NURS 221 HESI

Place the following nursing actions in the correct order for a client with esophageal varices prescribed a blood transfusion: -Verify the blood product with another nurse against the client's ID bracelet. -Check the client's vital signs. -Establish IV access with IV normal saline. -Monitor the client's vitals and status according to agency policy.

-Check the client's vital signs. -Establish IV access with IV normal saline. -Verify the blood product with another nurse against the client's ID bracelet. -Monitor the client's vitals and status according to agency policy.

Which response would the nurse provide to a client receiving digoxin who calls the clinic and complains of "yellow vison"?

"The medication may need to be discontinued. Come to the clinic this afternoon."

Which response would be given by a nurse providing discharge teaching to an older adult who was admitted to the hospital to be treated for dehydration when the client asks what to do about itchy, dry skin?

"Use a moisturizer on the skin daily to help reduce itching."

Which condition contraindicates the use of ginseng herbal therapy?

Pregnancy

What is the purpose for encouraging active foot and leg exercises for a patient who has had hip surgery?

Prevent clot formation

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?

"Before I start the procedure, I will measure the residual volume."

Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia?

"I have abnormal hemoglobin."

Which explanation will the nurse give when a client asks about what causes varicose veins?

"Incompetent valves of superficial veins"

How will the nurse respond to a client with cancer experiencing severe nausea and vomiting from chemotherapy who wants to know if it is true that smoking marijuana will help?

"Some THC-based medications that contain marijuana control chemotherapy-induced nausea and vomiting in some people."

Which volume of a solution would be prepared when the nurse receives an order to prepare a solution for administering a cleansing enema for an adolescent client?

500 to 750 mL

Which blood glucose levels would the nurse identify as hypoglycemia?

68 mg/dL (exp. range: 72-108)

Which statement's regarding acne are correct?

Acne may be caused by stress Family history could be a reason for acne Propionibacterium acnes causes acne It is commonly found on the face, chest, upper back, & neck

Which action would the nurse expect in a plan of care for a client scheduled for an adrenalectomy?

Administer parenteral corticosteroids

Which explanation would a nurse provide for administering prednisone to a client with an exacerbation of colitis?

Although the medication decreases intestinal inflammation, it will not cure the colitis.

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster?

American Red Cross

Which property of acetylsalicylic acid would a nurse recall when administering to a client?

Analgesic

Which property would the nurse understand that the medication is being used primarily for when aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis?

Anti-inflammatory

Which antipyretic medication may cause Reye syndrome in children?

Aspirin

Which action will the nurse take after stopping the antibiotic infusion of a patient who becomes restless and flushed, and begins to wheeze during administration of an antibiotic?

Assess the client's respiratory status

Which type of allergic skin condition is associated with immunological irregularity, asthma, and allergic rhinitis?

Atopic dermatitis

Which advice will the nurse provide about doxorubicin to a client with Hodgkin's disease?

Expect urine to turn red for a few days after taking this medication

Which response would the nurse give when an adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations?

By acknowledging that the pain is real and administering medication to relieve it

Which medication is derived from a natural source and may be prescribed for treatment of osteoporosis?

Calcitonin

Which mineral deficiency would a nurse expect in a client who reports tingling in the fingers and around the mouth and exhibits carpopedal spasm and tremors after a surgical thyroidectomy?

Calcium

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis?

Carina

Which action would the nurse take after contacting the primary health provider of a post-surgical client complaining of nausea, fatigue, and headache during the fourth hour of the infusion of total parenteral nutrition (TPN) instituted via a central venous infusion who has an hourly urine output that is twice the amount of the previous hour?

Check the serum glucose level

Which toxic effect would the nurse expect to find on a client who had overdosed on isocarboxazid?

Circulatory relapse

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary health care provider prescribes the anticholinergic medication benztropine, 2 mg daily. Which symptom should the nurse inquire about when assessing the patient?

Constipation

Which finding leads the nurse to conclude than an IV has infiltrated rather than caused inflammation?

Coolness

When a client has a superficial tumor involving only 1 vocal chord, which surgery would the nurse anticipate?

Cordectomy

Which autoantigens are responsible for the development of Crohn's disease?

Crypt epithelial cells

Which response indicates that a beta blocker prescribed for persistent ventricular tachycardia is working effectively?

