Hesi Study
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing:
" By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem ? A. "I have to turn my head to see around my room." B. "I can't see on my left side." C. "I have specks floating in my eyes." D. "I have constant blurred vision."
A. "I have to turn my head to see around my room."
During report, the charge nurse informs a nurse that she must work on another unit. The nurse begins to sign deeply and tosses about her belongings as she is preparing to leave, making it known that she is very unhappy about having to "float." What is the best immediate action for the charge nurse to take? A. Continue with report, and talk to the nurse about the incident at a later time. B. Ask the nurse to call the supervisor to see if she can be reassigned. C. Stop report and remind the nurse that all the staff must "float" at some time. D. In the presence of other staff members, inform the nurse that her behavior is inappropriate.
A. Continue with report, and talk to the nurse about the incident at a later time.
The registered nurse (RN) assesses a client who had a total colectomy 2 weeks ago. The client appears to be confident in the management of the new colostomy, but is having problems managing the odor. What instructions should the RN provide the client to help decrease odor in the colostomy bag?Select all that apply: A. Eat foods containing yogurt. B. Chew mint flavored gum. C. Drink a glass of buttermilk. D. Eat sprigs of parsley. E. Consume raw vegetables.
A. Eat foods containing yogurt. C. Drink a glass of buttermilk. D. Eat sprigs of parsley.
A 4-month-old infant is brought to the clinic by the parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress ? A. Flaring of the nares. B. A resting respiratory rate of 35 breaths/min. C. Bilateral bronchial breath sounds. D. Diaphragmatic respirations.
A. Flaring of the nares
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitch wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A. Has increased airway obstruction B. Has improved airway obstruction C. Needs to be suctioned D. Exhibits hyperventilation
A. Has increased airway obstruction
Unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior? Place them in order A. Discuss the issue privately with the UAP B. Note date and time of the behavior C. Plan for Scheduled break times D. Evaluate the UAP for signs for improvment
A. Note date and time of the behavior B. Discuss the issue privately with the UAP C. Plan for Scheduled break times D. Evaluate the UAP for signs for improvement
An adult client who is hospitalized after surgery reports sudden onset of chest pain dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further asses the client for which condition? A. Pulmonary embolism. B. Heart failure. C. Tuberculosis. D Bronchitis.
A. Pulmonary Embolism
The nurse is assessing a 3-month-old infant who had a plyorotomy yesterday. This child should be medicated for pain based on which findings? A. Restlessness B. Clenched Fist C. Increased pulse rate D. Increased respiratory rate E. Increased temperature F. Peripheral pallor of the skin
A. Restlessness B. Clenched Fist C. Increased pulse rate D. Increased respiratory rate
The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance in diet post op. What action should the nurse implement ? A. Review information about dumping syndrome B. Have the client sign another consent C. Notify the surgeon about the clients comment D. Explain the surgical procedure
A. Review information about dumping syndrome
The nurse is preparing a client for cardiac catherization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply A. Verify consent has been signed B. Explain procedure to client C. Ensure Family support D. Obtain a 12 lead ECG E. Obtain history of shellfish allergy
A. Verify consent has been signed B. Explain procedure to client D. Obtain a 12 lead ECG E. Obtain history of shellfish allergy
The nurse understand that the following clinical findings are indication for dialysis. Select all that apply: A. Volume Overload B. K 5.2 meq/l C. Metabolic Acidosis D. Calcium 9 E. Cr 5.0 mg/dl
A. Volume Overload B. K 5.2 meq/l C. Metabolic Acidosis E. Cr 5.0 mg/dl
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor for osteoarthritis? A.)Long distance runner since high school. B.)Lactose intolerant since childhood C.)Photosensitive to a drug currently taking D.)Recently treated for deep vein thrombosis
A.)Long distance runner since high school.
The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply A.Elevate HOB B. Decrease intake of caffiene C. Discuss strategies for weight loss if overweight D. Take omeperazole E. Take ranitidine
A.Elevate HOB B. Decrease intake of caffiene C. Discuss strategies for weight loss if overweight E. Take ranitidine
The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? a. Remind the client to hold his breath after inhaling the medication b. Confirm that the client has correctly shaken the inhaler c. Affirm that the client has correctly positioned the inhaler d. Ask the client if he has a spacer to use for this medication
A.Remind the client to hold his breath after inhaling the medication
After having coronary artery bypass surgery, a client develops a deep vein thrombosis in the left leg. Which nurse should be responsible for coordinating the progression of the client's care? A. Risk management nurse B. Nurse case manager C. Cardiology unit supervisor D. Adult nurse practitioner
C. cardiology unit supervisor
The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding(s) would cause the nurse concern regarding the development of compartmental syndrome? Select all that apply. A. Decrease in pulse rate in leg B. Paresthesia distal to area of injury C. Toes on affected leg cool to touch and edematous D. Complaints that pins are hurting E. Complaints of leg pain unrelieved by analgesics or repositioning F. Client angry and calling loudly to the nurse every 10 minutes
B.Paresthesia distal to area of injury C. Toes on affected leg cool to touch and edematous E. Complaints of leg pain unrelieved by analgesics or repositioning
A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client ? A)The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department
C) A notarized original of advance directives brought in by the partner
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client
C) Notify the admissions office and wait to apply the bracelet
A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) hasdied. Which type of precautions is the appropriate type to use when performing post mortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions
C) contact precautions
A nurse who works in an acute minor illness clinic returns from lunch and finds several clients who need attention. Which client should the nurse attend to first? A. A 10yo with asthma who is responding well to nebulizer treatments. B. A 3-week-old infant who is nursing and was brought in because he had a fever. C. A 4yo receiving IV fluid for dehydration whose fluid bag is empty. D. A 6yo with Down syndrome who has been coughing productively
