HESI 114 Review Question's from Prep U

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids. Explanation: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order? Deferoxamine Montelukast Ramipril Flurazepam

deferoxamine Explanation: Deferoxamine is used for the treatment of iron overload by ridding the body of the extra iron. Montelukast is a bronchodilator used for chronic asthma. Ramipril is a antihypertensive used to treat hypertension. Flurazepam is a sedative/hypnotic that is used for insomnia.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

"I will administer the enema while lying on my left side with my right knee flexed." Explanation: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

The nurse administers the wrong dose of a medication. Instead of giving furosemide 20 mg orally, the nurse forgets to break the tablet in half and gives furosemide 40 mg orally. The client experienced no harm as a result. What should the nurse do? Select all that apply. 1. Continue to monitor the client's vital signs and urinary output. 2. Notify the health care provider, supervisor, and client. 3. Complete an incident report, outlining the events of the incident. 4. Document the time and amount of medication given. 5. Nothing, because no harm came to the client and no further action is needed.

1. Continue to monitor the client's vital signs and urinary output. 2. Notify the health care provider, supervisor, and client. 3. Complete an incident report, outlining the events of the incident. Explanation: The medication given was double the amount prescribed, and it is important to document the amount given and continue to monitor the client. An incident report needs to be completed that outlines the events, provides the client's status, and documents that all parties involved were notified of the events and the client's current status. The incident report is a process used by health care organizations to monitor events that occur. Documenting this information on the client's chart allows a legal team the option to subpoena the document. Doing nothing prevents a health care organization from analyzing the near misses or errors that occur and facilitating identification of system processes that need to be changed.

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations?

Encourage the family members to express their feelings and listen to them in their frank communication. Explanation: Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying patient. It is not advisable for the nurse to encourage conversations on the impending death of the patient. Being a silent observer or encouraging the family members to spend time with the dying patient may not help the family members to express their feelings.

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?

Extravasation Explanation: The client is exhibiting signs of extravasation, which occurs when the medication leaks into the surrounding tissues and causes swelling, burning, or pain at the injection site. Erythema is redness of the skin that results from skin irritation. Flare is a spreading of redness that occurs as a result of drawing a pointed instrument across the skin. Thrombosis is the formation of clot within the vascular system.

The nurse is assisting in moving a client in bed. Which muscles should the nurse use during this move to prevent a personal injury? Select all that apply. Back Legs Arms Buttocks Abdomen

Legs Arms Buttocks Abdomen Explanation: The longest and strongest muscles of the arms and legs should be used to provide the power needed in strenuous activities. The muscles of the buttocks and abdomen stabilize the pelvis and protect the abdominal viscera when pulling. The muscles of the back are less strong and more easily injured when used improperly.

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation?

Return the neonate to the nursery, inform the physician so the physician can thoroughly examine the neonate for injuries, and notify social services for assistance. Explanation: The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

A client asks the nurse why epoetin alfa is administered during dialysis sessions. Which response by the nurse is accurate?

"The medication is a form of erythropoietin that stimulates red blood cell production." Explanation: Epoetin alfa stimulates red blood cell production essential for clients with chronic renal failure. It is not used to eliminate the rise of creatinine, to assist activity levels, or to increase renal output. Remediation:

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?

Assess the vital signs and oxygen saturation levels. Explanation: The correct response is based on the principle of prioritizing assessment of airway, breathing, and circulation (ABC) for every client. Assessing vital signs and oxygen saturation, therefore, is the priority. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the postanesthesia care unit. Checking the dressing and level of pain are both important but not the priority.

The roommate of a recently deceased client is observed sitting in the client lounge crying. What should the nurse do to support this person?

Console the roommate as grieving begins. Explanation: In a health care facility, other clients are often aware of a death and may need to be consoled. Other clients may have a grief reaction and should be supported through the grief process. The client's roommate should not be left alone. The room should not be changed without first discussing it with the client. The facility chaplain should not be notified without the client's permission or request.