Decreased heart rate

By which process would TPN on an outpatient basis help a client with Crohn's disease prepare for surgery?

Decreasing fecal bulk

Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator?

Demonstrates use of a metered-dose inhaler

When evaluating fluid loss for a client with burns, which relationship between a client's burned body surface area and fluid loss would the nurse consider?

Directly proportional

Which diagnosis study is used to detect deep vein thrombosis in the client's lower extremities?

Duplex venous Doppler

Which clotting factor would a nurse explain is deficient to the parents of a child newly diagnosed with hemophilia A?

Factor VIII

Which condition would be indicated by the presence of ketones in the urine of a client?

Fat metabolism

Which nursing intervention assists in decreasing the potential occurrence of pressure ulcers when providing care for a client with quadriplegia?

Frequently reposition the client on a scheduled basis

Which hormone aids in regulating intestinal calcium and phosphorus absorption?

Glucocorticoids

Which assessment after administration of diltiazem to a client with supraventricular tachycardia (SVT) and a heart rate of 170 bpm indicates that the medication was effective?

HR 98 bpm

Which type of hepatitis spreads through contaminated food and water?

Hepatitis A virus

Which is an inborn error of metabolism that affects growth and development?

Hunter syndrome

A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect?

Hypertensive crisis

Which surgery will a client undergo if the pituitary gland must be removed?

Hypophysectomy

Which complication will a nurse monitor for before replacement steroid therapy is regulated fully in a client who has had an adrenalectomy?

Hypotension

Which age-related effects on the immune system occur in the older client?

Increased autoantibodies

Which medication is specifically responsible for the action of the medication ranitidine?

Inhibiting the histamine at H2 receptors?

Which cytokine stimulated the liver to produce fibrinogen and protein C?

Interleukin-6

Which factor is likely cause of the laboratory result when arterial blood gases are done on a client who is being resuscitated after cardiac arrest and show a low pH?

Lactic acid production

In which component of the nephron does furosemide decrease fluid reabsorption?

Loop of Henle Distal Tubules Proximal Tubules

Which medication may be used to treat postpartum hemorrhage?

Methylergonovine

Which medication would the nurse identify as being used both for cervical ripening during labor and for prevention of gastric ulcers?

Misoprostol

Which benign condition of the client's skin is associated with the grouping of normal cells derived from melanocyte-like precursor cells?

Nevi

Which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation after a cerebrovascular accident (CVA)?

Parietal

Which technique would be appropriate for clients who exhibit mild neurocognitive impairment?

Reality orientation

Which medication action would the nurse identify as the purpose of azathioprine, cyclosporine, and prednisone given before receiving a kidney transplant?

Reduce antibody production

Which area of the client's body would the nurse consider a high risk for developing a pressure injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a semi-Fowler position in bed?

Sacrum

Which complication may develop in a child with hypospadias with chordee?

Sexual difficulties

Which action would the nurse take when caring for a severely depressed client?

Sit down next to the client at frequent intervals

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?

Slow, weak cry

Which organism would the nurse explain is responsible for a client's diagnosis of malaria?

Sporozoa

Which mechanism of action explains how glyburide decreases serum glucose levels?

Stimulates the pancreas to produce insulin

Which hormone increases the rate of protein synthesis?

Thyroxine

For which purpose would enoxaparin 40 mg subQ daily be prescribed for a patient who had abdominal surgery?

To provide prophylaxis against postoperative thrombus formation.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?

Validating availability of a bag-valve-mask during transfer

Information about which vitamin would be included when teaching a client with atrial fibrillation about a new prescription for warfarin?

Vitamin K

Which nutrient would the nurse teach the parents of a child with celiac disease to avoid?

Wheat and oat products

Which test would the nurse identify as specific for the diagnosis of myasthenia gravis?

Edrophonium chloride test

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?

Encourage the client to ambulate multiple times daily

Which adverse effect would the nurse monitor for in a patient taking clopidogrel?

Epistaxis

Which cation regulated intracellular osmolarity?

Potassium

A medication is administered to a client in her third trimester of pregnancy. Which statement regarding the medication administration is correct?

The dose of medication may need to be increased for pregnant clients

Which organism would the nurse identify as causing syphilis?

Treponema pallidum