Exit 2024 #3 hesi exit

A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.

"Antidepressants usually begin to improve your mood after 2 to..4 weeks

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? a. "When did these voices begin?" b. "Have you taken any hallucinogens?" c. "Are you planning to obey the voices?" d. "Do you believe the voices are real?"

"Are you planning to obey the voices?"

While providing a health history, a female client tells the clinic nurse that she frequently..herself. Which question is most important for the nurse to ask?

"Have you thought about taking your life?"

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

"When I get out of bed quickly, I feel a little dizzy."

Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands and his anterior legs, Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? a. 50% b. 36% c. 9% d. 27%

27%

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess

Bacterial meningitis

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 100 beats/minute, and respirations of....manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse...

Begin supplemental oxygen

The nurse is caring for a client who is admitted to the emergency center...begins to experience a decreased level of consciousness and the...vital signs changes indicate the client is manifesting cushing's triad?

Blood pressure of 180/80 mmHg, bounding heart rate....apneic episodes

The nurse is teaching a primigravida about preeclampsia. Which findings...should be reported to the healthcare provider? SATA

Blurred vision Headache Swollen hands

The nurse observes a client prepare a meal in the kitchen of the rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (SATA) A) Leans forward to pull a pan from a high shelf B) Bends from the waist to pick trash off the floor C) Locks knees while preparing food on the counter D) Brings a heavy can close to the body before lifting E) Widens stance while working near the sink

Brings a heavy can close to body before lifting Widens stance while working near the sink

22. An older male client who was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? A) Contact the healthcare provider about the need to resume the client's antiviral medication. B) Teach the client about the importance of completing the full course of antiviral medication. C) Reassure the client that the infection is resolved and the pain should soon disappear. D) Review the medication record to determine when the last analgesic was administered.

D) Review the medication record to determine when the last analgesic was administered.

An adult woman who was recently diagnosed with type 2 diabetes mellitus...laboratory tests..The client's height is 5 feet 2 inches and weight is....SATA

Decrease processed carbohydrate in diet Eliminate alcohol intake except for special occasions Increase dietary fiber such as whole grains

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is..nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the...

Determine the client's level of mobility and need for assistance

An older client admitted to the psychiatric unit for assessment of a recent...that in the evening this client often becomes restless, confused, and agitated...important for the nurse to implement?

Ensure that the client is assigned to a room close to the nurses station

When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a.. Fruits without sauce b.Canned soup. c.Fresh or frozen vegetables without sauce. d.Cottage cheese. e.Pickled olives.

Fruits without sauce Fresh or frozen vegetables without sauce Cottage cheese

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? Assess for discomfort when procedure is completed. Instruct the client to keep hands under the sterile field Pour cleansing solution onto the sterile cloth field. Verify that the client has given informed consent.

Instruct the client to keep hands under the sterile field

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports...of causing bleeding. Which guideline is indicated for care for this child?

Keep the nails trimmed short

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH)....Which intervention is most important for the nurse to include in the plan of care?

Limit oral water intake

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement? a. Using analgesic spray to the perennial area to reduce pain b. Apply an ice pack to the perineum for the first 24 hours c. Teach the client how to practice kegel exercises d. Review the use of sitz bath equipment with the client

Review the use of sitz bath equipment with the client

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus...accurate for the nurse to provide?

The disease is characterized by alternating periods of flare-ups and..

The parents of a 6-year-old child recently diagnosed with Duchenne...child wants to continue attending swimming classes. How should...

Encourage the parents to allow the child to continue a...supervision

The nurse is caring for a client who is having a sickle cells crisis. What...this client's plan of care?

Ensure adequate IV and oral fluid intake

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication? A. Excessive lochia. B. Saturation of more than one pad per hour. C. Hypertension. D. Difficulty locating the uterine fundus.

Hypertension

During shift report, the charge nurse receives notice of several problems...Address first?

A bucket of water was spilled in the hallway

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow and requiring staff to observe airborne, as well as standard precautions?

A client with a positive Mantoux and sputum cultures results positive for AFB

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply).

A full pitcher of water is on the bedside table The client is lying in a supine position in bed

An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department and tranfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark, with fluctuation in the water seal...hour 74 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

Add sterile water to the suction control chamber

An older woman with a history of atrial fibrillation fell at home and fractured her left hip. She is currently...value of 5.0. Upon admission, which prescription should the nurse expect to implement?

Administer vitamin K injection

The nurse is assessing a client's breath sounds. Which medication from the client's..most positive effect on the respiratory finding?

Albuterol

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

An 18-year-old client with antisocial behavior who is being yelled at by other clients

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease (CKD) C. A restaurant chef who was diagnosed one year ago with hepatitis A D. A sales person who travels internationally and eats food in foreign countries.

An office worker who requires hemodialysis for chronic kidney disease

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dl. While assessing the client, what is the priority?

Assess for signs of fluid volume deficit

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute. The client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse...

