HESI-Focus on Adult Health

a client with an AKI has a rx for oral sodium polystryene sulfonate. Which serum electrolyte value does the nurse recognize as the cause for this rx

potassium 5.9

a nurse is monitoring a client with MI for signs of left ventricular HF. The nurse specifically monitors the client for

pulmonary congestion

a client who sustained a major burn is beginning to take an oral diet again. Which b/w meal menu selections meet the client's needs for wound healing and tissue repair SATA a) apple slices and skim milk b) whole milk a shake and granola c) baked potato topped with cheese d) cheese and whole wheat crackers e) cauliflower with low fat ranch dip

b-d

a client is undergoing anticonvulsant therapy with phenytoin. Which lab parameter does the nurse monitor most closely in this client

CBC count

a nurse caring for a client with a spinal cord injury is watching for signs of autonomic dysreflexia. For which manifestation of this complication does the nurse monitor the client

nasal stuffiness and headache

a nurse is caring for a client who is experiencing spinal shock after sustaining a spinal cord injury. The nurse monitors the client for GI complications, watching for

a distended abdomen with an absence of bowel sounds

a client infected with HIV has a T4 count of 150 and a low CD4/CD8 ratio. On the basis of these values, the nurse concludes that the client is

a risk for opportunistic infection

a nurse performs a fingerstick glucose test on a client who is receiving TPN and obtains a reading of 410. On the basis of this finding, the nurse would most appropriately

notify the HCP

for which findings, early signs of increased ICP, does the nurse caring for a client who sustained a head injury monitor the client. SATA a) headache b) decorticate psoturing c) widened pulse pressure d) shallow, slowed resp e) decreased LOC

a) headache e) decreased LOC

a client who is undergoing hemodialysis is receiving epoeitin alfa. With which nutrients does the nurse instruct the client to supplement his diet to enhance the effects of therapy SATA a) iron b) protein c) calcium d) folic aicd e) potassium f) vitamin D

a) iron d) folic acid

a client sustains a fractured femur and pelvic fractures in a MVA. For which s/s, indicative of hypovolemic shock, does the nurse monitor the client closely SATA a) fever b) oliguria c) bradypnea d) tachycardia e) hypotension

b, d, e

a nurse is caring for a client with a cervical spine injury to whom Crutchfield tongs have been applied. Which intervention listed in the nursing care plan would the nurse question

obtaining help from another nurse to remove the weights when repositioning the client

a nurse caring for a client with a dx of peptic ulcer is monitoring the client for signs of perforation. Which findings would cause the nurse to suspect perforation SATA a) bradycardia b) abdominal rigidty c) a sudden bout of diarrhea d) projectile vomiting of bile e) sudden sharp pain in the midepigastrium

b, e

A nurse is monitoring a client who is taking spironolactone for the tx of HTN. Which findings denote adverse effects of this med SATA a) constipation b) tall T waves c) hyporeflexia d) shallow resp e) prolonged PR interval f) hyperactive bowel sounds

b, e, f

A nurse is caring for a client who underwent mastectomy 1 day ago. To help restore arm fxn on the affected side, the nurse encourages the client to use that arm to

perform finger and elbow flexion and extension exercises

a client with severe HF suddenly becomes tachycardic, shows signs of air hunger and is extremely anxious. The nurse listens to the client's breath sounds and suspects pulmonary edema. The nurse should first

place the client in a high Fowler position

a nurse is assessing a client's fluid balance on the day after craniotomy. Which lab result would the nurse report to the HCP

plasma osmolarity 265

a client is using diphenhydramine 1% as a topical agent to treat allergic dermatosis. Which outcome indicates to the nurse that the med is having the intended effect

relief of urticaria

a nurse is preparing to care for a client who just returned from the recovery room after a Billroth II procedure. Which intervention in the plan of care does the nurse question

reposition the NG tube if drainage ceases

a nurse is reviewing the lab results of a client with cytomegalovirus retinitis, who is recieving foscarnet sodium. Which lab test result that will identify a toxic effect of the med, does the nurse check

