroid hormones.

addisons disease

the surgical removal of the lateral half of the larynx

hemilaryngectomy

a type of cancer that affects the lymphatic system, which is part of the body's germ-fighting immune system.

hodgkin disease

The primary health care provider prescribes fludrocortisone to a client with adrenal gland hypofunction. What does the nurse instruct the client about this medication?"

"The medication can cause hypertension; regularly monitor blood pressure.