Exit Hesi PN

A mother has just given birth to a baby who died soon after. The mother has been crying and states, "I can't believe this has happened to me. I did everything right during this pregnancy." How should the nurse respond to this mother?

Tell her nothing and let her mourn this loss in the manner she chooses.

The nurse is preparing to administer an enteral feeding to a client via an nasogastric feeding tube. The MOST important action of the nurse is

Verify correct placement of the tube

The difference between spirituality and religion is that spirituality is:

an individual's relationship with a higher power.

The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following?

"We will be sure to not leave hot liquids unattended."

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 6. Educate regarding symptoms of retinal detachment.

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

1. Monitor the client's ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client's ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage.

A nurse knows the clinical manifestations of a client with Addison's disease include which of the following? Select all that apply:

1. Nausea 4. Hyperpigmentation 5. Hypotension

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

1. Oliguria 4. Proteinuria 3+ 6. Blood pressure 168/116 mm Hg

A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply.

1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count.

The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply:

1. Presence of cardiac pain. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis.

A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.

1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 6. Medication that is antagonistic to antidiuretic hormone (ADH)

A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.

1. Skin 3. Inhalation 4. Gastrointestinal

A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications?

A 10-year-old female client with a urinary tract infection

Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood?

Check the blood pressure.

A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She states to the nurse, "I am so angry that my doctor didn't take better care of me and my baby." Which of the following responses should the nurse make?

It is important to share what you are feeling, even if it is anger

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection?

Psychosocial

In teaching the client about proper umbilical cord care, the nurse recommends that:

The area be cleansed at diaper changes with alcohol and inspected for redness or drainage

A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client?

When you raise your voice, it makes me feel uncomfortable and unsafe."

Client room environments should include:

a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.

Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?

Thiamine and pyroxidine

An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which of the following is the best action?

Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent.

A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:

Treat hypocalcemic tetany.

A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

Tyramine-free

A nurse in a long-term care center is caring for an adult client who has Alzheimer's disease and whose partner died several years ago. The client appears upset and asls the nurse when his partner will visit again. The nurse states, "It seems like you are feeling lonely. Let's take a walk outside and talk.' Which of the following communication strategies is the nurse using?

Validation therapy

While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?

Unplug the bed's power source.

The nurse can promote relief of muscle pain, spasms, and tension by:

applying heat, cold, pressure, or vibration to the painful area.

For a client requiring total oral care, it is important for the nurse to:

assemble all equipment, place the client in a side-lying position, and place a towel under his chin.

The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?

creatinine clearance

In children suspected to have a diagnosis of diabetes, which one of the following complaints would be MOST likely to prompt parents to take their school age child for evaluation?

bed wetting

Spirituality affects a client's life in all of the following areas except:

genetic makeup.

After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?" This is an example of:

seeking consensual validation.

When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first?

semen analysis

The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?

two non-nucleoside reverse transcriptase inhibitors

The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply:

1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes.

The nurse is evaluating a client's response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply:

1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 5. BUN decreases from 110 to 90 mg/dL

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

"I need to limit playing football to only the weekends." "I should exercise in the evening to encourage a good sleep pattern."

A nurse is reinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statements should the nurse identify as an indication that the client understands the information?

"I should expect some improvement of my symptoms in about 10 days

Which of the following statements indicates adequate dietary understanding in a client with constipation?

"I should increase my intake of apples."

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis 6. A client with congestive heart failure

A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, "My youngest child died 6 months ago while serving in the military." Which of the following responses should the nurse make?

-This must be very difficult time for you -Your child's death must be a terrible loss -Tell me something you remember about your child

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply.

1. Auscultating lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations

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:

1. Elevate the HOB. 2. Decrease intake of caffeine. 3. Discuss strategies for weight loss if overweight. 5. Take ranitidine (Zantac) at hs.

The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply:

1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happening.

The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply:

1. Verify consent has been signed. 2. Explain procedure to client. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy.

The nurse understands that the following clinical findings are indications for dialysis. Select all that apply:

1. Volume overload 3. K 5.2 mEq/L 5. Metabolic acidosis 6. Cr 5.0 mg/dL

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client

Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply:

2. Avoid use of donut type devices. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in a chair or wheelchair.

When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.