serum creatinine

A nurse is monitoring a client with a head injury for signs of DI. Which finding would cause the nurse to suspect that this complication is developing

serum sodium level of 155

a nurse is providing dietary instructions to the spouse of a client with newly diagnosed AIDS who is being discharge from the hospital. The nurse instructs the spouse to

serve foods at room temp

a client has been taking pyrazinamide for 2 months. Which culture result does the nurse monitor as an indicator that the med may soon be discontinued

sputum

a nurse is conducting an assessment of a client with angina pectoris. The client reports that the anginal pain is triggered by exercise and relieved by rest or nitro. In the client's record, the nurse notes that the client is experiencing

stable angina

a nurse is administering a dose of oral pyridostigmine bromide to a client with myasthenia gravis. What does the nurse ask the client to do before administering the med

take sips of water

a nurse is teaching the client with newly diagnosed DM how to perform fingerstick blood glucose measurements. The nurse tells the client to

hold the finger in a dependent position and massage the finger toward the puncture site

a client hospitalized with an abdominal aortic aneurysm suddenly complains of severe back and flank pain. The nurse notes on the cardiac monitor that the client's HR has increased from 80 to 110bpm. The nurse should

immediately contact the HCP

a nurse planning care for a client who has undergone TURP remembers that the most common cause of postop is

bladder spasms

a client is experiencing frequent PVCs. To which assessment would the nurse give priority

peripheral perfusion

a nurse is admitting a client with a dx of CKD to the hospital. Which early sign of CKD does the nurse expect to note during assessment

BP of 168/94

a nurse is providing dietary instructions to a client with COPD who is experiencing a loss of appetitie and complains of feeling "too full to eat". What does the nurse encourage the client to do SATA a) avoid drinking fluids before and during meal b) eat a variety of dark-green vegetables such as broccoli c) have snacks, such as crackers and cheese, b/w meals d) select foods that are easy to chew and are not gas forming e) consume high-calorie drinks, such as milkshakes b/w meals

a, d

a nurse is monitoring a client who sustained a blunt chest injury when she hit the steering wheel in a MVA. Which findings would cause the nurse the suspect flail chest SATA a) cyanosis b) chest pain c) bradycardia d) increasing dyspnea e) slow, shallow resp f) asymmetric chest movements

a, b, d, f

a nurse is assessing a client admitted to the ED with a dx of DKA. The nurse observes the client for respirations that are

deep and rapid

cyclophosphamide is prescribed for a client with a dx of breast cancer. The nurse has provided instructions to the client regarding the med. Which statement by the client indicates an understanding of this chemo regimen

I need to increase my fluid intake to 2,000 to 3,000mL a day

a nurse has taught a client with COPD about positions that will ease breathing during dyspenic episodes. Which statement by the client indicates a need for further instructions

I should lie flat on my side in a fetal position

a nurse is assessing a dyspneic client who has been found to have Guillain-Barre syndrome. Which ABG finding would cause the nurse to conclude that the client is experiencing hypoxemic resp failure

PaO2 of 50mmHg, PaCO2 of 40mmHg

on the first day after undergoing total knee arthroplasty, the client tells the nurse that he is experiencing pain when he extends his leg. The nurse should

administer an analgesic and evaluate the response

cyclobezaprine has been prescribed for a hospitalized client to treat painful muscle spasms c/b a damaged intervertebral disc. The nurse would withhold the med and question the rx if the client had a concurrent rx for

tranylcypromine

a nurse in the ED is assessing a client who sustained an open leg fx in a fall from a ladder. Which question is most important for the nurse to ask the client

when was your last tetanus vaccine

a nurse is interpreting a CVP reading from a client in whom right ventricular failure has been diagnosed. From this dx, the nurse would expect that the most likely results is a pressure of

14 cm H2O

a client arrives in the ED after sustaining a chemical splash to the eye. The nurse immediately flushes the eye with copious amounts of normal saline sltn for 15min and then tests the pH of the eye, using litmus paper. The nurse should continue the saline flushes until the pH test reads

