HESI study Questions

The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the clients eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the clients plan of care? a. Assess for signs of increased ICP b. Prepared to administer intravenous levothyroxine c. Obtain a prescription for artificial tear drops d. Review the clients serum electrolyte value

C

The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information stated by the client indicates understanding? a. Avoid seasoning foods with salt and salt-containing spices b. Keep any wounds covered with an antibiotic ointment c. Check blood sugar levels every four to six hours every day d. Soak feet daily in hot water no longer than 10 minutes

C

an adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Encourage turning and deep breathing b. Auscultate for presence of bowel sounds c. Administer IV antibiotics as prescribed d. Monitor hemoglobin and hematocrit

C

the nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Maintain intervascular infusion rate b. Progress diet slowly from ice chips to clear liquid c. Apply intermittent pneumatic compression devices d. Obtain frequent pain level assessments

C

During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours and a headache. Which intervention is most important for the nurse to implement first? a. Draw blood cultures b. Administer an antipyretic c. Prepare for a lumbar puncture d. Initiate isolation precautions

D

A client has a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial reaction? a. Administer the first dose of prescribed antibiotic b. observe color, consistency, and amount of sputum c. encourage the client to consume plenty of liquids d. send the specimen to the lab for analysis immediately

B

A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? a. "whenever I am sitting in a chair I will keep my legs up to reduce swelling" b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown" c. "I will try to keep moving if leg pain occurs to help promote good circulation" d. "I will use my swimming pool early in the day while the water is still very cool.

B

The nurse observes pitting edema in both hands and all fingers of a client with diffuse systemic sclerosis (Scleroderma). Which action should the nurse include in the plan of care? a. Cover areas liberally with lubricant b. Examine skin for ulcerations c. Observe for scleral jaundice d. Apply cold packs as needed

B

The home health nurse provides teaching about insulin self-injecting to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? a. Lie down flat for better skin exposure b. Select a different injection site c. Keep the skin flat rather than bunched d. Continue with the insulin injection

D

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis a. Decreased renin-angiotensin response related to an increase in renal blood flow b. Decreased portacaval pressure with greater collateral circulation c. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules d. Hypoalbuminemia that results in decreased colloidal oncotic pressure

D

The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the health care provider? a. Moon facies b. Gastric irritation c. Abdominal striae d. Rapid weight gain

D

The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Administer a PRN dose of an antispasmodic agent c. Measure the clients intake and output d. Increase the flow of bladder irrigation

D

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 breaths/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHG. Which intervention is most important for the nurse to implement? a. Medicate for pain and monitor vital signs according to protocol b. Administer intravenous fluid bolus as prescribed by the healthcare provider c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter d. Encourage the client to splint the incision with a pillow to cough and deep breathe.

A

The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage clients use of picture charts b. Ask the client simple questions c. Speak slowly to the client d. Teach the client use of basic sign language

A

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? a. Call the clinic if undesirable side effects of medication occur b. Increase the daily intake of oral fluids to liquify secretions c. Teach anxiety reduction methods for feelings of suffocation d. Avoid crowded enclosed areas to reduce pathogen exposure

B

A client with gout arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation above the ankle area. The client receives prescription for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Encourage active range of motion to limit stiffness b. Drink at least 8 cups (1920 mL) of water per day c. Use electric heating pad when pain is at its worse d. Eat high protein foods to achieve ideal body weight

B

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first? a. Remove all of the morphine patches b. Administer a narcotic antagonist c. Measure the clients blood pressure d. apply oxygen mask per mask

B

The healthcare provider prescribes diagnostic test for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Arterial blood gases (ABG) b. Sputum culture and sensitivity c. Computerized tomography (CT) of the chest d. Blood cultures

B

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide? a. Apply moisture lotions daily to the radiation portal site b. Protect the skin of the radiation portal site from sunlight exposure c. Avoid washing the skin inside the radiation portal site d. Remove the ink marks of the portal after each radiation treatment

B

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Color and consistency of feces b. Eating patterns and dietary intake c. Level and amount of physical activity d. Presence and activity of bowel sound

B

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? a. Marked loss of weight and appetite over the last 3 or 4 months b. Upper mid-abdominal pain described as gnawing and burning c. Frequent use of chewable and liquid antacids for indigestion d. Severe abdominal cramps and diarrhea after eating spicy foods

B

The nurse is performing the postoperative assessment of a client with an abdominal aortic aneurysm. Which finding is most important for the nurse to provide in the preoperative report? a. Respirations 20 breaths/minute b. Diminished peripheral pulses c. Hypoactive bowel sounds d. S3 hear sound on auscultation

B

The nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more b. Family members can help with regular foot exams c. Heat pads are useful if on the lowest setting d. Shoes should be worn outside the house, but it is fine to be barefoot inside

B

While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. The client reports join pain and trouble twisting a doorknob due to weakness. Which action should the nurse take in response to these findings? a. Explain the relief of the migraine pain will reduce related symptoms b. Consult with the occupational therapist for a functional assessment c. Implement fall precautions to reduce the client's risk for injury d. Gather additional assessment data about the pain and weakness

