Hesi exit

62. A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct?

"An antibiotic ointment is placed in each newborn's eyes to prevent infection."

A nurse determines that dietary teaching for a client with mild preeclampsia has been effective when the client says:1"I should follow a diet that includes high sodium and calories and low protein."2"I should follow a diet that includes low sodium and calories and high protein."3"I should follow a diet that includes unrestricted sodium and lots of calories and protein."4"I should follow a diet that includes moderate sodium and low calories with ample protein."

"I should follow a diet that includes unrestricted sodium and lots of calories and protein." One of the many factors believed to contribute to the development of preeclampsia is inadequate nutrition. Therefore recommendations call for a nutritious diet that includes unrestricted sodium, high protein, and a sufficient number of calories. Additional intake of 300 calories/day is required during pregnancy.

Which information would the nurse give a pregnant client about having a chorionic villus sampling (CVS) before the 10th and 12th weeks?

1. The test can cause fetal anomalies.

Indicate the first step involved in the disposal of sharp wastes after use on a client with acquired immunodeficiency syndrome (AIDS).

3 Place the waste in a puncture-resistant container.

A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the GTPAL system?

4-1-2-0-4

During which week of gestation would a ruptured tubal pregnancy most commonly occur?

6th

A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client?

A terminally ill and depressed client with cancer.

While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? Continue the interview process and record the findings. Refer the client to a psychiatric outpatient clinic. Determine if there is a family history of emotional disorders. Encourage the woman to attend citizenship classes. Submit

Continue the interview process

An electronic fetal monitor is applied to a client in labor who is dilated to 4 cm. Which assessment finding would cause the nurse to notify the health care provider?

Contractions every 1 to 2 minutes lasting 90 seconds

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan?

Method used to aspirate medication from a vial.

Confabulation

the act of filling in memory gaps (false memories)

The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment?

urine output to 55ml

The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective?

Cleans perianal area with mild soap and water after each diarrhea stool.

A newly pregnant client reports that she is taking isotretinoin. Which statement applies to the care of this client?

Isotretinoin is teratogenic and is associated with major fetal malformations, so the client should stop the medication immediately.

Which statement by a new mother observing her preterm infant in the neonatal intensive care nursery indicates that she has not yet begun the bonding process?

It is such a tiny baby

Which education is appropriate to give a client at 16 weeks' gestation whose partner has just informed her that he has genital herpes?

Latex or polyurethane condoms must be used when the couple is having intercourse.

A client at 36 weeks' gestation has gained 5 lb (2.3 kg) in the previous week and has a pronounced increase in blood pressure. Which is the initial intervention upon admission of the client to the high-risk unit?

Providing a dark, quiet room with minimal stimuli

The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first?

Reassess the rate and characteristics of the client's pulse.

A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented?

Acetylcysteine(mucomyst) 140 mg/kg

Which condition contraindicates oxytocin induction?

Active genital herpes infection

The charge nurse, along with another RN and a practical nurse (PN) are caring for clients on a medical/surgical unit. Which nursing action should be assigned to the PN?

Administer a bolus tube feeding through a gastrostomy tube.

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take?

Complete an adverse occurrence report and submit it to the nurse-manager.

Which instruction regarding fluid and nutritional intake would the nurse give to a client with mild preeclampsia?

Continue pregnancy diet

While assessing a client with acquired immunodeficiency syndrome (AIDS), the nurse suspects that the client has developed cryptococcosis. Which clinical manifestations support the nurse's suspicion of a cryptococcosis infection? Select all that apply.

Seizures fever confusion

The nurse is assessing a pregnant client at the end of her second trimester. Which clinical finding causes the nurse to suspect that the client has preeclampsia?Progressive weight gainTwo urine samples showing proteinuriaDependent ankle edema during the late afternoonBlood pressure fluctuations on three successive measurements

Two urine samples showing proteinuria

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare?

immediate cesarean birth

A nurse is assessing a client who presents with a circumscribed, hypertrophic, flesh-colored papule on the skin. The client reports pain upon lateral compression. What should the nurse suspect in the client?

Verruca vulgaris

Which dietary nutrients would the nurse teach a client regarding the support of natural defense mechanisms?

Vitamins ACE and selenium support immune funciton

An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first?

ask if she is going to the bathroom frequently

A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question?

because it is an anticholinergic, which causes pupil dilation.

ulcerative colitis

chronic inflammation of the colon with presence of ulcers

A client is admitted at 40 weeks' gestation with her cervix dilated 5 cm and 100% effaced, the presenting part at station 0, and fetal heart tones heard just above the umbilicus. Which fetal presentation is indicated by these assessment findings?

Answer: 3 Breech In the breech presentation, the fetal head is in the fundal portion of the uterus; the chest or back is at or above the umbilicus, where fetal heart tones can be heard. In the vertex presentation the head is the presenting part; the chest and back are in lower quadrants, where the fetal heart is heard. The brow presentation is a type of cephalic presentation in which the fetal head is partially extended; the fetal heart is heard in the lower abdomen, not above the umbilicus. In the shoulder presentation the fetal heart usually is heard in the midabdominal region.

Which comfort intervention would the nurse recommend to a client's coach when the client reports low back pain?

