hesi practice
A client is diagnosed with a moderate case of acute ulcerative colitis. The nurse doing dietary teaching should give the client examples of foods to eat that represent which therapeutic diet?
Low fiber without milk. The client with a mild to moderate case of acute ulcerative colitis often is prescribed a diet that is low in fiber and does not include milk. This will help to reduce the frequency of diarrhea for this client. The remaining options are incorrect diets and may cause discomfort for the client.
A client has received a dose of dimenhydrinate. The nurse should observe relief of what sign or symptom to evaluate that the medication has been effective? 1. Chills 2. Headache 3. Nausea and vomiting 4. Buzzing sound in the ears
3. N/V Dimenhydrinate is used to prevent and treat the symptoms of dizziness, vertigo, nausea, and vomiting that accompany motion sickness. The other options are incorrect reasons for administering the medication.
The nurse is caring for an older client. Which finding should the nurse expect to note in this client while evaluating renal function? 1.Tubular reabsorption increases 2.Urine-concentrating ability increases 3.Medications are metabolized in larger amounts 4.The glomerular filtration rate (GFR) diminishes
4. As part of the normal aging process, the GFR decreases, along with each of the other functional abilities of the kidney. Tubular reabsorption and urine-concentrating ability also decrease. The kidneys have decreased ability to metabolize medications.
A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin for treatment. The nurse teaches the client to perform which action? 1. Report any change in urine color. 2.Take both medications with food. 3.Take both medications together once a day. 4.Expect to take the medications for 2 to 3 weeks.
3. Rifampin in combination with isoniazid prevents the emergence of medication-resistant organisms. This combination, taken together daily, eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and should be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness, and the therapeutic effect may be evident in 2 to 3 weeks.
A 4-year-old child is diagnosed with otitis media. The mother asks the nurse about the causes of this illness. Which risk factors should the nurse include in response to this mother? Select all that apply. 1. Bottle-feeding 2.Household smoking 3.Exposure to illness in other children 4.A history of urinary tract infections 5.Congenital conditions such as cleft palate
1, 2, 3, 5 Factors that increase the risk of otitis media include bottle-feeding, household smoking, exposure to illness from other children in day care centers, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has been identified as another risk factor. Allergies are also thought to precipitate otitis media.
The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply. 1.A client with extensive burns 2.A client with cancer who is septic 3.A client who has had an open cholecystectomy 4.A client with severe exacerbation of Crohn's disease 5.A client with persistent nausea and vomiting from chemotherapy
1, 2, 4, 5 PN is indicated in clients whose gastrointestinal tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include those clients with burns, exacerbation of Crohn's disease, and persistent nausea and vomiting due to chemotherapy. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery.
The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Encourage coughing with deep breathing. 2.Place in high Fowler's position for eating. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.
1, 3, 4 The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements 5.What the client ate in the 2 hours preceding seizure activity
1,2,3,4, Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.
A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? 1.Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 2.Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. 3.Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn. 4.Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.
1. Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore, the remaining options are incorrect.
The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? 1.Rice 2.Oatmeal 3.Rye toast 4.Wheat bread
1. rice Celiac disease also is known as gluten enteropathy or celiac sprue and refers to intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements—especially the fat-soluble vitamins, iron, and folic acid—may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.
A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 1.Slow the IV infusion. 2.Sit the client up in bed. 3.Remove the IV catheter. 4.Call the health care provider (HCP).
1. slow the infusion! The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the HCP. The IV catheter is not removed; it may be needed for the administration of medications to resolve the complication.
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1.Pain and erythema 2.Pallor and coolness 3.Numbness and pain 4.Edema and blanched skin 5.Formation of a red streak and purulent drainage
2, 3, 4 An infiltrated intravenous (IV) line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, edema, pain, numbness, and blanched skin are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop, and if an electronic pump is being used, it will alarm. Erythema can be associated with infection, phlebitis, or thrombosis. Formation of a red streak and purulent drainage is associated with phlebitis and infection.
A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1.Glucose level 2.Calcium level 3.Potassium level 4.Prothrombin time
2. Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.
Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson-Pratt drain 4. Complaints of decreased sensation near the operative site
2. arm edema on the post op side Arm edema on the operative side (lymphedema) is a complication after mastectomy. It can occur immediately postoperatively or months to even years after surgery. The remaining options are expected occurrences after mastectomy and do not indicate a complication.
The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2.Temperature of 99.4°F (37.4°C) orally 3.Blood pressure of 198/110 mm Hg 4.Respiratory rate of 28 breaths/minute
3. Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the HCP before initiating therapy.
The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1. Capillary refill is less than 3 seconds 2.Pulses present and with swollen, pink fingers 3.Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers
3. Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.
The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1. Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia
3. autonomic dysreflexia The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in the remaining options.
The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. The nurse anticipates that which diagnostic test will be prescribed to confirm this diagnosis? 1.Lumbar puncture 2.Electroencephalogram 3.Polymerase chain reaction 4.Computed tomography scan
3. polymerse chain reaction The diagnosis of herpes simplex encephalitis can be made by a polymerase chain reaction test (usually through a blood specimen) to detect viral DNA or RNA in the cerebrospinal fluid. Diagnosing specificity and sensitivity in encephalitis is excellent, especially herpes simplex virus. The test is rapid and noninvasive, replacing the brain biopsy for diagnosis.
The nurse in an ambulatory care clinic is performing an admission assessment for an African American client who is scheduled for a cataract removal with intraocular lens implantation. Which question would be appropriate for the nurse to ask the client on an initial assessment? 1. "Do you have well-behaved children?" 2."Do you have a close family relationship?" 3."Do you have specific religious practices?" 4."Do you have any breathing or heart problems?"
4. In the African American culture, asking personal questions on an initial contact or meeting is considered intrusive. Options 1, 2, and 3 are personal questions. Cardiovascular and respiratory assessments include physiological assessments, which are the priority assessments.
he nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction 1. "I should use tepid water for bathing." 2."I need to keep my skin lubricated and cool." 3."After bathing, I should pat my skin dry rather than rubbing it." 4."I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."
4. The client should be instructed that a lubricant is applied immediately after the bath, while the skin is still damp, to help increase hydration of the stratum corneum. Options 1, 2, and 3 are appropriate home care measures to control the symptoms associated with pruritus.
The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? 1. Stress 2.Trauma 3.Infection 4.Fluid overload
4. fluid overload Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1½ to 2 times the daily requirement to prevent dehydration.
On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?
At 1 minute after birth and 5 minutes after birth
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds?
Crackles Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?
Generalized edema Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.
The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position? 1. Prone 2.Supine 3.Left side-lying 4.Right side-lying
Supine position should be avoided because it does not facilitate drainage from the oral cavity after tonsillectomy. The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage.
The health care provider (HCP) writes a prescription for carbamazepine for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which condition is noted in the assessment data?
bone marrow depression. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. It is used to treat seizure disorders, trigeminal neuralgia, and diabetic neuropathy. The medication can cause blood dyscrasias as an adverse effect and is contraindicated if the client has a history of bone marrow depression, hypersensitivity to tricyclic antidepressants, or concurrent use of monoamine oxidase inhibitors.