The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply. Sloughing tissue Tissue necrosis Active bleeding Effectiveness of the antidote

Sloughing tissue Tissue necrosis Effectiveness of the antidote Explanation: Extravasation of vesicant chemotherapeutic agents can lead to erythema, sloughing, and necrosis of surrounding tissue, muscle, and tendons. To reduce the likelihood and severity of symptoms due to extravasation of a vesicant, antidotes matched to the vesicant are administered. Nurses caring for a client who experienced extravasation of a vesicant should assess for sloughing tissue, tissue necrosis, erythema, and effectiveness of the antidote.

A nurse-manager is preparing for annual staff performance evaluations. Which action is most appropriate for the nurse-manager to include?

Provide feedback on strengths as well as areas for improvement while formulating a plan to improve. Explanation: An effective performance evaluation recognizes strengths, identifies areas for improvement, and clarifies performance expectations. Recognizing strengths increases employee morale, so limiting the evaluation to areas of improvement and goals may leave an employee feeling defeated. The nurse-manager should conduct performance evaluations privately, not in front of others. The nurse-manager should document in writing all components of a performance evaluation. Although input from staff members can be useful in preparing performance evaluations, asking other nurses to conduct performance evaluations is inappropriate. The nurse-manager is responsible for the performance of the staff

Which is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area. Explanation: When a fingertip is pressed over the reddened area and the area does not blanch but remains consistently reddened, it is an indication of deep tissue injury. The other choices are not appropriate ways to treat a reddened area.

The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?

The difference between the systolic and diastolic pressure Explanation: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.

The nurse is justified in assessing for sexual dysfunction among male clients who are taking

anti-hypertensives Explanation: Antihypertensives are among the drugs implicated in sexual dysfunction. Antibiotics, bronchodilators, and NSAIDs do not typically have this effect.

Vasoactive drugs, which cause the arteries and veins to dilate, thereby shunting much of the intravascular volume to the periphery and causing a reduction in preload and afterload, include agents such as

sodium nitroprusside. Explanation: Sodium nitroprusside is a vasodilator used in the treatment of cardiogenic shock. Norepinephrine is a vasopressor that is used to promote perfusion to the heart and brain. Dopamine tends to increase the workload of the heart by increasing oxygen demand; thus, it is not administered early in the treatment of cardiogenic shock. Furosemide is a loop diuretic that reduces intravascular fluid volume.

When moving a client in bed, the nurse can ensure proper body mechanics by:

standing with her feet apart. Explanation: When moving a client in bed, the nurse should stand with her feet apart to establish a wide base of support. To reduce the amount of energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull rather than lift the client. The nurse should flex her knees and use her arm and leg muscles instead of her back. To minimize stress, the nurse should stand as close to the client as possible.

The parent of a 28-year-old client who is taking clozapine states, "Something's wrong. My son is drooling like a baby." What response by the nurse would be most helpful?

"Excess saliva is common with this drug; here's a paper cup for the client to spit into." Explanation: Telling the parent that excess saliva is a common adverse effect of the drug is most helpful because it gives the parent information about the problem, thereby helping to decrease anxiety about what is occurring with the client. By offering the paper cup, the nurse also demonstrates concern for the client, thereby leading to increased trust. Saying "I wonder if they are having an adverse reaction to the medicine" shows the nurse's lack of knowledge about the drug, decreases confidence in the nurse, and indicates poor judgment. Saying "Don't worry about it, it's only a minor inconvenience compared to its benefits" or telling the parent that the nurse has seen this happening to other clients is insensitive and does not assuage the parent's anxiety.

A patient near the end of life is experiencing anorexia-cachexia syndrome. What characteristics of the syndrome does the nurse recognize? (Select all that apply.) Neurologic dysfunction Bladder incontinence Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia

Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia Explanation: Anorexia and cachexia are common in the seriously ill. The profound changes in the patient's appearance and a lack of interest in the socially important rituals of mealtime are particularly disturbing to families. The approach to the problem varies depending on the patient's stage of illness, level of disability associated with the illness, and desires. The anorexia- cachexia syndrome is characterized by disturbances in carbohydrate, protein, and fat metabolism; endocrine dysfunction; and anemia. The syndrome results in severe asthenia (loss of energy).