C. A 4yo receiving IV fluid for dehydration whose fluid bag is empty.
A 19-year-old client has sustained a c-7 fracture, which resulted in his spinal cord being partially transected. BY 2 weeks' post injury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatining complication the nurse monitors the client for is: A. Pulmonary Embolisim B. Infection C. Autonomic Dysreflexia D. Lack on nutrition
C. Autonomic Dysreflexia
The nurse is is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint call for immediate nursing action ? A. Tremors B. Anorexia C. Diaphoresis and Shakiness D. Muscle cramps
C. Diaphoresis and Shakiness
A 16 year-old client is admitted to psychiatric unit with a diagnosis of attempt suicide. The nurse is aware that the most frequent cause for suicide in adolescents is: A. Peers B. School C. Feelings of isolation or alienation D. Body Image
C. Feelings of isolation or alienation
The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety ? A. Assess for discomfort when procedure is completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour cleansing solution onto the sterile cloth field
C. Instruct the client to keep hands under the sterile field
A client has an indwelling catheter with continuous bladder irrigation. After undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider A. Light, pink urine B. Occasional suprapubic cramping C. Minimal drainage into the urinary collection bag D. Complaints of the feeling of pulling on the urinary catheter
C. Minimal drainage into the urinary collection bag
The registered nurse (RN) is caring for a client who was recently diagnosed with type 2 diabetes mellitus (DM). What information is most important for the RN to teach the client about life-style changes ? A. Daily fingerstick glucose monitoring. B. Regular exercise program. C. Portion-controlled, heart healthy diet selections. D. Compliance with oral hypoglycemic medications.
C. Portion-controlled, heart healthy diet selections.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client who was recently admitted for an intestinal obstruction. Which Statement indicates that the family understands the instructions ? A. Increase protein and carbohydrates in the daily diet B. Limit activity to bed rest for the first week and increase mobility incrementally each week C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare provider D. Drink liquids 2 hours after meals instead of during meals
C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare provider
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not loose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to: A. Clean the sutured laceration twice a day with povidone- iodine (Betadine) B. Remove his scalp sutures after 5 days C. Return to the hospital immediately if he develops confusion, nausea, or vomiting D. Take meperidine 50 mg po q4-6h prn for headache
C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms
B) A toddler with severe deep abrasions over 98% of the body
A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? Select all that apply. a. Arrange in service training through the education department b. Obtain informed consent from clients who will receive care c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee
C. Submit a Sentinel event report to the research committee
A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement ? A) Provide typed instructions for healthy diet selections. B) Reinforce need for adequate hydration. C) Explain exercises daily regimen. D) Demonstrate specific strengthening exercises.
B) Reinforce need for adequate hydration.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why don't we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let's check to see if the suppository is far enough. D) Did you feel any stool in the intestinal tract?
B) That was done correctly. Did you have any problems with the insertion?
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? A) Increased edema and weight gain B) Unchanged urine specific gravity C) Rapid protein excretion D) Decreased blood potassium
B) Unchanged urine specific gravity
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urin
B) clean the meatus, begin voiding, then catch urine stream
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A. "Tell each child what he can do to help with the baby." B. "Focus on your sons' needs during the first days at home." C. "Suggest that your partner spend more time with the boys." D. "Ask the children what they would like to do for the newborn."
B. "Focus on your sons' needs during the first days at home."
At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself."
B. "Yes, I will be leading this group. What would you like to accomplish?"
The nurse-manager is talking to a new nurse who is thinking about resigning before orientation to the unit is over. The nurse-manager explains that reality shock after graduation is common. Which explanation should the nurse-manager use to best describe reality shock to the new nurse? A. A realization that practice and education are not the same. B. A period of role adjustment from school into the workforce. C. A phase that new nurses go through before changing jobs. D. A client scheduled for a femoral-popliteal bypass surgery tomorrow.
