Cat 4 Hesi Exit
2- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
Ask the woman if she also performs monthly breast self- exams.
17- Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
Ineffective Tissue Perfusion
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
Ineffective airway clearance
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
Inspection of the mouth
The UAP asks if it is necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day. What information should the nurse provide the UAP?
It is important to continue straining all the client's urine
A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?
Prepare for intubation with an endotracheal tube
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
Prepare the medication using a new syringe
The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
a. Tachycardia, mental status change, and low urine output
84- A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?
a. Usual and current weight
22- A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?
d. Breath sounds
A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. The nurse should allow this client to have how much oral intake during the next 24 hours?
d. Limit oral intake to 900 to 1,000 ml
52- The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother, as gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understand the instruction?
d. Positions the infant supine in the crib to sleep(cuna)
71- A client whose finger stick glucose is 210 mg/dl is receiving a sliding scale dose of short-acting insulin before breakfast. In what sequence should the nurse prepare the dose of insulin? (Arrange from first on top to last on the bottom)
determiner,cleanse,use,verify)
A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, "I wish this medicine would hurry up and dissolve this clot in my ling so that I can go home". What response is best for the nurse to provide?
"Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely"
The nurse believes that a client who frequently requests pain may have a substance abuse problem. Which intervention reflects the nurse's value of client autonomy over veracity?
a. Administer the prescribed analgesic when requested
A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, "altered nutrition, less than body requirements related to anorexia, nausea, vomiting" is identified. Which intervention should the nurse include in this child plan of care?
a. Allow the child to eat foods desired and tolerated
The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?
a. Assess the need for continued restraint
54- "Oxygen at liters/min per nasal cannula PRN difficult breathing" is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
a. Avoiding the administration of oxygen at high levels for extended periods.
After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol's effectiveness?
a. Compare the number of falls that occurred before and after protocol implementation
The nurse is making assignments for a new graduate from a practical nursing program that is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client
. Whose discharge has been delayed because of a postoperative infection
A client who had an intraosseous (IO) cannula placed by the healthcare provider for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO sit. The skin around the site is pale and edematous. What action should the nurse takes first?
a. Discontinue the IO infusion
68- A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?
A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol
An angry client screams at the emergency department triage nurse, "I've been waiting here for two hour! You and the staff are incompetent" What is the best response for the nurse to make?
"I understand you are frustrated with the wait time"
When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?
"I will use crutches to keep my weight off my knee"
The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?
"Make her responsible for the consequences of her drinking behaviors"
The nurse teaches the mother of a 6 year-old anemic boy to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
"The iron tablets will be absorbed between meals, on a empty stomach"
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, "What do you think you're doing?" How should the nurse respond?
"This shot will help relieve the pain in your feet.""This shot will help relieve the pain in your feet."
When the nurse enters the room to change the dressing of a male client with cancer, he asks, "Have you ever been with someone when they died?" What is the nurse's best response to him?
"Yes I have. Do you have some questions about dying?"
55- The healthcare provider prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administer every 8 hours. The medication is available in a bottle labeled, "Amoxicillin (Amoxil) suspension 200 mg/5 ml." How many ml should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
55- The healthcare provider prescribes amoxicillin Ans: 12.5
24-Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?
A middle-age male client in renal failure following an unsuccessful kidney transplant
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers hisbreakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
Instruct the client to eat his breakfast and take the Zithromax two hours after eating
37- When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll o the bottom right corner of each tab to view all information contained in the client's medical record.
ANS 5
A client receives a prescription for acetylcysteine (Mucomyst) 1.4 grams per nasogastric tube q4 hours. Acetylcysteine is available a 10% solution (10 grams/100ml). How many ml of the 10% solution should the nurse administer per dose? (Enter the numerical value only.)
Ans: 14
A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. what is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)
Ans: 2 0.4 mg/dose = x mg/5 doses X= 2 mg
36- When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.
Ans: 42
The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
Ask the girl if she will be eating her breakfast this morning
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
Ask the nurses to meet with the nurse-manager to identify ways of working together
A female client tells the clinic nurse that she has doubts of binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?
Interview the client about her use of laxatives and diuretics
A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?
Begin visualizing himself driving each route to the freeway
40- A 9 year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
Blow cool air from a hair dyer under the cast
The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?
Calcium
The nurse in the newborn nursery admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finds helps to confirm this diagnosis?