7.40

benztropine mesylate is prescribed for a client with Parkinson Disease. For which GI s/e of the med does the nurse monitor the client SAT a) mucositis b) dry mouth c) constipation d) increased appetite e) hyperactive bowel sounds

b, c

radiation therapy is prescribed for a client with a brain tumor. Which s/e would the nurse expect the client to experience SATA a) cough b) alopecia c) dizziness d) dysphagia e) hoarseness

b) alopcia c) dizziness

a nurse is developing a plan of care for a client who has had stroke and is experiencing homonymous hemianopsia. Which intervention does the nurse include in the care plan to help the client to overcome this deficit

encouraging the client to turn the head from side to side to scan the complete range of vision

a client with AIDS is admitted to the hospital with a dx of histoplasmosis and the nurse monitors the client for signs of progression of the disease. Which finding indicates progression of histoplasmosis

enlargement of the LN

a nurse is preparing to teach a client with newly diagnosed CKD about the disease and its mgmt. The client's ability to learn is diminished as a result of uremia and anxiety. The nurse makes it a priority to include which when conducting teaching sessions with this client

family members

a nurse is caring for a client who has ust undergone craniotomy with an infratentorial incision. In which position does the nurse expect that the HCP will prescribe the client to be placed

flat and on the side

a nurse is developing a plan of care for an older client with diabetic neuropathy of the lower extremities resulting from type 2 DM. Which problem does the nurse recognize as the highest priority for this client

increased risk for injury

Hep A vaccine is prescribed for a client who is planning a trip out of the country. The nurse tells the client that

a booster dose is needed 6-12 months after the initial injection

the nurse is teaching a client with newly diagnosed DM who has been prescribed NPH insulin how to recognize s/s of hypoglycemia. The client states that he must look for certain s/s in the late afternoon, indicating to the nurse that he has understood the instructions. What are these s/s SATA a) shakiness b) drowsiness c) blurred vision d) increased thirst e) feelings of hunger f) N&V

a, c, e

a nurse is caring for a client who is undergoing lumbar puncture. In which position should the nurse place the client after the procedure

dorsal recumbent

a client has a rx to have blood drawn from the radial artery for a set of ABG determinations. for which test does the nurse look for a positive result before the blood is drawn

allen test

a nurse is monitoring a client who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse, examining the screen, notes no ECG complexes. The nurse would first

assess the client

a nurse is evaluating goal acheivement for a client in skeletal traction. Which finding would indicate to the nurse that the goals require revision

the client has a bowel movement every 5 days

a nurse provides dietary instructions to a client with viral hepatitis whose lab results indicate liver impairment. The nurse teaches the client

the most calorie intake should consist of foods high in carbs

a nurse is checking a client's closed chest drainage system and notes rapid bubbling the water seal chamber. The nurse checks the system for an air leak but does not find one. The nurse interprets this to indicate that

there is an incision or tear in the pulmonary pleura

a client who sustained an extensive full thickness burn injury is being admitted to the nursing unit. which rx by the HCP would the nurse question

administer morphine sulfate 6mg IM q3h PRN

a client with MI is being monitored closely for signs of cardiogenic shock. For which signs of this type of shock is the nurse alert SATA a) polyuria b) bradypnea c) tachycardia d) restlessness e) hypotension f) increased CVP

c-f

a nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding

checking for moisture on the back of the dressing over the client's neck and shoulders

a nurse is reviewing lab results for a client who has been taking digoxin for the tx of HF. The nurse notes that the report indicates a serum digoxin level of 0.8. The nurse would most appropriately

document the lab result

a client is scheduled to have blood obtained for a serum digoxin determination. The nurse should arrange to have the blood sample drawn

8 hours after the dose is given

a nurse is studying the results of periodic lab studies in a client with DKA who is receiving an IV insulin infusion. Which finding should prompt the nurse to contact the HCP

K level of 3.1

a client is recovering from ARDS. Which entry in the medical record is the indicator of the greatest improvement to the nurse