2. Early onset cough 4. Purulent mucus production 5. Mild episodes of dyspnea

The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse's instructions? Select all that apply:

2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in sitting position, he should keep his legs elevated. 4. Avoid standing for long periods of time.

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply.

2. Increased clotting time. 3. Hypertension. 4. Headaches.

A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply.

2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client

A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply.

2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 6. Lack of follow-up nursing actions

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.

2. Notify the registered nurse. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask.

The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply:

2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 5. Complaints of leg pain unrelieved by analgesics or repositioning.

A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply:

2. Too rapid installation 4. Accumulation of dialysate solution under the diaphragm

A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply.

3. Constipation 4. Bleeding gums 5. Hyperglycemia

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that

5. In a semi-Fowler's position 6. With the head in a midline position

How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?

6 feet

A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findings is referred to as a negative symptom of schizophrenia?

Apathy

A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first?

A client on a ventilator

A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

A client who requires frequent ambulation

A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have:

A low birth weight

A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence?

A nurse does not notify the provider of a change in condition for a client who has schizophrenia

When caring for a 3-year-old child, the nurse should provide which toy for this child?

A wagon

A nurse is caring for a client who has major depressive disorder(MDD). The client states. "I have nothing to live for anymore. I just can't go on." Which of the following responses should the nurse make?

Are you thinking about ending your life

A 24-hours' postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first:

Assist her with a sitz bath

Which cultural group has the highest incidence of inflammatory bowel disease (IBD)?

Caucasians

While assessing the quality of home care for a client with Alzheimer's disease, the PRIORITY for the nurse is to emphasize

Client safety

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming

A postpartum woman admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome?

Cranial facial abnormalities are noted

A nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action?

Decline to sign the will.

The major purpose of community health research is to

Describe the health conditions of populations

A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first?

Determine the client's intentions

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

A nurse is reinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include?

Do not drive until your reaction to the medication is determined

A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take?

Encourage the client to develop a safety plan

A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting?

Establish and explain consequences for the client's behavior

A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?

Gloves, a gown, and goggles

A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client?

Have the client's favorite snacks available at all times.

A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?

Her pregnancy is threatened, and the fetus is at risk for teratogenesis.

A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statements should the nurse make to gather information about the client's ability to think abstractly?

How is an orange similar to an apple

A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client's use of this substance?

Hypertension

A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist. "I know more than you do about the people in this room!" The nurse should identify that which of the following findings is the likely explanation for the client's behavior?

Hypomania

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe?

Naloxone

A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?

Nursing staff are led by a nurse when providing care to a group of clients.

A nurse in a mental health facility is caring for a client who has dementia. The client's agitation is increasing. Which of the following actions should the nurse take first?

Offer diversionary activities

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum:

Potassium level of 6.3 mEq/L

After securing the client's safety from a faulty electric bed, the nurse should take which action?

Prepare an incident report.

The nurse practicing in a maternity setting recognizes that the post mature infant is at risk due to

Progressive placental insufficiency

A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect?

Projects blame onto others

A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulin dependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?

Regular insulin by IV infusion

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely

Respirations that are abnormally deep, regular, and increased in rate

When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that:

She must use a reliable form of birth control.

A nurse in a provider's office is collecting data from an older adult client whose adult child reports that she "seems confused and can't seem to remember much." Which of the following findings should lead the nurse to suspect delirium?

The client's level of consciousness changes during the interview

A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client's confidentiality?

The nurse places the client's diagnosis on the white board in the client's room

A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statements should the nurse include in the teaching?

The voices you have been hearing should decrease."

Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?

Vomiting, impaired consciousness, decreased blood pressure

Which of the following foods can cause diarrhea when eaten by a client with an ileostomy?

coffee

In infants and children, the side effects of firstgeneration over-the counter (OTC) antihistamines, such as diphenhydramine (Benedryl) and hydroxyzine (Atarax), can include:

paradoxical CNS stimulation.

Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include:

the nail beds and the tissue surrounding the nails.