310 HESI practice
Correct Answer: 1, Banana Rationale: A medium banana contains only 1 mg of sodium. All the rest are higher than a banana. Carrots are low in sodium, but ¼ cup contains 10 mg. Yogurt contains over 80 mg, while tomato juice is the highest.
The nurse has taught a client about a low-sodium diet. Which food choice by the client indicates successful learning? 1) Banana 2) Carrots 3) Yogurt 4) Tomato juice
4) Ask client about shortness of breath with various activities Because dyspnea is subjective, the nurse will need to ask the client about whether dyspnea has improved. Auscultation of breath sounds provides objective evidence of whether problems like pneumonia or asthma have improved, but does not evaluate for subjective improvement. The nurse may observe respiratory effort, but this is objective evidence and does not always correlate with subjective improvement. Oxygen saturation provides clear objective data about oxygen level, but is not the best indicator for improvement in dyspnea on exertion. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
Which action would be best for the nurse to take to evaluate whether interventions have been effective in treating a client's exertional dyspnea? 1) Auscultate client breath sounds. 2) Observe respiratory effort with activity. 3) Obtain oxygen saturation at rest and with activity. 4) Ask client about shortness of breath with various activities
2) Reports of leg fatigue 5) Tortuous veins in the legs 6) Pain in lower extremities when standing Leg fatigue is a common clinical manifestation caused by venous stasis and inadequate tissue oxygenation. Vein walls weaken and dilate resulting in distended, protruding veins that appear tortuous and darkened. As vein walls weaken and dilate, venous pressure increases and the valves become incompetent; venous stasis and inadequate oxygenation result in leg pain. Discolored toenails result from a fungus under the nail or chronic hypoxia, not varicose veins. Localized heat in a calf and reddened areas on the calf are signs of thrombophlebitis. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.
Which clinical findings can the nurse expect to identify when assessing a client with varicose veins? Select all that apply. One, some, or all responses may be correct. 1) Discolored toenails 2) Reports of leg fatigue 3) Localized heat in a calf 4) Reddened areas on a calf 5) Tortuous veins in the legs 6) Pain in lower extremities when standing
3) Pain when exercising and thickening of the toenails Inadequate oxygenation of tissues of the affected limb causes intermittent claudication and thickened toenails. Edema of the feet and ankles occurs with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, dependent edema may be associated with decreased cardiac output related to heart failure. Reddened and painful areas on the calves are adaptations related to thrombophlebitis, a venous rather than arterial problem. Ulcers around the ankles and reports of a dull ache in the legs occur with venous, not arterial, insufficiency in which the veins are unable to return blood adequately from the affected legs to the heart; also, these adaptations may be associated with decreased cardiac output related to heart failure.
Which clinical manifestations would the nurse expect to identify when performing an admission history and physical for a client with chronic peripheral arterial disease? 1) Edema of the feet and ankles 2) Reddened and painful areas on the calves 3) Pain when exercising and thickening of the toenails 4) Ulcers around the ankles and reports of a dull ache in the legs
1) Serum sodium of 150 mEq/L (150 mmol/L) Hypercortisolism manifests as hypernatremia, or an elevated sodium level. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). A serum sodium concentration of 150 mEq/L (150 mmol/L) is an abnormal finding that supports hypercortisolism. The normal chloride ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5 mmol/L). The normal serum bicarbonate concentration ranges between 22 and 26 mEq/L (22-26 mmol/L). Decreased serum calcium level occurs in hypercortisolism.
Which laboratory finding is a characteristic feature in a client with hypercortisolism? 1) Serum sodium of 150 mEq/L (150 mmol/L) 2) Serum chloride of 100 mEq/L (100 mmol/L) 3) Serum potassium of 4.1 mEq/L (4.1 mmol/L) 4) Serum bicarbonate of 25 mEq/L (25 mmol/L
3) Can complete ROM with gravity eliminated A muscle strength rating of 2 signifies a poor ROM. This rating is given if a client completes ROM with gravity eliminated. A rating of 3 is given if the client has a complete range of motion against gravity. A rating of 1 indicates no joint motion and slight evidence of muscle contractility. A rating of 4 is given to a client who has the ability to complete ROM against gravity with some resistance.
