HESI Fundamentals practice - Semester 2

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? "May I ask your daughter to help you with your personal hygiene?" "I will ask one of the female nurses to bathe you." "A staff member on the next shift will help you." "I will keep you draped and hand you the supplies as you need them."

"I will ask one of the female nurses to bathe you."

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? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase."

"I will limit my intake of beef to 4 ounces per week."

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." "It is OK if you don't want to talk about your surgery. I will be available when you are ready." "I will ask a woman who has had a mastectomy to come by and share her experiences with you."

"It is OK if you don't want to talk about your surgery. I will be available when you are ready."

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? "Your children are old enough to help you make decisions about their futures." "The social worker can tell you about placement alternatives for your children." "Tell me what you would like to see happen with your children in the future." "You have just received bad news, and you need some time to adjust to it."

"Tell me what you would like to see happen with your children in the future."

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 is your daily calorie consumption?" "What vitamin and mineral supplements do you take?" "Do you feel that you are overweight?" "Will a clear liquid diet be okay after surgery?"

"What vitamin and mineral supplements do you take?"

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? Solicit information on hospitalization from the insurance company. Look up previous medical records from archived hospital documents. Ask the client to discuss previous hospitalizations in the last 5 years. Elicit specific facts about past hospitalizations with direct questions.

Elicit specific facts about past hospitalizations with direct questions.

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

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

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 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

Foods and liquids consumed during the past 24 hours.

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first?

31.When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.

A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. Correct Answer: D

Serum albumin.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time?

0800; 1200; 1600; 2000

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription?

Examine one's own culturally based values, beliefs, attitudes, and practices.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? Accused of diversion. Reported for stealing. Reported for a HIPAA violation. Accused of unprofessional conduct.

Accused of diversion.

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? Passive ROM exercises to all joints on all extremities four times a day. Active ROM exercises to both arms and legs two or three times a day. Active ROM exercises with weights twice a day with 20 repetitions each. Passive ROM exercises to the point of resistance and slightly beyond.

Active ROM exercises to both arms and legs two or three times a day.

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? Assessment. Analysis. Implementation. Evaluation.

Analysis.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? Document the client's request in the medical record. Ask the client if this decision has been discussed with his healthcare provider. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Ask the client if this decision has been discussed with his healthcare provider.

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? A quasi-intentional tort because a similar mistake can happen to anyone. Failure to respect client autonomy to choose based on intentional tort law. Assault and battery with deliberate intent to deviate from the consent form. An unintentional tort because the client benefited from having the myelogram.

Assault and battery with deliberate intent to deviate from the consent form.

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? Assault. Battery. Malpractice. False imprisonment.

Battery

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? Autopsy of the body is prohibited. Blood transfusions are forbidden. Alcohol use in any form is not allowed. A vegetarian diet must be followed.

Blood transfusions are forbidden.

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? Portable syringe pump. Cassette infusion pump. Volumetric controller. Nonvolumetric controller.

Cassette infusion pump.

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? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses.

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? Low fat and low sodium foods. Combination of plant proteins to provide essential amino acids. Limited complex carbohydrates and fiber. Increased amount of vitamin C and beta carotene rich foods.

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. Remind the client that protein in the diet should be avoided. Suggest that the client also select orange juice, to promote absorption. Encourage the client to attend classes on dietary management of CKD. Rationale

Commend the client for selecting a high biologic value protein.

42.The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.

Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally. Correct Answer: C

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? Review the client's most recent laboratory reports. Refer the client and family members for hospice care. Notify the hospital ethics committee of the client situation. Determine who is legally empowered to make decisions.

Determine who is legally empowered to make decisions.

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. Auscultate the client's breath sounds bilaterally. Elevate the head of the bed to a high Fowler's position. Administer a PRN dose of a prescribed antiemetic.

Discontinue the administration of the bolus feeding

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? Bewilderment is to be expected, and progresses with age. Disorientation often follows relocation to new surroundings. Uncertainty is a result of irreversible brain pathology. Being perplexed can be prevented with adequate sleep.

Disorientation often follows relocation to new surroundings.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? Notify the charge nurse that a medication error occurred. Submit a medication variance report to the supervisor. Document the events that occurred in the nurses' notes. Discard the original medication administration record.

Document the events that occurred in the nurses' notes.

When making the bed of a client who needs a bed cradle, which action should the nurse include? Teach the client to call for help before getting out of bed. Keep both the upper and lower side rails in a raised position. Keep the bed in the lowest position while changing the sheets. Drape the top sheet and covers loosely over the bed cradle.

Drape the top sheet and covers loosely over the bed cradle.

