hesi foundations 1
The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide?
"It's highly likely that she will recover and return to her pre-illness state."
A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment?
"What vitamin and mineral supplements do you take?"
A client's daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric value only.)
1 Rationale 30 mg (total dose) - 15 mg (dose already administered) = 15 mg that still needs to be administered. Using the Desired/Have formula: 15 mg/15 mg = 1 table
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
What action by the nurse demonstrates culturally sensitive care?
Asks permission before touching a client.
When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement?
Continue the planned nursing interventions to restore the client's fluid volume.
What activity should the nurse use in the evaluation phase of the nursing process?
Examine the effectiveness of nursing interventions toward meeting client outcomes.
A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?
Herbs should be obtained from manufacturers with a history of quality control of their supplements.
Which documentation best reflects the nurse's objective assessment?
His deep cough produces a small amount of pale yellow sputum.
When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action?
Locate the perineum.
An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?
The nurse who transferred the client to the chair when the fall occurred.
The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client?
Move the chair parallel to the right side of the bed, and stand the client on the right foot.
The client reports, prior to the stroke, getting up five or six times to urinate nightly but controlled the urge long enough to make it to the bathroom. How should the nurse document the urinary pattern that the client is describing?
Nocturia
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
Nutritional history.
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?
"I will limit my intake of beef to 4 ounces per week."
A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.)
1.5
Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
1.5 1, 000 mg : 1 gram :: X mg : 0.1 gram X = 100 mg D/H = 150/100 = 1.5 tablets
Each teaspoon contains 5 mL. Two teaspoons equals ?
10 mL.
The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine. The catheter is secured and the client is resting comfortably. In documenting the catheter insertion procedure, which statement should be included?
16 French indwelling catheter inserted by student nurse, with supervision, with return of 200 mL of clear, yellow urine.
Following surgery, the client returns to the nursing unit with an intravenous infusion and PCA pump. The order states, "morphine sulfate 0.5 mg/hour IV with additional demand dose of 1 mg every 6 minutes. Hourly limit of 10 mg." Prior to giving report to the oncoming nurse, the nurse reviews the client's usage of the PCA pump and determines that she has received four demand doses of morphine each hour for the last 4 hours. What is the total dosage of morphine the client has received in the last 4 hours?
18
A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)
2 Rationale Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same unit of measurement, which is 1 gram = 1000 mg. Using the formula, Desired / Available x 1 tablets: 1000 mg / 500 mg x 1 = 2 tablets
A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.)
2 Using Desired/Available formula: 500 mg/250 mg x 1 tablet = 2
Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer?
3 Rationale Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same unit of measurement, which is 0.3 gram = 300 milligram. Using the formula, Desired / Available x 1 capsule = 300/100 x 1 = 3 capsules
The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup. Which is the best explanation for the HCP's prescription?
A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults.
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next?
Cradle the client's heel.
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion and extension of the client's knee joint.
The nurse assesses the client's pain and determines that the evaluation of her use of the PCA pump is correct. The client's pain has lessened, and she no longer needs any demand doses of morphine. The nurse consults with the surgeon, and the morphine is discontinued. The client's new order for pain medication is hydrocodone/acetaminophen. What is the rationale for combining these two ingredients?
The synergistic effect of the two medications improves pain control.
When assisting with the planning of care for this client, the nurse's priority is focused toward what client goal?
To maintain the child's oxygen saturation greater than 95% on room air.
The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?
Turn the client q2h.
A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond?
"I will ask one of the female nurses to bathe you."
A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?
"Be sure to have a complete physical examination before beginning your planned exercise program."
What client statement indicates to the nurse that the client requires assistance with bathing?
"I don't understand why I'm so weak and tired."
A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer?
2
A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.)
2 500 mg/250 mg = 2 tablets
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.
Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process?
Analysis.
The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement?
Ask the client to relax and run a small amount of fluid into the rectum.
A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction?
Assault and battery with deliberate intent to deviate from the consent form.
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention.
The nursing staff continues with bladder-training, but the client's incontinence shows little improvement. Since bladder training has not been successful, the nurse obtains a prescription to apply an external male catheter. Which intervention is most important for the nurse to include in the client's plan of care?
Assess for signs of skin breakdown.
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse?
Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client.
The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP?
Bend at the knees when lifting heavy objects.
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use?
Cassette infusion pump.
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding.
Which is the best goal for the nurse to include in the plan of care related to the problem statement of "acute pain related to strain on muscles with movement?"
Client reports pain of less than 1 on a 0 to 10 scale.
