HESI Compass Questions
A nurse is caring for a client who has had a cast applied to his arm after fracturing his humerus. The nurse is teaching the client how to care for the injured area once he has been discharged home. Which statements by the client indicate a need for further instruction? Select all that apply. "I should keep my arm in an elevated position as much as possible." "I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." "I should do isometric exercises to make sure my arm muscles stay strong." "If I notice any wet spots on the cast or a funny smell, I should contact my doctor."
"I can expect some numbness and tingling in my fingers for a few days." "I can stick a small object between the cast and my skin if I have an itch." The nurse should teach the client with a casted arm to keep the arm elevated, which will help prevent or ease swelling. The client is also taught the signs and symptoms of infection (e.g., the presence of wet spots on the cast, foul odor). The client should also be taught to perform isometric exercises, which will help prevent muscle atrophy. Numbness and tingling are signs of circulatory compromise, and the client should be instructed to contact the health care provider if these signs are noted. The client must also be instructed not to stick anything inside the cast because of the risk of disrupting skin integrity. The nurse should tell the client that if he experiences itching inside the cast, he may aim a hairdryer adjusted to the cool setting into the cast.
A nurse is providing instruction to a client with a muscle sprain about the procedure for applying cold packs to the site of injury. Which of the following statements by the client indicate an understanding of the procedure? Select all that apply. "I'll place the cold pack on the site of injury and lie on the pack." "I'll place the cold pack directly on the skin at the site of the injury." "I'll leave the cold pack on until the ice melts and then replace it with another cold pack." "I'll cover the cold pack with a pillowcase and apply the pack to the injury site for no more than 30 minutes." "I should remove the cold pack right away if I notice any changes in sensation or if I experience discomfort after I apply it to the injury site."
"I'll cover the cold pack with a pillowcase and apply the pack to the injury site for no more than 30 minutes." "I should remove the cold pack right away if I notice any changes in sensation or if I experience discomfort after I apply it to the injury site." To help prevent skin injury, the client is instructed not to lie on the cold pack. The cold pack is covered with a flannel cover, towel, or pillowcase and applied to the injury site for no longer than 30 minutes. The client is instructed to immediately remove the cold pack if changes in sensation or discomfort occur after its application. If the changes in sensation or discomfort are not relieved after removal of the cold pack, the health care provider should be notified.
A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? "My risk for malnourishment is much higher while I'm pregnant." "How I eat can affect my baby's growth." "I need to take vitamins throughout my pregnancy." "I need to eat foods high in calcium."
"My risk for malnourishment is much higher while I'm pregnant." Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished. Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.
A health care provider prescribes cholestyramine, an anion exchange resin, to treat a client's persistent diarrhea. Which vitamin deficiency may occur if medication is needed long-term? 1 Retinol (Vitamin A) 2 Riboflavin (Vitamin B 2) 3 Thiamine (Vitamin B 12) 4 Pyridoxine (Vitamin B 6)
1 Retinol (Vitamin A) Cholestyramine is a fat-binding agent; it binds with and interferes with all the fat-soluble vitamins (A, D, E, and K). Thiamine is not a fat-soluble vitamin and is unaffected. Riboflavin is not a fat-soluble vitamin and is unaffected. Vitamin B 6 is not a fat-soluble vitamin and is unaffected.
A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? 1 cm below the ischial spines 1 cm above the ischial spines At the level of the ischial spines Above the level of the ischial spines
1 cm below the ischial spines Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.
A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 4 days 10 days 14 days 21 days
10 Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.
A nurse is caring for a client with a continuous bladder irrigation (CBI). The nurse notes that at the end of the shift a total of 3475 mL of irrigation fluid instilled and a total of 4725 mL was emptied from the urinary catheter bag. The nurse determines that the client's actual urine output is how many mL? ________mL
1250 mL To determine the actual urine output for a client receiving a continuous bladder irrigation, the nurse would subtract the amount of irrigation fluid instilled into the bladder from the total urine output. Therefore, if 4725 mL was emptied from the urinary catheter bag and 3475 mL of irrigation fluid was instilled, the actual urine output is 1250 mL.
