Exam 1 HESI Questions

Which is the best therapeutic approach for the nurse to engage in conversation with the client?

"I sense a spiritual strength about you."

Which class of medication should the nurse expect to administer?

An antihistamine, such as diphenhydramine.

The nurse explains to the client that this precaution reduces the risk for what potential problem?

Anaphylactic reaction.

To reduce the effects of moisture on the client's skin, which intervention should be implemented?

Apply a moisture-repellent ointment to intact skin areas.

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? (Select all that apply. One, some, or all options may be correct.)

Apply light pressure to the area with the fingertips, and Measure the diameter of the redness.

Which irrigation technique is best?

Apply steady pressure using a 35 mL syringe and 19-gauge needle.

Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first?

Ask the client if he is aware of any allergies to medications.

What teaching should the nurse provide?

Hydrocolloid dressings should be continued over the ulcer.

What action should the nurse implement?

Identify these areas as sites where pressure damage has occurred.

Which nursing diagnosis best applies to the client's nutritional assessment?

Imbalanced nutrition: less than body requirements.

When the client's foot pain is controlled, which nursing diagnosis should take priority ?

Impaired physical mobility.

Which etiology identified by the nurse is accurate?

Impaired physical mobility.

Which educational information would the nurse provide the client to help prevent constipation? (Select all that apply. One, some, or all options may be correct.)

Increase physical activity as tolerated, Drink plenty water, and Choose foods higher in fiber.

After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?

Contact precautions.

The client replies, "My wife is my rock. She reads the Bible to me every morning." His eyes become teary. What should the nurse do to provide for the client's spiritual needs?

Place a sign on the door to allow the client some quiet time in the mornings.

The nurse correctly uses which technique when pouring the suspension?

Place the medication cup on a flat surface at eye level.

During the course of antibiotic treatment with linezolid, which of the client's serum laboratory values requires intervention by the nurse?

Platelet count (100 x 103/mcL (100 X 109 /L)

How should the nurse teach the student nurse to position the chair to ensure a safe transfer?

Position the chair at the head of the bed facing the foot on the client's left side close to the bed.

How should the nurse describe the drainage in documenting the wound?

Purulent

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document?

Reactive hyperemia.

The client says he has faith that God will be with him through this challenge to regain his health. What nursing diagnosis should be included in the plan of care?

Readiness for enhanced spiritual well being.

Which nursing action should be included in the plan?

Reposition the client in bed from supine to a 30 degree side-lying position every 2 hours.

Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? (Select all that apply. One, some, or all options may be correct.)

Teach the client to dorsal flex and plantar flex his feet while in the bed and chair, Instruct the client to wear sequential compression stockings, and Explain that enoxaparin injections will be administered routinely.

Which action should the nurse implement?

Teach the client to take ten deep breaths an hour while awake.

The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI?

Transparent film dressing.

The client is wearing thigh-high antiembolic hose prescribed by the Healthcare provider (HCP). The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP?

Unilateral calf edema.

Which instruction should the nurse give to the nursing student for positioning the client's legs when he is sitting?

Use two pillows and place one lengthwise under each calf.

Client is prescribed enoxaparin while admitted to hospital per protocol. The dose is 1mg/kg subcutaneously every 12 hours and the client weighs 140 lbs. Dose available is 80mg per 0.8 mL. How many milliliters will the nurse administer to the client? (Enter the numeric value only. If rounding is necessary, round to the nearest tenth.)

0.6 mL

Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate to severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should the nurse draw up for administration? (Patient weighs 140 lbs on admission). (Enter the numerical value only. If rounding is necessary, round to the nearest tenth.)

1.6 mL

How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.)

20

What is the total daily dosage (in mg) that the client will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.)

800

To provide pressure relief at night, the nurse teaches the client to sleep in which position?

Thirty-degree lateral inclined position.

The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene?

Assessing the Homan's sign in bilateral extremities.

What action should the nurse take?

Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.

The nurse instructs the client to increase his intake of which foods to prevent a decrease in bone density?

Calcium rich foods.

The nurse also develops a dietary teaching plan to reduce the risk of constipation. Which dietary selection should the nurse encourage the client to eat?

Chicken Caesar salad with a whole wheat roll and skim milk.

The nurse encourages the client to select which breakfast items to provide a good source of protein?

Eggs and orange juice.

Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take?

Encourage them to continue to use this device in their wheelchair at all times.

What is the priority nursing action?

Gently lower the client to the floor.

Which nursing response best promotes effective communication?

Help the client identify the concerns he is trying to cope with at this time.

What is the best response by the nurse?

Help the client perform the correct technique for deep breathing exercises.

Which areas are most important for the nurse to observe for additional pressure injuries (PI)?

Ischial tuberosities.

What is the purpose of this type of dressing?

Mechanically debride the tissue.

Which foods should the nurse encourage?

Milk, oatmeal, and an orange.

Which technique should the nurse use to mix the linezolid?

Mix according to directions.

What initial action should the nurse take?

Offer the client the opportunity to discuss their feelings of anger.

Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity?

Peak and trough.

Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?

Pharmacist.

It is most important to include this group in which aspect of the client's overall care?

Reviewing class notes and studying for exams.

The nurse explains to the student nurse that the Braden Scale is used to measure which client parameter?

Risk for pressure sores.

Which equipment should the nurse utilize to assess the length of the tract?

Sterile cotton-tipped applicator.

How should the nurse assess for orthostatic hypotension?

Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions.

Which goal is correct for the client's diagnosis of impaired physical mobility?

The client will sit in the chair for each meal beginning on the day of admission.

Which goal should the nurses include in the client's plan of care?

The client's skin will remain intact without deterioration.

Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group?

The clients girlfriend and his two best male friends from the college.