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? Removing the empty food tray from a client with a urinary catheter. Washing and combing the hair of a client with a fractured leg in traction. Administering oral medications to a cooperative client with a wound infection. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? Review the client's medical record for an advance directive. Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice. Evaluate the client's mental status for competence to refuse treatment.

Evaluate the client's mental status for competence to refuse treatment.

What activity should the nurse use in the evaluation phase of the nursing process? Ask a client to evaluate the nursing care provided. Document the nursing care plan in the progress notes. Determine whether a client's health problems have been alleviated. Examine the effectiveness of nursing interventions toward meeting client outcomes.

Examine the effectiveness of nursing interventions toward meeting client outcomes.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first? Ask the nursing supervisor to meet with the students. Notify the student's clinical instructor of the situation. Ask the student if permission was obtained from the client. Explain that the records are hospital property and may not be removed.

Explain that the records are hospital property and may not be removed.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? Flush the lumen with the saline solution and administer the medication through the lumen. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Flush the lumen with the saline solution and administer the medication through the lumen.

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? Report the healthcare provider for the violation in aseptic technique. Allow the completion of the procedure. Ask if the glove and sterile field are contaminated. Identify the break in surgical asepsis and provide another set of sterile supplies.

Identify the break in surgical asepsis and provide another set of sterile supplies.

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? At the beginning, middle, and end of the shift. After client priorities are identified for the development of the nursing care plan. At the end of the shift so full attention can be given to the client's needs. Immediately after the assessments are completed.

Immediately after the assessments are completed.

When caring for an immobile client, what nursing diagnosis has the highest priority? Risk for fluid volume deficit. Impaired gas exchange. Risk for impaired skin integrity. Altered tissue perfusion.

Impaired gas exchange.

Notify family members of the client's condition.

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first?

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? Ensure cultural customs are observed. Increase oxygen flow to 4L/minute. Auscultate bilateral lung fields. Inform the family that death is imminent.

Inform the family that death is imminent.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Inquire about the source and type of pain. Examine the nose for congestion and discharge. Take vital signs for temperature elevation. Explore the abdominal area for distension.

Inquire about the source and type of pain.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin.

Observe the appearance of the skin under the ice pack.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? Demonstrates loss of remote memory. Exhibits expressive dysphasia. Has a diminished attention span. Is disoriented to place and time.

Is disoriented to place and time.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? Listen and show interest as the client expresses these feelings. Reinforce that this behavior means they were not true friends. Ask the healthcare provider for a psychiatric consult. Continue with the assessment and tell the client not to worry.

Listen and show interest as the client expresses these feelings.

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. Transfer to a commode. Attach the catheter to a drainage bag. Manipulate a syringe to inflate the balloon.

Locate the perineum.

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? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Move the chair parallel to the right side of the bed, and stand the client on the right foot.

71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation.

Position prone with a small pillow below the diaphragm.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? Temperature increases from 98.8 to 99.0 F. Pulse rate decreases from 78 to 52 beats/min. Respiratory rate increases from 16 to 24 breaths/min. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Pulse rate decreases from 78 to 52 beats/min.

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. Elevate the head of the bed 45 degrees. Place a pillow behind the client's back. Bring the client to one edge of the bed.

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? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions.

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? Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. Re-oxygenate the client before attempting to suction again.

Re-oxygenate the client before attempting to suction again.

The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Tell the UAP to use a larger cuff at the next scheduled assessment. Reassess the client's blood pressure using a larger cuff. Have the unit educator review this procedure with the UAPs. Teach the UAP the correct technique for assessing blood pressure.

Reassess the client's blood pressure using a larger cuff.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? Review the steps in the procedure manual. Ask another nurse to assist while implementing the procedure. Follow the agency's policy and procedure. Refuse to perform the task that is beyond the nurse's experience.

Refuse to perform the task that is beyond the nurse's experience.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? Check for a blood return. Reposition the client's arm. Remove the IV site dressing. Flush the lock with saline.

Reposition the client's arm.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? Transferrin. Prealbumin. Serum albumin. Urine urea nitrogen.

Serum albumin.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, and vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey salad, roll, and vanilla ice cream.

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? Determine when the IV solution was started. Slow the IV infusion to keep vein open rate. Assess the IV insertion site for swelling. Report the finding to the healthcare provider.

Slow the IV infusion to keep vein open rate.

6.Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.

The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. Correct Answer: C

Vitamin B12.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan?

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? The nurse will provide client instruction for daily foot care. The client will demonstrate proper trimming toenail technique. Upon discharge, the client will list three ways to protect the feet from injury. After instruction, the nurse will ensure the client understands foot care rationale.

Upon discharge, the client will list three ways to protect the feet from injury.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? Arms. Upper torso. Head. Feet.