Assess the delivery mechanism of the oxygen tank, tubing, and cannula

A male client who fell of a roof has right and left femur fractures and crushing injuries to both ankles. he is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention is most important for the nurse to implement? A. Request the healthcare provider to consider a different analgesic B. Evaluate the traction for amount of tension applied to each extremity C. Determine if client is experiencing cumulative effects of the total dosage D. Assess the extremities for signs of compartment syndrome q2 hours

Assess the extremities for signs of compartment syndrome q2 hours

A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 103/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain clients temperature q4 hour

Assess urine and stool for occult blood

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A.Serum sodium level. B.Hematocrit. C.Neutrophil count. D.Platelet count.

Neutrophil count

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Report any painful urination, blood in urine, or fever

A client with atrial fibrillation receives a new prescription for dabigatran etexilate...for the nurse to emphasize when teaching the client about this medication?

Report unusual bruising or bleeding

A 3-year-old boy successfully toilet trained prior to his admission....fall. His parents are very concerned that the child has regressed in his...should the nurse provide to the parents?

Children usually resume their toileting behaviors when...

The nurse is evaluating a tertiary prevention program for client with cardiovascular disease implemented in a rural health..

Clients who incurred disease complications promptly received rehabilitation

When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrants immediate action?

Complaint of increased pain and pressure Change in the quality of the peripheral pulses Loss of sensation to the left lower extremity

A 62-year-old male client tells the nurse that he has a high- density lipoprotein (HDL) level of 85 mg/dl. Which action should the nurse take? A. Encourage the client to reduce consumption of fatty foods B. Ask the client about hereditary cardiac risk factors C. Confirm that this value is helpful in reducing cardiac risk D. Explain that the client may need medication therapy

Confirm that this value is helpful in reducing cardiac risk

A client is admitted with the diagnosis of Wernicke's Syndrome. What assessment finding should the nurse use in planning the clients care? A. Right lower abdominal pain. B. Confusion. C. Peripheral neuropathy. D. Depression.

Confusion

The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of a FEST ? Confusion, restlessness Petechial rash. Tachycardia, fever Pulmonary crackles.

Confusion, restlessness

Which conditions are most likely to respond to treatment with an...

Contact dermatitis Allergic rhinitis

The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion siteB. Equal bilateral chest expansion C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute A. Diminished breath sounds over the trocar insertion site

Diminished breath sounds over the trocar insertion site

A new nurse preparing to irrigate an intravenous catheter is a attaching a...the charge nurse implement?

Direct the nurse to change the IV tubing

The nurse is preparing to send a client to the cardiac catherization lab for eletive...intervention should the nurse implement before the client leaves the medical unit?

Document that the client has remained NPO

A client arrives for an annual physical exam and complains o having calf pain. The client's health history..the client about expected findings related to chronic arterial symptoms?

Does the calf pain occur when walking short distances?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Ear pain, and fever

The nurse observes a practical nurse (PN) pouring warm water over...frequent urinary incontinence while the client is positioned on a bedpan..

Evaluate the effectiveness of this measure to stimulate

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? Experiences facial swelling after eating crab. Drank a glass of water in the past 2 hours. Reports left chest wall pain prior to admission. Verbalizes a fear of being in a confined space.

Experiences facial swelling after eating crab

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A.Regular contractions occurring every 10 minutes B.Biophysical profile results showing oligohydramnios. C.Sterile vaginal exam revealing 3 cm dilatation D.Fetal heart tones located in upper right quadrant

Fetal heart tones located in upper right quadrant

After an in-service about electronic health record (EHR) security and safeguarding client information, the...information in a uniform pocket. Which action should the nurse take?

File a detailed incident report with the specific hiring facility

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? - take out dentures and place in a labeled cup - apply a body shroud - place a small pillow under the head - remove resuscitation equipment from the room - gently close the eyes

Gently close the eyes Remove resuscitation equipment from the room Place a small pillow under the head

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take?

Give the client a glass of orange juice

Which woman should the nurse consider at the highest risk for cervical...cancer?

History of unprotected sex with multiple partners

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis. Which education should the nurse provide the client with regard to take prednisone?

If sequential doses are missed, notify the healthcare provider

A young woman with multiple sclerosis just received several immunizations...college dormitory . Two days later, she reports to the nurse that she is experiencing...problems. What teaching should the nurse provide?

Immunizations can trigger a relapse of the disease, so get....

The nurse is caring for a client admitted for evaluation of a descending aortic...documenting, the nurse hears the client screaming. The client tells the nurse..something inside is ripping and tearing. The client also reports dizziness...cause?

Impending rupture of the aneurysm

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving lactated ringers 50...IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client heart rate is 155 beats/minute, and his blood pressure ... In addition to reporting the findings to the surgeon, which action should the nurse implement first?

Increase the infusion rate of Lactated Ringer's solution

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (APTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A.Increase the warfarin dose. B.Withhold the heparin and continue the same dose of warfarin. C.Decrease the heparin dose. D.D Increase the heparin dose and decrease the warfarin dose.

Increase the warfarin dose

A woman who had bariatric surgery 2 months ago is it admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client's plan of care? A. Encourage positive self accolades for dietary adherence. B. Determine if the client is over-hydrating to feel satiated. C. Maintain the client on an NPO status. D. Administer daily vitamin supplements.