Apply pressure to her back during contractions

A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that she has shoulder pain. The nurse concludes that the pain is caused by:

Blood accumulation under the diaphragm

What information in a postpartum client's health history should alert the nurse to monitor the client for signs of infection?

Blood loss of 850 mL after a vaginal birth

The nurse is assessing an older adult client's living arrangements and care. Which situation should the nurse identify as contributing the most to the client's vulnerability for elder abuse?

Caregivers stress level is overwhelming

A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms?

Chlorpheniramine

A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first?

Describe the placement and rationale for care of the catheter.

Which action would the nurse take based on receiving a laboratory report stating that a client receiving magnesium sulfate 2 g/h IV for preeclampsia has a magnesium level of 6.4 mEq/L (0.30 mmol/L)?

Documenting the level in the client's electronic medical record

A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority?

Intensity of pain

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest?

Mild preeclampsia Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.

To which of these four assigned clients with a mouth infection would the nurse anticipate administering nystatin as an oral suspension?

Moniliasis

Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder?

Participates in one social or recreational activity each morning and afternoon

About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat?

Peanut butter crackers

Why is a multiple-gestation pregnancy considered a high risk?

Perinatal mortality is two to three times more likely in multiple than in single births.

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. Which is the nurse's most important goal for the client at this time?

Reducing her blood pressure

stpes in inflammation

Stage I is the vascular part of the inflammatory response that first involves changes in blood vessels. Blood vessel changes cause redness and warmth of the tissues. Increased blood flow to the area causes swelling at the site of injury. Capillary leakage allows blood plasma to leak into the tissues, which causes pain. Edema at the site of injury protects the area from further injury by creating a cushion of fluid. To enhance the inflammatory response, cytokines are released, which trigger the bone marrow to shorten the time needed to produce white blood cells.

A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response?

Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. Correct

An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority?

Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute.

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next?

Start the transfusion of blood

The nurse inflates the cuff on a tracheotomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow?

A. Inject air until no air is auscultated over the larynx during a deep breath.

A client in early active labor at 40 weeks' gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168 and 174 beats/min. Which is the priority nursing action?

Assessing maternal vital signs

The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first?

Auscultate heart lungs

The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.)Correct0. Clamp the drainage tubing.1. Label the urine specimen.2. Place in a biohazard bag.3. Document the procedure

Clamp the drainage label the urine specimen -place in biohaz bag -document said procedure

A client is scheduled for a sonogram at 36 weeks' gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect?Hydatidiform moleVena cava syndromeMarginal placenta previaComplete abruptio placentae

Complete abruptio placentae(Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.)

Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? Improve the client's body perception. Consume at least 50% of all meals. Exercise no more than one hour daily. 5% decrease in serum potassium level

Consume 50% of all meals

Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6 F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take?

Notify HCP

The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged?

Observe the client while demonstrating crutch walking.

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction?

Obstruction at the urinary bladder neck.

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. Which instruction would the nurse provide to the client in this situation?

Pant while resisting the urge to bear down

Which action should the nurse implement when using the confrontation technique during a vision exam?

Sit facing the client and while look directly at the client's face, move an object inward from the periphery.

The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider?

Sp02 of 88% with shallow and slow respirations

A pregnant client is concerned that she may have been infected with human immunodeficiency virus (HIV). Which information should a nurse include when counseling this client regarding HIV testing?

The risks of passing the virus to the fetus. What positive or negative test results indicate. The emotional, legal, and medical implications of test results.

When admitting a client at 38 weeks +2 days' gestation, the nurse notes that the woman is sweating profusely, has dilated pupils and irregular respirations, is hypertensive, and complains of very severe pain with contractions. The external fetal monitor shows fetal tachycardia with excessive fetal activity. Which problem would the nurse suspect?

cocaine abuse

When assessing a client with a new diagnosis of syphilis, which actions would the nurse implement? Select all that apply. One, some, or all responses may be correct. -Ask the client about medication allergies. -Use the fingers of one hand to palpate lesions. -Examine the client's lymph nodes for enlargement. -Gather information about any ulcers or rashes. -Perform a Papanicolaou (Pap) test (smear) of the cervix. -Ask about the client's sexual activity and protection methods.

correct1 Ask the client about medication allergies. Incorrect2 Use the fingers of one hand to palpate lesions. Correct3 Examine the client's lymph nodes for enlargement. Correct4 Gather information about any ulcers or rashes. Incorrect5 Perform a Papanicolaou (Pap) test (smear) of the cervix. Correct6 Ask about the client's sexual activity and protection methods.

A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement?

encourage family members to bring food from home

Which medication can be administered via the intramuscular route to treat anaphylaxis?

epinephrine

A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential?

fundal height

How to reduce Hep A in school?

immunization

Where can fetal heart tones be heard best when the fetus is in the right sacrum anterior (RSA) position? Select the location based on the

top right When the fetus is in a breech (sacrum and feet) presentation, fetal heart tones are heard above the umbilicus. With a right anterior position, the back is on the maternal right side. Option b is the location in which to place the ultrasound transducer when the fetus is in the left sacrum anterior (LSA) presentation/position. Option c is the location at which to place the ultrasound transducer when the fetus is in the right occipitoposterior (ROP) presentation/position. Option d is the location at which to place the ultrasound transducer when the fetus is in the left occipitoposterior (LOP) presentation/position.