PaO2 of 84mmHg with no infiltrates on CXR

a nurse educator conducts an information session for hospital nurses about skin anthrax. Which statements by the nurse educator are correct SATA a) skin anthrax can lead to septicemia if it goes untreated b) symptoms may appear as soon as 24 hours after exposure c) this type of anthrax results from the inhalation of spores d) contact precautions are not always necessary with skin anthrax e) early clinical manifestations include mild upper resp symptoms

a, b, d

a client with DVT is undergoing anticoagulant therapy with warfarin. The client's PT is 18sec, with a control of 11 sec and the INR is 2.0. The nurse recognizes these results as

within the therapeutic range

a nurse is caring for a 25 year old married client who will undergo bilateral orchidectomy for testicular cancer. On which psychosocial concern directly related to the surgery does the nurse place priority in formulating the postop plan of care for the client

ineffective role performance

a nurse teaches a client with GERD about measures to manage the disease. What does the nurse encourage the client to do to obtain relief of the symptoms SATA a) limit intake of coffee and tea b) use chewing gum and oral lozenges c) eat a peppermint candy after each meal d) eat 3 large, well-balanced meals per day e) rest in a supine position for 30min after each meal f) elevate HOB at least 6-8 inches for sleep

b, f

a nurse caring for a client with leukemia who is undergoing chemo reviews the client's lab results and notes that the client has thrombocytopenia. Which interventions does the nurse implement when caring for the client SATA a) inspecting all stools for occult blood b) measuring the client's abdominal girth everyday c) removing all live plants and flowers from the room d) providing the client with an electric razor for shaving e) avoiding the administration of IM injections f) placing the client on a low-bacteria diet that excludes raw vegetables

a, b, d, e

a nurse provides information regarding postop restrictions and arm care to a client who has undergone mastectomy of the left breast with axillary LN dissection. What does the nurse tell the client to do SATA a) use mild soaps and lotions on the left arm b) carry a handbag and heavy objects on the left arm c) apply sunscreen to the arm whenever she is outside d) wear protective gloves when working in the garden e) avoid wearing rubber gloves when doing housework f) use a new straight razor each time she shaves her underarms

a, c, d

Glargine insulin is prescribed for a client with type 1 DM. What does the nurse tell the client about this type of insulin SATA a) it does not have a peak effect b) it is usually given once daily, at bedtime c) it usually has a 24 hour duration of action d) it may be mixed in a syringe with regular insulin e) its onset of action comes 4 hours after administration

a-c

a client is found to have hypoparathyroidism. Which nutritional supplement does the nurse, teaching the client about measures to manage the disorder, tell the client to take on a daily basis

calcium carbonate with vitamin D

a nurse is reviewing the nursing care plan for a client who has seizure precautions in place. Which intervention documented in the plan of care should the nurse question

keep a padded tongue blade at the bedside

the wife of a client with type 1 DM calls the nurse in the HCP's office about her husband. She states that her husband is sleepy, his skin is warm and flushed and that his breathing is faster than normal. The nurse instructs the wife to

check his blood glucose level

a nurse prepares to treat frostbite of the toes of a homeless man who was brought to the ED by the police. Which action by the nurse is appropriate

continuously rewarming the toes in the warm-water bath for 15-20 min

a nurse is caring for a client who has had an estrogen-receptor positive breast tumor surgically removed. The client is told that follow up with hormonal therapy will be prescribed. The nurse outlines a teaching plan, knowing that client will most likely receive

tamoxifen citrate

a hospitalized client has just been found to have AKI. The lab calls the nursing unit and reports that the client has a serum K level of 6.4. On the basis of this lab finding, the nurse should first

call the HCP

a nurse is conducting an admission assessment of a client hospitalized with a dx of Meniere's disease. Which question would elicit information specific to the attacks that occur with this disorder

do you have a feeling of fullness in your ear

a client arrives at the ED and reports a buzzing sound in his ear. The client tells the nurse that an insect flew into his ear. Which intervention does the nurse take first to remove the insect