The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pre-transfusion protocol, the nurse should administer the transfusion over what period of time? 2 hours 4 hours 6 hours 15 to 30 minutes
15 to 30 minutes The volume of a unit of platelets may vary from 200 mL for single-donor platelets to 300 mL per unit for pooled platelets. Because the platelet is a fragile cell, platelet transfusions are administered rapidly once they have been brought to the client's room, usually over the course of 15 to 30 minutes. The other options are time frames that are too long for the administration of a platelet transfusion.
Which preferred medication will the nurse administer to a client hospitalized with pneumococcal pneumonia? 1 Penicillin G 2 Ceftriaxone 3 Vancomycin 4 Meropenem
2 Ceftriaxone Streptococcus pneumoniae causes pneumococcal pneumonia. The medication preferred for the disease caused by this bacterium is ceftriaxone. Streptococcus pneumoniae is resistant to penicillin G. Vancomycin is preferred for the treatment of the infections caused by Staphylococcus aureus. Meropenem is used for treating the infections caused by Klebsiella pneumoniae.
The nurse is working with a newly licensed nurse who is undergoing education prior to inserting an IV and is gathering the equipment needed to start an IV line in an older client who will be receiving an IV solution of 0.9% NS. The nurse realizes that teaching has been effective if the newly licensed nurse selects which gauge of catheter for this client? 14 16 19 21
21 For an older client, the smallest gauge IV catheter possible should be used. A gauge of 21 or smaller is preferred. A 14-, 16-, 18-, or 19-gauge needle is used for rapid emergency administration of fluids, blood products, or anesthetics, as well as other products of thicker viscosity than that of standard IV fluids.
A mother who notes that her newborn regurgitates after feedings asks the nurse whether her baby is ill. Which information would the nurse consider before responding? 1 It is caused by a spasm of the pyloric valve. 2 It is caused by the infant's position after feeding. 3 An underdeveloped cardiac sphincter causes regurgitation. 4 An infant swallows air while suckling, resulting in regurgitation.
3 An underdeveloped cardiac sphincter causes regurgitation. The cardiac sphincter of the newborn is not fully developed; if the stomach is too full, the feeding backs up through the sphincter, and the infant regurgitates. A spasm of the pyloric valve is marked by projectile vomiting, not by regurgitation. Basing the answer on the infant's position is too vague; the position is not described. Swallowing air while suckling may cause cramping or colic.
Which clinical finding supports the nurse withholding methylergonovine maleate from a postpartum client? 1 Urine output of 50 mL/h 2 Third-degree perineal laceration 3 Blood pressure of 160/90 mm Hg 4 Respiratory rate of 12 breaths/min
3 Blood pressure of 160/90 mm Hg Methylergonovine maleate can cause hypertension and should not be given to a client with an increased blood pressure. Urine output of 50 mL/h is an expected finding in a healthy adult. Perineal lacerations are not related to methylergonovine maleate use. Methylergonovine maleate does not affect respiration.
A client is receiving dexamethasone to treat acute exacerbation of asthma. For which side effect would the nurse monitor the client? 1 Hyperkalemia 2 Liver dysfunction 3 Orthostatic hypotension 4 Increased blood glucose
4 Increased blood glucose Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. Hypokalemia, not hyperkalemia, is a side effect. Liver dysfunction is not a side effect. Hypertension, not hypotension, is a side effect.
A non-stress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? Fetal well-being has been established. A contraction stress test will be scheduled. Placental function and oxygenation are adequate. The results are inadequate and the non-stress test must be repeated.
A contraction stress test will be scheduled. A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if non stress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.
In caring for a client receiving PN (parenteral nutrition) via the central venous access catheter, which actions should be done by the nurse to prevent or identify potential complications? A. Weighing daily B. Monitoring the daily liver function tests C. Monitoring the daily electrolyte laboratory results D. Monitoring the daily serum albumin, prealbumin, transferrin levels E. Assessing blood glucose every 6 hours for 48 hours, then daily
A, C, & E. The nurse should weigh the client daily to monitor for weight gain. Electrolyte disturbances and hyperglycemia can occur in clients who are severely malnourished and started on PN. Therefore the daily electrolyte laboratory results and the blood glucose need to be monitored. Many infections occur with central lines and the risk of infection increases with the high levels of glucose that are present in the PN solution. Additionally, the central line dressing should be changed every 5 to 7 days or if moist, in accordance with CDC recommendations and the site. The liver function tests and serum albumin and transferrin levels will not change rapidly so they will not need to be monitored daily, usually they are monitored weekly.