B

A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? a. Call the PACU nurse to prepare for prolonged ventilatory support b. Hold a prescription for dantrolene until fever is reduced c. Prepare ice packs for placement in the client's axillary area d. Determine if prescribed antibiotics were administered preoperatively

C

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. Profuse diaphoresis and severe, pounding headache b. Complaints of chest pain and shortness of breath c. Pain and a burning sensation upon urination and hematuria d. Hypotension and venous pooling in the extremities

C

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? a. Clay colored stool b. Radiating sharp pain in right shoulder c. Distended, hard and ridged abdomen d. Bile-stained emesis

C

A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the clients blood pressure drops from 150/90 mmHG to 80/30 mmHG. Which action should the nurse take first? a. Administer 5% albumin IV b. Monitor blood pressure q45 minutes c. Stop the dialysis treatment d. Lower the head of the chair and elevate feet

C

After three days of persistent epigastric pain, a female presents to the clinic, she has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70 mmHG. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? a. Complaint of radiating jaw pain b. Irregular pulse rate c. ST elevation in three leads d. Bile colored emesis

C

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets b. Elevate extremities on pillows c. Assess pulses with a vascular doppler d. evaluate edema for pitting

C

When conducting discharge teaching for a client with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals b. Eat a soft diet with increased intake of milk and milk products c. Eat a high-fiber diet and increase fluid intake . d. Eat a bland diet and avoid spicy foods

C

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Purple marks on skin of the abdomen b. Pitting ankle edema c. Quarter size blood spot on dressing d. Irregular apical pulse

D

A client with herpes zoster (shingles) on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. Noctuia b. Dyspnea c. Frequent cough d. Pain

D

The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicions? a. He refuses to see any of his friends or to return their phone calls b. He has begun to sleep 19 out of 24 hours c. He exhibits angry outburst when the subject of dying is approached d. A change has recently occurred in his handwriting

D

an adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg pO daily. Which laboratory values should the nurse monitor? a. Serum iron and ferritin b. Platelet count and hematocrit c. Neutrophils and eosinophils d. Serum electrolytes

A

the nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b. Experiences additional stress since adopting a child c. Jogs more frequently than usual daily routine d. Drinks several bottles of carbonated water daily

A

A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. Place the client in high fowler position b. Perform passive range of motion exercises c. Increase the clients activity level d. Administer oxygen per nasal cannula

A

A client with acute renal injury (AKI) weights 50 kg and has potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first? a. Sodium polystyrene sulfonate 15 grams by mouth b. Sevelamer one table by mouth c. Calcium acetate one tablet by mouth d. Epoetin alfa, recombinant 2,500 unit subcutaneously

A

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium 185 mEq/L b. Apical rate of 110 beats per minute c. Dry skin with inelastic turgor d. Polyuria and excessive thirst

A

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. White blood cell count d. Hemoglobin levels

A

the nurse is caring for a client who is newly diagnosed with adrenocortical insufficiency. The client is experiencing chronic fatigue and weakness. Which intervention should the nurse implement? a. Begin education about fluid restriction and ways to incorporate into ongoing therapy b. Explain that the hormone therapy will be needed for a time until adrenal glands are stimulated c. Provide encouragement that symptoms will rapidly improve as hormone therapy is initiated d. Advise the client to schedule energy intensive activities for later in the day

B

A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based on? a. Extra pillows can be used if needed to elevate the client's head b. Orthopnea is frequently caused by a clients uncontrolled anxiety c. The procedure is performed with the client in an upright position d. A thoracentesis is a brief procedure that has minimal discomfort

C

What food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Citrus fruits and juices b. Green leafy vegetables c. Fortified milk and cereals d. Red meats and eggs

C

Which client has the highest risk for developing skin cancer? a. a 25 year old dark skinned whose mother had skin cancer b. a 70 year old fair skinned client who works as a secretary c. a 65 year old fair skinned client who is a construction worker d. a 16 year old dark skinned client who tans in tanning beds once a week

C

An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? SATA a. Signs of respiratory tract infection b. Serum creatine and blood urea nitrogen (BUN) c. Skin condition of lower extremities d. Sensation in feet and legs e. Visual acuity

C,D,E

An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel". The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Maintain prescribed eye drop regimen c. Avoid frequent eye pressure measurements d. Eat a diet high in carotene (vit C)

B

An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Methods for weight gain b. Guidelines for oxygen used c. Strategies for smoking cessation d. Approaches to conserve energy

B

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. White blood cell (WBC) count b. Blood pH level c. Platelet count d. Hematocrit

A

the nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. Notify the health care provider of the clients medication history b. Have the client sign the surgical and transfusion permits c. Observe the heparin injection sites for signs of bruising d. Ensure that the potential for bleeding is explain to the client

A

An older client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Administer a prescribed sedative b. Assist client to an upright position c. Apply a high-flow venturi mask d. Encourage client to drink water

B