instilling lidocaine into the ear

a client with chronic arterial occlusive disease has a hx of intermittent claudication. Which question does the nurse ask to assess the degree to which the client is affected by this condition

is your leg pain sharp and does it occur with exercise

a client with cancer is admitted to the hospital for a chemo tx with IV bleomycin sulfate. Which nursing assessment would be given the highest priority while the chemo is being administered

lung sounds

a nurse is caring for a client who has just had a plaster leg cast applied. Which measure does the nurse implement to prevent the development of compartment syndrom

elevating the limb and applying ice to the affected leg

Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides information to the client about the med. Which occurrences does the nurse tell the client to report to the HCP SATA a) lethargy b) chest pain c) palpitations d) weight gain e) constipation f) rapid heart rate

b, c, f

the result of two ELISA tests performed to detect HIV is positive. Which diagnostic test does the nurse anticipate will be prescribed next

western blot

a client is receiving digoxin for the tx of HF. For which signs of digoxin toxicity does the nurse monitor for the client SATA a) tinnitus b) bradycardia c) hypotension d) muscle twitching e) visual disturbances

b) bradycardia e) visual disturbances

a client is recieiving heparin by way of continuous IV infusion. For which adverse effect of this therapy does the nurse monitor the client SATA a) tinnitus b) petechiae c) hematuria d) tarry stools e) increased HR f) decreased BP

b) petechiae c) hematuria d) tarry stools

a nurse provides instructions to a client who is taking allopurinol for the tx of gout. Which statements by the client indicate an understanding of the med SATA a) I should put ice on my lips if they swell b) I shouldn't drink coffee or tea anymore c) I need to drink at least 8 glasses of fluid everyday d) I need to take the med 1 hour before I eat e) I'll start taking a vitamin c supplement each morning f) I can use an antihistamine lotion if I get an itchy rash

b, c

a nurse educator conducts an informational session for ED nurses about small pox. Which statements by the nurse educator are correct SATA a) small pox is transmitted by way of the enteric route b) early manifestations include influenza like symptoms c) vacinating within 3 days of exposure lowers the risk of active disease d) the infected person is infectious from the onset of the rash until the scabs separate e) a difuse red rash noted over the entire body is the first manifestation of the infection f) airborne precuations are not necessary if the nurse has received the smallpox vaccine

b, c, d

A nurse provides d/c instructions to a client who was hospitalized for an acute attack of Meniere's disease. Which statement by the nurse are correct SATA a) unrestricted salt is allowed in the diet b) position changes should be made slowly c) underwater swimming should be avoided d) it is best to switch to decaffeinated tea and coffee e) a glass of red wine in the evening will ease symptoms f) if an acute attack occurs, sit down and keep the eyes closed

b-d, f

A client with phantom limb pain has decided to use transcutaneous electrical nerve stimulation (TENS) as prescribed by the health care provider, and the nurse provides instructions regarding the use of the TENS unit. Which statements by the client indicate a need for further instruction regarding this pain-relief measure? Select all that apply. a) I'm so glad this will help relieve the pain b) Now I wont need to take so many pain meds c) I need to put the electrodes on the areas that you marked d) I'm not happy about having to stay in the hospital for this tx e) I'm not sure I'm going to like having those electrodes attached to my skin

c, d

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do which of the following as a next step?

call his HCP to have these values rechecked ASAP

a nurse instructs a client with DM and HTN in illness mgmt and lists carb-containing beverages that the client may consume when he cannot tolerate food orally. The nurse determines that the client needs additional instructions if he states that he should consume

canned orange juice

a client is scheduled to undergo insertion of an inferior vena cava filter in 2 days. What med should the nurse anticipate to withhold as prescribed during the preop period

warfarin

a nurse preparing an IV infusion for a client with leukemia is adding a chemo agent to the IV sltn. Which safety measure does the nurse implement while preparing this infusion

wearing gloves and a gown and preparing the med in a biological safety cabinet