A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to this theory, which choice represents the primary developmental task of the child? A. To master useful skills and tools B. To gain independence from parents C. To develop a sense of trust in the world D. To develop a sense of control over self and body functions
A. To master useful skills and tools According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Development of a sense of trust in the world is the psychosocial task of an infant. Development of a sense of control over self and body functions is the psychosocial task of the toddler.
A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction? Rhubarb Spinach Fish American cheese
American cheese Rationale: The client's laboratory value reflects hypernatremia; the normal serum sodium range is 135 to 145 mEq/L (135-145 mmol/L). On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods from animal sources, which contain physiological saline (e.g., cheese, highly processed meats), and other foods that have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus.
A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? Checking the woman's blood pressure Calling the obstetrician to the examining room Placing a cool cloth on the woman's forehead Assisting the client into a lateral recumbent position
Assisting the client into a lateral recumbent position When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Signs/symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.
A nurse is providing information to the parents of a 5-month-old infant about introducing solid foods to the infant. Which of the following instructions should the nurse give to the parents? A. Cheese should not be used as a substitute for B. Introduce one new food at a time at intervals of 4 to 7 days. C. Mix soft solid food with formula if the infant refuses to eat. D. Start with fruits and vegetables; if these are tolerated, add cereal to the diet.
B. Introduce one new food at a time at intervals of 4 to 7 days. Solids may be added to feedings when the infant is 5 to 6 months old. Rice cereal is introduced first because of its low allergenic potential. The recommended sequence after the introduction of rice is weekly introduction of fruits, followed by vegetables and then meat. Cheese may be used as a substitute for meat or as a finger food. Parents are instructed to introduce one food at a time, usually at intervals of 4 to 7 days, as a means of identifying food allergies. Foods are never mixed with formula in the bottle.
Which instruction should the nurse provide to the mother? A. Place the child in the back seat of the car in a booster seat B. Place the child in the back seat in a forward-facing convertible seat with a harness C. Restrain the child in the passenger side of the front seat as long as an air bag is in place D. Place the child in the back seat of the car in a forward-facing position using the car seat belts
B. Place the child in the back seat in a forward-facing convertible seat with a harness The convertible restraint is used for toddlers and preschoolers. It is best that the child ride in a rear-facing position for as long as possible, to the highest height and weight allowed by the manufacturer of their convertible seat. Once a child has outgrown the rear-facing seat, a forward-facing seat with a full harness should be used for as long as the child fits. Booster seats are for older children who have outgrown their forward-facing car safety seats. Air bags can be harmful or even lethal to small children.
Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? The result of the Rh factor screen is normal. Because the Rh factor is not present, no additional testing is necessary. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.
Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation. If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.
A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions? Cabbage Coffee with cream Boiled potatoes Milk
Boiled potatoes Rationale: During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and foods such as raw fruits and some vegetables, that are very high in fiber. Vitamins and iron supplements may be prescribed.
A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? Contacting the nurse-midwife Continuing to monitor the FHR pattern Administering oxygen at 10 L by face mask Preparing the woman for immediate delivery
Continuing to monitor the FHR pattern Early deceleration of FHR is a visually apparent gradual decrease and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.
A nurse in a daycare center is planning play activities for a group of toddlers. Which choices are the most appropriate play materials for these children? A. Videos, compact disc player, board games B. Rattles, stuffed animals, squeaky dolls, soft mobiles C. Cards, Monopoly game, sewing kits, paint-by-number kits D. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper
D. Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper The toddler engages in parallel play. Appropriate toys promote increased locomotive skills, meet the need for tactile play, and are safe. Blocks, a rocking horse, finger paints, wooden puzzles, thick crayons, and paper are all appropriate toys for a toddler. Videos, a compact disc player, board games, sewing kits, and paint-by-number kits are more appropriate for a school-age child. Rattles, stuffed animals, squeaky dolls, and soft mobiles are more appropriate for an infant.
A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectiveness of the tube feedings? Daily weight Daily intake and output records Calorie count sheets Serum protein level
Daily weight Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is the daily weight. The client should be weighed at the same time (preferably early morning) each day, wearing the same clothes, on the same scale. The incorrect options may be used to assess nutrition and hydration status, but the effectiveness of the diet is measured by whether the client's body weight is maintained.