Main the client on an NPO status

Which intervention is most important for the nurse to include in the plan of care..mechanically ventilated and is receiving continuous enteral feedings?

Maintain the head of the bed elevated a 45 degrees

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's...the nurse take first?

Match ID bands of all infants and mothers on the unit

The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? a. Measure ankle circumference b. record usual eating patterns c. Evaluate for muscle cramping d. Document abdominal girth

Measure ankle circumference

The charge nurse in an extended care facility is organizing unit activities for...delegated to the practical nurse (PN)?

Measure the client's body weight each morning

A client with metabolic syndrome plans to begin an exercise program. What instruction...nurse to provide this client?

Monitor blood pressure and heart rate as exercise activity is increased

The nurse notices that a male is particularly delusional one afternoon...appears to be losing control of himself. Which intervention is best for....

Move the client to a quiet place on the unit

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse...client's living will. Which action should the nurse take?

Notify the healthcare provider of the client's wishes

The nurse provides sliding scale insulin administration instructions to an...diabetes mellitus. The client demonstrates an understanding of the instructions...procedure in which order? Arrange answers

Obtain blood glucose level Verify insulin prescription Draw insulin into insulin syringe Cleanse the selected site

A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA)...should the nurse implement during the admission process for this client?

Obtain psychiatric and medical admission records Interview client about reason for admission to hospital Review the list of home medications and dosages

The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. What action should the nurse take next? A. Open the roller clamp on the tubing B. Label the bag of IV solution C. Attach the tubing to the saline lock D. Flush the saline lock with saline

Open the roller clamp on the tubing

While changing a client's postoperative dressing, the nurse observes....amount of yellow and green drainage and a foul odor...Given there is...Staphylococcus aureus (MRSA), which is the most important action...?

Request a wound culture and sensitivity

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Place the side rails in an up position

A female child is brought to the emergency department after awakening with...arrival to the hospital, her respirations are labored, and she is drooling. What...implement?

Prepare for emergency tracheotomy

The nurse is providing care for a child who is brought to the emergency department...to the leg from a barbed wire fence. The child has not received any tetanus injections...early signs of muscular rigidity with spasms and jaw clenching or trismus...nurse's highest priority for this child?

Prepare for intubation with mechanical ventilation

The nurse should be most concerned about risk for injury (falls) after administering...

Promethazine

To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse...

Provide education both verbally and in written format

The laboratory findings for a client with chronic kidney disease (CKD) include elevated..and serum creatinine levels. The client reports feeling fatigued and is unable to con..assessments. Based on these findings, which action should the nurse implement?

Provide high protein snacks.

A nurse determines that more than 25% of students at a middle school are overweight. The nurse presents the information..important for the nurse to include in the meeting?

Provide information on ways to increase activity for the family

The nurse is feeding an older adult who was admitted with aspiration...coughing while attempting to drink through a straw. Which intervention...

Request thick nectar liquids for the client

Following a total knee replacement, a client is discharged from the hospital....reviewing discharge teaching, the client ells the nurse that he will avoid eating bananas and melon. How should the nurse respond?

Review teaching about the effects of foods rich in vitamin K

An older adult client withchronic emphysemais admitted to the emergency room from home withacute onset of weakness, palpitation, and vomiting. Whichinformation is most importantfor the nurse to obtain during the initial interview? A.Recent compliance with prescribed medications. B.Sleep patterns during the previous few weeks. C.History of smoking over the past 6 months. D.Activity level prior to onset of symptoms

Recent compliance with prescribed medications

An older client is admitted to the hospital because of recurring transient ischemic attack...assessments for the past 24 hours were within normal limits/ One day after admission...becomes confused and combative indicating impaired mental status (IMS). What in...implement first?

Reduce environmental stimuli

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client..take?

Remind the UAP to continue rubbing the hands together until they are dry

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

Serum potassium, calcium, phosphorus

The nurse is assigned to care for a client diagnosed with psoriasis....client's psychosocial need for acceptance?

Shaking the client's hand during an introduction

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicated...provider?

Skin tenting occurs when the client's forearm is pinched

A male client with right-sided weakness calls for assistance with ambulating...the nurse implement?

Stand on the client's right side as he walks

A client develops urticaria on the trunk and neck shortly after a secondary infusion of puperacillin in initiated. In what...the actions in order of priority..

Stop the infusion Assess vital signs Contact the healthcare provider Document reaction to the drug Initiate an adverse event report

Which snack selection indicates to the nurse that a school-aged boy with gas...dietary retrictions?

Sugar cookies

An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? A. Use hand and arm gestures to improve communication and comprehension B. Provide additional light in the room to promote sensory stimulation C. Place a clock and calendar in the room to improve orientation D. Teach the client to turn his head from side to side for visual scanning

Teach the client to turn his head from side to side for visual scanning

A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should...

Tell the client in a matter-of-fact manner to stop the sexual advances

The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm3. What intervention should the nurse implement?

Verify that Client B has two units of packed cells available