While assessing a client with a musculoskeletal disorder, the nurse determined the client's muscle strength had a rating of 2. Which observation would correspond with this rating? 1) The client can complete range of motion (ROM) against gravity. 2) The client does not have joint motion and has evidence of slight muscle contractility. 3) The client is able to complete range of motion (ROM) with gravity eliminated. 4) The client can complete range of motion (ROM) against gravity with some resistance
1) Providing thorough perineal care after each voiding Weakened urinary sphincters and shortened urethras are age-related physiological changes in older adults. Because a shortened urethra has an increased potential for bladder infections, the nurse should provide thorough perineal care after each voiding. Encouraging the client to use the toilet or bedpan every 2 hours will help avoid overflow urinary incontinence. Responding quickly to the client's indication of the need to void will help alleviate urinary stress incontinence episodes. Applying voiding stimulants to the perineum will help initiate voiding in the client. Test-Taking Tip: Recall the effect on weakened urinary sphincters and shortened urethra in the client and choose the correct answer.
While reviewing the result of an intravenous pyelogram, the nurse discovers that the client has a shortened urethra. Which nursing intervention helps prevent complications associated with this condition? 1) Providing thorough perineal care after each voiding 2) Encouraging the client to use the toilet or bedpan every 2 hours 3) Responding quickly to the client's indication of the need to void 4) Applying voiding stimulants to the perineum
4) Educate the client about the effect of caffeine on the heart's conduction system. Education about the effect of caffeine on cardiac conduction will help the client understand the need to reduce caffeine intake. The other actions are appropriate, but will not help meet the client goal of making needed lifestyle changes. The client may have decaffeinated coffee, but providing decaffeinated coffee without any explanation will not help with understanding the reason for reducing caffeine intake. Tea usually does have less caffeine content than coffee, but the client needs education about the purpose of caffeine restriction. Many telemetry units do not permit caffeinated drinks, but the client needs to understand how decreasing caffeine may help reduce palpitations.
A client with palpitations who is admitted to telemetry for observation, asks the nurse for a cup of coffee. Which is the nurse's best response? 1) Bring the client a cup of decaffeinated coffee. 2) Offer to bring the client a cup of hot tea instead. 3) Tell the client that caffeinated drinks are not permitted on the telemetry unit. 4) Educate the client about the effect of caffeine on the heart's conduction system.
Clamp drainage tubing Attach a sterile syringe Aspirate the urine. Remove the clamp. In a client with an indwelling catheter, urine sample is collected by first applying a clamp, distal to the injection port, on to the drainage tubing. Then the injection port cap of the catheter drainage tubing is cleaned with alcohol. The next step is to attach a 5-mL sterile syringe into the port and aspirate the urine sample required. Finally, the clamp is removed so that the drainage is resumed. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.
Arrange the steps for the collection of a urine sample from a client with an indwelling catheter in correct order. 1.) Aspirate the urine. 2.) Remove the clamp. 3.) Attach a sterile syringe. 4.) Clamp drainage tubing.
1) Administering water after the feeding is completed Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question. 60%
The nurse provides education to a client who is learning how to self-administer gastrostomy tube feedings and would include which instruction? 1) Administering water after the feeding is completed 2) Maintaining the supine position during the feeding 3) Heating the feeding solution to slightly above body temperature 4) Determining tube placement by instilling water before the feeding
3) Keep the client in the semi-Fowler position With the head elevated, rather than horizontal or dependent, fluid will not collect in the interstitial spaces around the trachea. Because the client's gag reflex may not be intact, ice chips or fluid would not be offered. There is no restriction on turning the head after bronchoscopy. Medicated lozenges would not be suggested because they may numb the throat, further decreasing the gag reflex.
When caring for a client who has had a bronchoscopy in the ambulatory surgery unit, which action would the nurse take? 1) Offer ice chips to decrease throat pain. 2) Avoid turning the head from side to side. 3) Keep the client in the semi-Fowler position 4) Suggest medicated lozenges for sore throat.
1) Autosomal dominant 2) Characterized by young age of onset MODY is an autosomal dominant disease that is characterized by the young age of onset, which is typically before the age of 25. MODY is not associated with obesity and hypertension as type 2 diabetes is. MODY is characterized by a single gene mutation that leads to beta cell dysfunction with an inability of the pancreas to produce sufficient amounts of insulin, which makes insulin necessary; it does not result from a combination of inadequate insulin secretion and resistance. Clients with MODY do not generally present with fatigue, recurrent infection, and prolonged wound healing, but rather with polyuria, polydipsia, polyphagia, weight loss, weakness and fatigue, and sometimes ketoacidosis.
Which descriptors for maturity-onset diabetes of the young (MODY) would the nurse identify as accurate? Select all that apply. One, some, or all responses may be correct. 1) Autosomal dominant 2) Characterized by young age of onset 3) Associated with obesity and hypertension 4) Polygenic (>25 genes affect susceptibility) 5) Combination of inadequate insulin secretion and resistance 6) Presents with fatigue, recurrent infection, and prolonged wound healing