A nurse in a prenatal clinic, performing an initial assessment of a pregnant client, is using Nagele's Rule to determine the client's estimated date of delivery (EDD). The client tells the nurse that her last menstrual period (LMP) began on February 10, 2016. What EDD does the nurse calculate with this information? October 17, 2016 November 17, 2016 September 17, 2016 December 17, 2017
For Nagele's Rule to be accurate, the woman must have a regular 28-day menstrual cycle. The nurse would subtract 3 months and then add 7 days to the first day of the LMP, then add 1 year to that date. Subtracting 3 months from February 10, 2016 is November 10, 2015. Adding 7 days to November 10, 2015 is November 17, 2015. Adding 1 year to November 17, 2015 yields the correct answer, November 17, 2016.
A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? Gravida 2, para 4 Gravida 3, para 5 Gravida 4, para 2 Gravida 5, para 3
Gravida 4, para 2 Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.
A nurse checks the laboratory test results of a client who is undergoing chemotherapy and notes that the client's platelet count is 90,000 cells/mm. In light of this result, which action by the nurse is appropriate? Instituting bleeding precautions Instituting neutropenic precautions Informing the client that the test result is normal Educating the client about the importance of increasing iron in the diet
Instituting bleeding precautions The appropriate action by the nurse would be to institute bleeding precautions for the client. Platelets are produced by the bone marrow to function in hemostasis. The normal platelet count ranges from 150,000 to 400,000 cells/mm. A decrease in the number of platelets puts the client at risk for bleeding. Neutropenic precautions are instituted when the WBC count is low because the client is at risk for infection. Increasing dietary iron would not help increase platelet formation.
A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? Meats and citrus fruits Eggs and bacon Cereals and broccoli Rice and fish
Meats and citrus fruits Rationale: The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron is absorbed from eggs and less than 5% from grains and vegetables.
The nurse is developing a plan of care for a client in skeletal traction. Which interventions should the nurse include in the plan of care? Select all that apply. Expect to note some purulent drainage from the pin sites. Ensure that there are no knots in any of the traction ropes. Monitor color, motion, and sensation in the affected extremity. Lift the weights only when it is necessary to reposition the client. Ensure that the weights for the traction device hang freely and do not touch the floor.
Monitor color, motion, and sensation in the affected extremity. Ensure that the weights for the traction device hang freely and do not touch the floor. RATIONALE: Traction is the exertion of a pulling force in two directions as a means of reducing and immobilizing a fracture. Nursing responsibilities for the client in traction include ensuring proper body alignment of the client, ensuring that weights hang freely and do not touch the floor, refraining from removing or lifting the weights without a health care provider's prescription, ensuring that pulleys are not obstructed and that the ropes in the pulleys move freely, and tying knots in the ropes to prevent slippage. The nurse should also monitor the color, motion, and sensation of the affected extremity frequently; changes could indicate circulatory compromise and could require health care provider notification. Purulent drainage, which is not an expected finding, is an indication of infection.
A client with diabetes mellitus who has been taught about food exchange system of dietary management of the disease wishes to have 8 oz (240 ml) of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt? Omitting salad dressing and butter at lunchtime Not eating ice cream for 2 days Eating only half of an allowed meat product at supper Omitting 8 oz (240 ml) of skim milk from that meal
Omitting 8 oz (240 ml) of skim milk from that meal Rationale: Yogurt is a milk product. Therefore if the client is going to eat 8 oz (240 ml) of yogurt at a meal, the client should eliminate the milk product from the same meal. Ice cream is not recommended for the diabetic diet because it is high in fat and sugar. Meat is not a milk product, and it is unnecessary to alter the meat allowance at suppertime. Salad dressing and butter are fats.
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? One high in carbohydrates One with a moderate amount of fat One high in fluids One low in protein
One low in protein Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the formation of ammonia. Therefore the client would benefit from a low-protein diet.
A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? Chicken, potatoes, and cranberries Spinach salad, milk, and a banana Linguini with shrimp, tossed salad, and a plum Peanut butter sandwich, milk, and prunes
Peanut butter sandwich, milk, and prunes Rationale: In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The incorrect options represent components of an acid ash diet.