Which information obtained by the nurse is most likely to influence the client's perception of her pain?
Client's younger child is an infant who feeds every 3 hours.
During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?
Closed-ended questions.
A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?
Combination of plant proteins to provide essential amino acids.
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take?
Commend the client for selecting a high biologic value protein.
The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings?
Complains of inability to empty bladder.
What action should the nurse implement when adding sterile liquids to a sterile field?
Consider the sterile field contaminated if it becomes wet during the procedure.
A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
Continue gabapentin.
the client voids after further interventions and is discharged from the acute care facility and transferred to the long-term care facility (LTAC). Since the client no longer has an IV, the order for the antibiotic is changed to an oral medication. The client has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help the client swallow the medication.Before deciding to open the capsule and mix it with food, what will the nurse need to determine?
Determine if the medication is an extended-release form.
Prior to applying a nasal cannula in the ED, which action is most important for the nurse to implement to ensure client safety?
Determine that all electrical equipment in the room is functioning correctly and is properly grounded.
After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
Determine the etiology of the problem.
While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first?
Discontinue the administration of the bolus feeding.
In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement?
Document the presence and volume of the pulse palpated.
An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?
Drape the sheets over the footboard of the bed.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?
Draw up the irrigating solution into the syringe.
A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information?
Elicit specific facts about past hospitalizations with direct questions.
Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?
Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
The nursing instructor encourages the student nurse to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing.
Encourage the student nurse to continue, maintaining aseptic technique.
Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?
Examining a chest x-ray obtained after the tubing was inserted.
An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings?
Fowler's
A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?
Generativity.
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings?
Immediately after the assessments are completed.
When caring for an immobile client, what nursing diagnosis has the highest priority?
Impaired gas exchange.
Since the client now voids spontaneously without recognizing the need to void, how should the nurse document the client's current urinary pattern in the medical chart?
Incontinence
A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority?
Inform the family that death is imminent.
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?
Inherited familial health disorders.
While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?
Instruct the client to take slow deep breaths and stop bearing down.
A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?
Mix each medication individually. When administering medications through a nasogastric feeding tube, the medications should be mixed separately to prevent clumping.
An older client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan?
Place a pillow between your knees while lying in bed to prevent hip dislocation.
An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day.What is the best action for the nurse to implement when assisting the client from the bed to the chair?
Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
The practical nurse (PN) evaluates the client's vital signs. Respirations are rapid and shallow. What technique should the nurse use to accurately evaluate the child's respirations?
Place hands flat against the back or chest and observe the rise and fall of the chest.
How should the nurse handle linens that are soiled with incontinent feces?
Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
Urinalysis results are as follows: pH 8.5 Specific gravity 1.015 Protein 0 g/day Glucose 0 mmol/L WBC 8/hpf RBC 2/hpf Based on the urinalysis results, the HCP orders a broad-spectrum antibiotic. After 24 hours of receiving the antibiotic, the client's condition has not improved.What additional nursing intervention should the nurse implement?
Provide a glass of cranberry juice daily.
What action is most important for the nurse to implement when placing a client in the Sim's position?
Raise the bed to a waist-high working level.
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?
Rashes in the axillary, groin, and skin fold regions.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
Re-oxygenate the client before attempting to suction again. Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen.
How should the nurse explain the mechanism that causes the skin to become reddened from prolonged exposure to cold?
Reflex vasodilation occurs following the initial vasoconstricting effects of cold.
After several weeks, the bladder training program is unsuccessful in stopping the client's incontinence. The client appears withdrawn and states that they are frustrated at the number of episodes that continue to occur. Which interventions should the nurse include in the client's plan of care?
Report signs of insomnia due to anxiety. Discuss possible coping strategies.
The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Report the results of the vital signs to the nurse.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
Reposition in a Sims' position with the client's weight on the anterior ilium.
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first?
Reposition the client on her side.
A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take?
Request and document the name of the certified translator. A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented. Client information that is translated is private and protected under HIPAA rules, so enaging anyone as a translator is not the best action. Family members are not preferred translators as they may skew information and not translate the exact information.
Which assessment finding further supports diagnosis?
Restlessness and dyspnea.
A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?
Sensory pattern, area, intensity, and nature of the pain.
A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client?
Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
The client voluntarily signed the form.
The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?
The nurse notes that there are numerous scatter rugs throughout the house.
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
Upper arm circumference.
During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?
Use the stethoscope bell over the valvular areas of the anterior chest.
To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?
Which activities during a routine day are impacted by your pain?