B. A period of role adjustment from school into the workforce.
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to: A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered -is B: Administer epinephrine 1:1000 as ordered
B. Administer epinephrine 1:1000 as ordered
A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to: A. Clean his inhaler with warm water and soak it in a 10% bleach solution B. Drink a glass of water C. Sit and rest D. Use his bronchodilator inhaler
B. Drink a glass of water
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A. Record the information on the chart B. Give information about advance directives C.Assume that this client wishes a full code D. Refer this issue to the unit secretary
B. Give information about advance directives
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the client to discuss the medication side effects with the health care provider B. Inform the client that gradual tapering must be used to discontinue the medication C. Remind the client that feeling better is the therapeutic side effect of the medication D. Tell the client that the medication side effects will most likely dissipate overtime
B. Inform the client that gradual tapering must be used to discontinue the medication
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Auscultate the lungs
D) Auscultate the lungs
The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification
D) Call the provider for clarification
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway
D) open the client's airway
The parents bring their one-year-old child with ventricular septal defect (VSD) to the clinic for a well-child visit. Which assessment finding should the nurse report to the healthcare provider immediately? A.Expected weight and growth curve for an infant. B.Respirations of 26 breaths/minute at rest. C.Heart rate of 105 beats/minute. D. 2+ pitting edema in the extremities.
D. 2+ pitting edema in the extremities
The charge nurse observes a newly employed nurse begin to administer a liquid medication via a clients gastronomy feeding tube system as seen in the picture. What action should the charge nurse take ? A. Advise nurse to lower bag to eye level B. Confirm the nurse checked solution compatibility C. Instruct nurse to flush the bag with sterile saline D. Direct the nurse to stop medication administration
D. Direct the nurse to stop medication administration
A female client is recieving an enteral feeding via nasogastric feeding tube. The daughter reports to the charge nurse that her mother is coughing vigorously and sounds congested. Which staff member should the charge nurse ask the check on the client ? A. RN who is admitting a new postop client to the unit. B. PN who is giving routine medications. C. PN who is talking with anxious family members. D. RN who is entering nursing notes at the computer.
D. RN who is entering nursing notes at the computer.
In preparing a nursing care plan for a client admitted with a diagnosis of Gullian-Bare Syndrome, which nursing problem has the highest priority?
Ineffective breathing pattern related to ascending paralysis
A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with 8- mm endotracheal tube. During ausculation of his chest, breath sounds were found to be absent on the left side
Right mainstream bronchus intubation
In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? a. Evaluate closet proximal pulse. b. Asses skin elasticity of the stump. c. Observe for swelling around the stump. d. Note amount color of wound drainage.
a. Evaluate closet proximal pulse.
The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? a. High-pitched or fine crackles. b. Rhonchi c. High-pitched wheeze d. Stridor
a. High-pitched or fine crackles.
Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.) a. Quality of the pain. b. Signs of inflammation. c. Ankle range of motion. d. Muscle strength testing. e. Visible deformities of the joint.
a. Quality of the pain. b. Signs of inflammation. c. Ankle range of motion. e. Visible deformities of the joint.
A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? a. Ask the client with her children present if she fully understands the decision she has made. b. Discuss success of clinical trials and ask the client to consider participating for one month. c. Explain to the family that they must accept their mother's decision. d. Explore the client's decision to refuse treatment and offer support
d. Explore the client's decision to refuse treatment and offer support
A client being treated for an acute myocardial infarction is to receive the tissue plasminogen activator altaplase (Activase). The nurse would be correct in providing which explanation to the client regarding the purpose of this drug?
This drug is a clot buster that dissolves clots within a coronary artery.
The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? A) Change in level of consciousness. B) Increase in urinary output. C) Onset of Kussmaul respirations. D) Decrease in serum potassium level
A) Change in level of consciousness.
The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client presenting with cardiogenic shock. Which action is most important for the nurse to take to prevent life-threatening complications from pulmonary artery monitoring? A) Fast flush the PA distal port for no more than 2 seconds. B) void infusing blood products through the PA catheter. C) Clear pressure tubing of any blood after with-drawing a sample. D) Maintain 300 mmHg pressure around the bag attached to the tubing.
A) Fast flush the PA distal port for no more than 2 seconds.
A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment findings should prompt the nurse to administer PRN dose of naloxone ? A. Unresponsive to verbal or tactile stimuli. B. Respiratory rate of 12 breath/minute. C. Statements about visual hallucinations. D. Complaints of increasing flank pain
A. Unresponsive to verbal or tactile stimuli.
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." B) "I'd rather not talk about it right now." C) "It's all the other guy's fault! He was going too fast." D) "My mother is heartbroken about this."
B) "I'd rather not talk about it right now."
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client's room C) Take the client to the day room and introduce her to the other clients D) Ask the nursing assistant to get the client's vital signs and complete the admission search
B) Introduce him/herself and accompany the client to the client's room
Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery.
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
A client who arrives at the urgent care clinic reporting diarrhea, fever, abdominal pain and nausea and tells the practical nurse (PN) the symptoms began after eating a can of beans. What is the likely cause of this type of foodborne illness?
Clostridum Botulinum
The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month old-infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper.
A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first? A) Give 0.3 mg nitroglycerin sublingual. B) Administer 4 mg IV morphine sulfate. C) Measure the ST segment height. D) Infuse 0.9% sodium chloride bolus.
D) Infuse 0.9% sodium chloride bolus.