A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys? Physiological stress Sympathetic nervous system stimulation Release of norepinephrine Release of dopamine
Release of dopamine Rationale: Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow. The factors set forth in the other options result in renal vasoconstriction.
A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication? Cranberries Rhubarb Oranges Prunes
Rhubarb Rationale: When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is required. Prunes, oranges, and cranberries are acceptable foods.
A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? Back of the head Right heel Scapulae Left heel
Right heel Rationale: Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg, which is used as a brace when the client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.
A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? The procedure will take about 2 hours. The obstetrician will locate the fetus with the use of the Leopold's maneuvers. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.
The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Leopold's maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.
A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? The man lightly pushes on his wife's sacral area with his fist. The man exerts steady pressure on his wife's abdomen during a contraction. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.
The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. Effleurage (light massage) and counter pressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counter pressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect
The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? The cervical os is completely dilated. The client will require induction with the use of oxytocin. Enlargement of the cervical canal that occurs during the first stage of labor is complete. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.
The shortening and thinning of the cervix that occurs during the first stage of labor is complete. Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of the cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.
A nurse is observing as a nursing student prepares and administers a tap water enema to an adult client. Which observation by the nurse indicates the need to intervene before allowing the nursing student to proceed? The student inserts the tube 1 inch into the client's rectum. The student places the client in the modified left lateral recumbent position. The student clamps the tubing when the client complains of abdominal cramping. The student checks the temperature of the enema solution before administering it.
The student inserts the tube 1 inch into the client's rectum. In an adult client, the rectal tube is pointed in the direction of the client's umbilicus and inserted 3 to 4 inches. If the rectal tube were inserted just 1 inch, solution would leak from the anus instead of flowing into the rectum. The rectal tube is inserted 2 to 3 inches in a child and 1 to 1.5 inches in an infant. Putting the client in the modified left lateral recumbent position, checking the temperature of the enema solution, and clamping the tubing if the client complains of abdominal cramping are all correct procedures in the administration of an enema.
A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? The umbilical cord holds two veins and one artery. Fetal blood circulation takes place strictly in the placenta. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.
The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.
A client is undergoing high-dose warfarin sodium therapy. The nurse checks the client's laboratory results and sees that the INR is 3.5. Which determination should the nurse make on the basis of this result? This value is expected. The dose of warfarin sodium needs to be adjusted. The primary health care provider should be notified, because the INR is too low. The primary health care provider should be notified, because the INR is too high.
This value is expected. The INR should be maintained at 2.0 to 3.0 in a client undergoing standard warfarin sodium therapy and 3.0 to 4.5 in a client undergoing high-dose therapy. A value of 3.5 is therefore expected.
A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. What is the best response the nurse should give to the client? To increase her daily intake of high-fiber foods That this is a normal occurrence during pregnancy To take the iron supplement every other day instead of every day To start taking an oral laxative daily until the constipation resolves
To increase her daily intake of high-fiber foods The best response is for the client to increase her daily intake of high-fiber foods. Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the primary health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.
A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? To have at least one serving each day of a citrus fruit To increase the intake of legumes That organ meats should be included in the diet That seafood should be included in the diet
To increase the intake of legumes Rationale: Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.
A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? Week 1 Week 5 Week 8 Week 9
Week 5 By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore, the other options are incorrect.
The nurse is monitoring a client receiving a blood transfusion. One hour after the transfusion is started, the client complains that her skin is extremely itchy. On assessing the client's skin, the nurse notes a rash and suspects a transfusion reaction. Which action should the nurse take after immediately stopping the transfusion? Removing the IV catheter Contacting the health care provider Completing a transfusion reaction report Rechecking the blood bag tags against the client's identification band
When a transfusion reaction occurs, the nurse first stops the blood transfusion, then maintains a patent IV line with normal saline solution and immediately notifies the health care provider and blood bank. After taking these actions, the nurse would recheck the blood bag tags against the client's identification band, check the client's vital signs and urine output, treat the client's symptoms in accordance with the health care provider's prescriptions, send the blood bag and tubing to the blood bank, complete a transfusion reaction report and document the reaction in the client's record, and collect required blood and urine samples in accordance with agency protocol and health care provider's prescriptions.