Upper torso.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? Fiber. Folate. Ascorbic acid. Vitamin B12.

Vitamin B12

Asks permission before touching a client.

What action by the nurse demonstrates culturally sensitive care?

Position prone with a small pillow below the diaphragm.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?

Impaired gas exchange.

When caring for an immobile client, what nursing diagnosis has the highest priority?

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? Can you describe where your pain is the most severe? What is your pain intensity on a scale of 1 to 10? Is your pain best described as aching, throbbing, or sharp? Which activities during a routine day are impacted by your pain?

Which activities during a routine day are impacted by your pain?

Respiratory rate.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?

The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.

Which statement best describes durable power of attorney for health care?

Upon discharge, the client will list three ways to protect the feet from injury.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention.

Assess for bladder distention.

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. Discontinue ibuprofen. Add aspirin to the protocol. Add oral methadone to the protocol.

Continue gabapentin.

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? Empty the client's urinary drainage bag. Draw up the irrigating solution into the syringe. Secure the client's catheter to the drainage tubing. Use aseptic technique to instill the

Draw up the irrigating solution into the syringe

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? Does not check capillary blood glucose as directed. Occasionally forgets to take daily prescribed medication. Cannot identify signs or symptoms of high and low blood glucose. Eats anything and does not think diet makes a difference in health.

Eats anything and does not think diet makes a difference in health

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? Aspirating gastric contents to assure a pH value of 4 or less. Hearing air pass in the stomach after injecting air into the tubing. Examining a chest x-ray obtained after the tubing was inserted. Checking the remaining length of tubing to ensure that the correct length was inserted.

Examining a chest x-ray obtained after the tubing was inserted.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Thalamus. Hypothalamus. Frontal lobe. Parietal lobe.

Frontal lobe.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? The drainage tubing is secured over the siderail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame.

The clamp on the urinary drainage bag is open.

What action by the nurse demonstrates culturally sensitive care? Asks permission before touching a client. Avoids questions about male-female relationships. Explains the differences between Western medical care and cultural folk remedies. Applies knowledge of a cultural group unless a client embraces Western

Asks permission before touching a client.

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? Help the client to accept the final stage of life. Assist and support the client in establishing short-term goals. Encourage the client to make future plans, even if they are unrealistic. Instruct the client's family to focus on positive aspects of the client's life.

Assist and support the client in establishing short-term goals.

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. Temperature of 99.8 ??F and pulse of 108. Post-voided residual volume of 750 ml. Specimen collection for culture and sensitivity.

Complains of inability to empty bladder.

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? Raise the bed to a comfortable working level. Bend the client's knee. Move the knee toward the chest as far as it will go. Cradle the client's heel.

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? Adequate venous blood flow to the lower extremities. Estimated amount of body fat by an underarm skinfold. Degree of flexion and extension of the client's knee joint. Change in the circumference of the joint in centimeters.

Degree of flexion and extension of the client's knee joint.

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. Ego integrity. Identification. Valuing wisdom.

Generativity.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Give the missed dose at 1300 and change the schedule to administer daily at 1300.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? Healthcare provider notified of failure to collect specimens for prescribed blood studies. Blood specimens not collected because client no longer wants blood tests performed. Healthcare provider notified of client's refusal to have blood specimens collected for testing. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified.

Healthcare provider notified of client's refusal to have blood specimens collected for testing.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Instruct the client that the stoma will become smaller when the initial swelling diminishes.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? Establish a new nursing diagnosis. Note which actions were not implemented. Add additional nursing orders to the plan. Collaborate with the healthcare provider to make changes.

Note which actions were not implemented.

39.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? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). Correct Answer: C

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? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

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 husband, who is the caregiver, begins to weep when the nurse asks how he is doing. The client tells the nurse that she does not have much of an appetite today. The nurse notes that there are numerous scatter rugs throughout the house. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

The nurse notes that there are numerous scatter rugs throughout the house.

59.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? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.

The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. Correct Answer: D

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? Administer a PRN antihypertensive prescription. Provide the client with an additional blanket. Encourage additional fluid intake. Turn the client q2h.

Turn the client q2h.

Speak initially with the oldest family member to show respect.

While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs?

50.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? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.

(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D). Correct Answer: D

61.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? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, Integrity vs despair. (C and D) are judgmental and not therapeutic. Correct Answer: B

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. Wearing a mask while cleaning will not help to avoid allergens. Purchase any type of clothing, but be sure it is washed before wearing it. Pollen count is related to hay fever, not to allergens.

Avoid any types of sprays, powders, and perfumes.

The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? Healthcare provider. Client's family. Case manager. Chief of staff.

Healthcare provider.

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 worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred.

The nurse who transferred the client to the chair when the fall occurred.