Hesi

A client who is suspected of having leukemia has a bone marrow aspiration. What should the nurse do Immediately after the procedure? a. Apply brief pressure to the site. b. Have the client lie on the affected side. c. Swab the site with an antiseptic solution. d. Monitor vital signs every hour for 4 hours.

a. Apply brief pressure to the site.

A client has returned from surgery with a nephrostomy tube. Which is the most essential nursing intervention for this client? a. Ensure free drainage of urine. b. Milk the tube every 2 hours. c. Keep an accurate record of intake and output. d. Instill 12 mL of normal saline every 8 hours.

a. Ensure free drainage of urine.

The nurse is planning to teach a client about a prescribed medication. Which factor is most important in assuring the client will safely self administer the medication? a. Health literacy. b. Follow-up with prescriber. c. Amount of co-payment. d. Social support.

a. Health literacy.

A 4-year-old child is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). A blood transfusion is ordered, and an intravenous line is started. What will the nurse do in regard to administering the transfusion? a. Infuse the blood over no more than 4 hours. b. Take the vital signs 3 hours after the transfusion. c. Check the vital signs 15 minutes after starting the transfusion. d. Have the blood warm at room temperature for 1 hour before administration.

a. Infuse the blood over no more than 4 hours.

What will a nurse teach the parents of a toddler with newly diagnosed cystic fibrosis about the administration of vitamins A, D, E, and K? a. Offer them in a water-miscible form. b. Give them during meals and snack times. c. The dosage is based on the child's height and weight. d. Present them to the child with fruit juice rather than milk

a. Offer them in a water-miscible form.

After a fire, many people were expected to be admitted to the emergency department. There is a need for prehospital care providers to provide continuous cardiac monitoring, advanced airway management, and intubation in a group of clients who are severely injured. Which team is responsible for providing these services? a. Paramedics b. Ancillary nursing staff c. Psychiatric crisis nurse team d. Emergency medical technicians (EMTs)

a. Paramedics

Which findings in a four-year-old indicates an appropriate development of socialization skills? Select all that apply. a. The child tends to be selfish and impatient. b. The child takes pride in his or her accomplishments. c. The child tells family tales to others with no restraint. d. The child is eager to do things correctly and please others. e. The child tries to follow rules during an associative play, but cheats to avoid losing.

a. The child tends to be selfish and impatient. b. The child takes pride in his or her accomplishments. c. The child tells family tales to others with no restraint.

Which of the following statements about a case manager is correct? a. "A case manager identifies and implements new and more effective approaches to problems." b. "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." c. "A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems." d. "A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families."

b. "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families."

The nurse instructs a multipara who has just given birth to a large-for-gestational-age (LGA) infant how best to maintain a contracted uterus. Which statement indicates to the nurse that the teaching was effective? a. "If I start to bleed, I'll call for help." b. "I'll massage my uterus regularly to keep it firm." c. "If I urinate frequently, my uterus will stay contracted." d. "I'll call you every 15 minutes to massage my uterus."

b. "I'll massage my uterus regularly to keep it firm."

Which nursing tasks would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? a. Performing venipuncture for serum CBC, electrolytes and blood cultures. b. Assisting clients with morning ADLs to include showering and shaving. c. Transporting a client with a fractured wrist to the cast clinic for cast placement. d. Placing a urinary indwelling catheter prior to a procedure. e. Assessing breath sounds of a client on admission to the asthma clinic.

b. Assisting clients with morning ADLs to include showering and shaving. c. Transporting a client with a fractured wrist to the cast clinic for cast placement.

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning? a. Shallow b. Blowing c. Slow chest d. Modified paced

b. Blowing

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? a. Irrigate the T-tube as necessary b. Protect the abdominal skin from bile drainage c. Have the client wear a binder when out of bed d. Empty the T-tube drainage bag every two hours

b. Protect the abdominal skin from bile drainage

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do? a. Hold the client's extremities firmly. b. Protect the client's head from injury. c. Insert an airway between the client's teeth. d. Have several staff members move the client to a soft surface.

b. Protect the client's head from injury.

Along with appropriate hand hygiene and respiratory etiquette, what nursing actions should be done next to prevent spread of a communicable disease from an infected client? a. Notify the client's healthcare providers and known contacts. b. Alert the public health authorities about the infection. c. Assist with rapidly identifying the disease and immediately isolating. d. Make a public announcement of the identified infectious disease.

c. Assist with rapidly identifying the disease and immediately isolating.

What is the best description of evidence-based practice (EBP) in nursing? a. Nurses measure the effects of interventions on populations to determine individual client care. b. Nurses implement interventions which have already been determined to be safe and effective in clinical practice. c. Nurses generate answers to questions about interventions not already used in the care of clients. d. Nurses exchange traditional interventions and established clinical nursing practice for alternative, non-traditional approaches.

c. Nurses generate answers to questions about interventions not already used in the care of clients.

A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What is the origin of the metabolic acidosis caused by aspirin toxicity? a. Deep rapid breathing b. Higher pH of gastric contents c. Rapid absorption of salicylate d. Increased renal excretion of bicarbonate

c. Rapid absorption of salicylate

A nurse is teaching about the function of the loop of Henle. Which function should the nurse include? a. Secretion of ammonia in the descending limb Incorrect b. Secretion of hydrogen in the descending limb c. Reabsorption of sodium in the ascending limb d. Reabsorption of water in the ascending limb

c. Reabsorption of sodium in the ascending limb

The nurse manager is designated as a unit Chief during the formulation of a Hospital Incident Command System (HICS) for disaster preparedness. Which responsibility does the nurse manager assume in this role? a. Public information b. Medical command c. Safety and security d. Logistics and operation

d. Logistics and operation

A nurse is administering 5,000 units of heparin to a prenatal client on prolonged bed rest. The label indicates that there are 20,000 units of heparin in each milliliter of solution. How much solution should the nurse give the client? Record your answer using two decimal places and include a leading zero if applicable. Do not include units in your answer. ___ mL

0.25

The parents of a child with acute poststreptococcal glomerulonephritis ask a nurse why their child is being weighed every morning. What is the best response by the nurse? a. "It's the best way to measure your child's fluid balance." b. "It provides a measure of how much protein is being lost." c. "The disease process is usually over when weight loss stops." d. "Plans for the daily caloric intake are made according to the daily weight change."

a. "It's the best way to measure your child's fluid balance."

A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication? a. Begin a program of meticulous mouth care. b. Avoid traumatic injury and exposure to infection. c. Increase oral fluid intake to at least 3 L/day. d. Report unusual muscle cramps or tingling sensations in the extremities.

b. Avoid traumatic injury and exposure to infection.

A reasonable short-term outcome for clients who are functioning below the optimal level of mental health is to help them become better able to do what? a. Understand the dynamics behind their inadequate interpersonal relations. b. Confront their inadequacies in interpersonal relations and be more sociable. c. Discuss feelings regarding their life experiences and their significant others. d. Take actions that will increase their satisfaction with their relationships with others.

c. Discuss feelings regarding their life experiences and their significant others.