Centralized cyanosis and tachycardia when crying
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
Change the position slowly
The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
Combine several legumes and grains such as beans and rice to form complete proteins
Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?
Complaints of shortness of breath on exertion
When preparing the client for a thoracentesis, it is essential for the nurse to take which action?
Determine if chest x-rays have been completed
57- A 2-year-old boy has short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?
Elevated urine specific gravity
56- A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every mouth. What action should the nurse implement in response to the client's statements?
Encourage the client to perform BSE 2 to 3 days after menstrual period ends
When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advances cirrhosis, he complains that it causes diarrhea. What action the nurse takes in response to the client's statement?
Explain that diarrhea is expected, but the drug reduces ammonia levels
28- The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority or this child?
Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr
1- A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
He is in a coma, and has a very poor prognosis
An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and is "too busy to eat." He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?
Imbalanced nutrition
A client who had a cerebral vascular accident (CVA) Is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
Impaired skin integrity related to altered circulation and pressure
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.)
Increased heart rate b. Visual disturbances Decreased mentation
Several clients on a telemetry unit are schedule for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is
Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?
Maintain possession of the evidence collection kit at all times until submitted to law enforcement
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
Maintain skeletal pin sites and assess for signs of infection
A male client admitted three days ago with respiratory failure is intubated and with 40% oxygen per facemask is initiated. Currently his temperature is 99 F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful estuation?
Maintains effective breathing pattern
A client a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
Measure all emesis accurately
The nurse notices that a client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
Measure the client's capillary blood glucose
While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
Measure the length of the apneic periods(longitude)
A client with a BMI of 60.2 kg/m is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?
Mechanical ventilation
The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?
Metabolic alkalosis
Which action should the nurse include in the plan of care a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
Monitor serum creatinine levels
One hour after delivery the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
Perform gentle massage at the level of the umbilicus
In deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factors is most important for the nurse to consider?
Personal value system
50- Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?
Propose a method for self-staffing labor and delivery
The nurse is caring for a laboring 22 year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
Raising the side rails and placing the call bell within reach
14- Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
Record the findings on the flow sheet
The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?
Red
A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?
Remove the client's peripheral IV access
Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?
Right calf is 3 cm larger in circumference than the left
15- A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?
Search all personal belongings
When obtaining a urine specimen from a female infant, which intervention should the nurse implement?
Secure the pediatric urine collector bag to the perineum
29- A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?
Seek treatment for the sarcoma immediately
A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?
Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client's plan of care?
Sit upright and flex chin forward while swallowing(quija)
42- A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
Take the client to a room for supervision by staff
While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witness the event take?
The Heimlich maneuver using chest thrusts
A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
The full thickness burn has destroyed the nerves
The nurse is preparing to teach the parents of a child who had surgical repair of a myelomeningcole how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
The incision should be protected from fecal contamination by an intact dressing
The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide?
The medication will help you think more clearly"
A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with this client, which information is most important for the nurse to determine?
The nurse's feeling about this client
11-What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?
Treat sexual partner (s) concurrently
62- An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action the nurse takes first?
Turn off the oxytocin (Pitocin) infusion
Which behavior is most likely to result in a breach of client confidentiality?
Two nurses planning a client's care while having lunch in the hospital cafeteria
A client has a history of vasovagal attacks resulting in brady-dysrthmias. Which instruction is most important to include in the teaching plan?
Use stool softeners regularly
The nurse is preparing to administer an IM injection to a 6 month-old child. Which injection site is best for the nurse to use?
Vastus lateralis
The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus infection in infants who are starting to eat foods?
Wash hands before any food preparation
A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
Wear a dosimeter film badge when in the client's room
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to male room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
b. A 35-year-old with lupus erythematous
A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?
b. Administer a retention enema of Kayexalate
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage cheese" appearance. Which prescription should the nurse implement first?
b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
83- The nurse is obtaining the medical histories of new clients at a community- based primary care clinic. Which individual has the highest risk for experiencing elder abuse?
c. A 78-year-old female on a fixed income who lives with her relatives
In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
c. Administer the dose of furosemide as scheduled
A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?
c. Inspire deeply and slowly over 3 to 5 seconds
46- When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?
c. Select a large, deep muscle mass
The nurse in a community health clinic is interviewing a female client who has tree children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?
d. A diaphragm and condom provide effective contraception when used together
The nurse is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client?amarillo,ictericia
d. Bilirubin
