HESI Evolve Adaptive Quizzing

Which iron-rich foods would the nurse encourage the client with mild anemia in early pregnancy to eat? Select all that apply. One, some, or all responses may be correct. 1 Dark leafy green vegetables 2 Legumes 3 Dried fruits 4 Yogurt 5 Ground beef patty

1235, Excellent food sources of iron include liver, meats, whole grain or enriched breads, dark green leafy vegetables, legumes, and dried fruits. Yogurt is a good source of calcium, not iron.

Which information would the nurse include when instructing a client with a rash to use baths to help decrease itching and promote comfort? Select all that apply. One, some, or all responses may be correct. 1 Add oil to the water to moisturize the skin. 2 Soak for 15 to 20 minutes up to 3 or 4 times a day. 3 Make sure to rub the skin thoroughly dry after the bath. 4 Fill the tub with tepid water to cover the affected areas. 5 Apply creams or moisturizers immediately after the bath.

2 4 5, The client can soak for 15 to 20 minutes 3 to 4 times per day depending on the problem and the amount of discomfort. Tepid water filled to cover the affected areas should be used for the bath. Creams or moisturizers should be used immediately after the bath to help seal the moisture in hydrated cells. Oil should not be added to bath water because it can increase the risk of falls. After the bath, the client should gently pat, not rub, the skin dry; rubbing the skin can increase irritation and inflammation.

Which discharge instruction would the nurse teach a client who receives a radium implant for uterine cervical cancer? 1 "Limit your daily fluid intake." 2 "Return for follow-up care." 3 "Change to a high-residue diet." 4 "Double the daily mineral supplements."

2, Before discharge, the nurse would instruct the client of the importance of returning for follow-up care at specified intervals. The client does not need to reduce fluids unless cardiac or renal pathology is present. With a uterine cervical radium implant, the client should be placed on a low-residue diet to prevent pressure from a distended colon. When the radium implant is removed, the client may return to a regular diet. If the low-residue diet were inadequate, the client would include mineral supplements.

The nurse assesses a client receiving antipsychotic medications for treatment of schizophrenia. The nurse notes the client has a temperature of 102°F (38.9°C) and an abnormal blood pressure. Which adverse effect of the antipsychotic medication would the nurse suspect causes this condition? 1 Akathisia 2 Tardive dyskinesia 3 Extrapyramidal symptoms 4 Neuroleptic malignant syndrome

4 Neuroleptic malignant syndrome is the adverse effect caused by antipsychotic medications. The symptoms are fever and unstable blood pressure. Akathisia is the one of the symptoms of pseudoparkinsonism. Tardive dyskinesia is one the adverse effects of antipsychotic medications. The symptoms of this adverse effect are characterized by involuntary contractions of oral and facial muscles. Extrapyramidal symptoms is one the adverse effects of antipsychotic medications. The symptoms of this adverse effect are involuntary motor symptoms.

Which interventions would the nurse include in the plan of care for a client with gastroesophageal reflux disease (GERD)? Select all that apply. One, some, or all responses may be correct. 1 Encourage client to follow the prescribed treatment regimen. 2 Keep the head of the bed elevated to approximately 30 degrees. 3 Avoid placing the client in the supine position for 2 to 3 hours after a meal. 4 Instruct the client to eat six small meals a day with the last just before bedtime. 5 Instruct the client to take a proton pump inhibitor before the first meal of the day.

1 2 3, Clients should be encouraged to follow the prescribed regimen. Nursing care of the client includes keeping the head of the bed elevated to approximately 30 degrees and avoiding the supine position for 2 to 3 hours after meals. The client should avoid food and activities that cause reflux such as eating late at night. Proton pump inhibitors should be taken before the first meal of the day and are more common in treating peptic ulcer disease.

Which side effect would the nurse monitor in a client receiving a calcineurin inhibitor to prevent organ rejection? Select all that apply. One, some, or all responses may be correct. 1 Hirsutism 2 Gingival hyperplasia 3 Peptic ulcer 4 Nephrotoxicity 5 Bone marrow suppression

1 2 4, Immunosuppressants belonging to calcineurin inhibitors may inhibit T helper cells to prevent production and release of IL-2 and γ-interferon. Hirsutism, gingival hyperplasia, and nephrotoxicity may occur as side effects of calcineurin inhibitors. Peptic ulcer may occur when injecting corticosteroids for immunosuppressant therapy. These drugs do not cause bone marrow suppression or alterations of the normal inflammatory response. Bone marrow suppression may occur when administering cytotoxic drugs.

The nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. One, some, or all responses may be correct. 1 "I will elevate the head of the client's bed to no more than 30 degrees." 2 "I will ensure that the client is turned and repositioned at least every 2 hours." 3 "I will advise the client to apply talc directly to the perineum." 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." 5 "I will teach the client to refrain from eating a high-protein and calorie diet."

1 2 4, The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure injuries. Turning and repositioning the client frequently improves circulation, and redistributes body weight over bony prominences, both of which reduce the risk of pressure ulcer formation. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps nourish the skin. The client should not apply talc directly to the perineum. The client should take in an adequate amount of protein and calories in the diet.

While caring for a client in traction, which actions could the nurse delegate to a licensed practical nurse (LPN)? Select all that apply. One, some, or all responses may be correct. 1 Padding traction connections 2 Determining correct body alignment 3 Assessing complications associated with immobility 4 Teaching the client about range-of-motion (ROM) exercises 5 Assisting the client with passive and active range-of-motion (ROM) exercises

1 5, The licensed practical nurse (LPN) could pad the traction connections to prevent skin irritation and assist the client with passive and active ROM exercises as directed by the RN. The registered nurse (RN) has to assure that the client is in proper body alignment to maintain effectiveness of the traction. It is the responsibility of the RN to assess for complications associated with immobility such as wound infection, constipation, and deep vein thrombosis. The RN has to teach the client about range-of-motion (ROM) exercises to help foster faster recovery.

A client is scheduled for a computed tomography (CT) of the brain with contrast. The nurse reviews the client's medical record before the start of the procedure. The nurse would report which significant finding to the primary healthcare provider before the test is performed? 1 The client takes metformin daily. 2 The client consumed a meal 1 hour before the scheduled test. 3 The client reports an allergy to gadolinium. 4 The client was not prescribed intravenous (IV) sedation.

1, A CT often requires a contrast agent to be administered. The contrast agent can cause temporary changes in kidney function. This change in kidney function can cause clients on metformin to have an increased risk of developing a serious side effect called lactic acidosis. Nothing by mouth (NPO) status is not required for a brain CT; however, clients may be instructed to be NPO for a CT of the abdomen or chest. Magnetic resonance imaging contrast contains gadolinium; contrast for CT scans contains iodine. Clients typically do not receive sedation for this diagnostic procedure.

A rubella vaccination is prescribed for a client. Which statement made by the client is cause for concern? 1 "I have been trying to conceive a baby for a few months." 2 "I have plans to have a baby next year." 3 "I have no history of rubella in childhood." 4 "I have plans to get married next year."

1, Rubella infection is a cause for concern in women of childbearing age because it increases the risk of congenital abnormalities in a developing fetus. However, the client should not be given the rubella vaccine if already pregnant because it could affect the fetus. The client can be given the rubella vaccine if they are in childbearing age, with the precautionary instruction to avoid conception for at least 3 months after vaccination. The nurse should give the rubella vaccination to the client who has not previously had rubella in childhood. This is because the client's body will not have developed antibodies against rubella and needs the vaccination. A client who is planning to get married next year should be encouraged to receive rubella vaccination to eliminate risk of developing the infection.

After insertion of a central venous catheter through the left subclavian vein, a client reports chest pain and dyspnea and has decreased breath sounds on the left side. Which action would the nurse take first? 1 Administer oxygen as prescribed. 2 Activate the Rapid Response Team. 3 Give the prescribed as needed morphine sulfate. 4 Assist the client to cough and deep breathe.

1, The client's history of a subclavian vein central line insertion and sudden onset of pain, dyspnea, and decreased breath sounds suggest tension pneumothorax. The nurse will initially administer oxygen. The next action would be to activate the Rapid Response Team, because chest tube placement is likely to be needed to allow lung reexpansion. Morphine sulfate may be needed for pain control, but would not be the initial action. Coughing and deep breathing will not help with dyspnea caused by tension pneumothorax, although the client would be encouraged to cough and deep breathe once the chest tube is in place.

Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis? 1 Place the client on airborne precautions. 2 Notify the client's health care provider. 3 Auscultate the client's breath sounds. 4 Notify the public health department.

1, The initial action by the nurse after learning that a client has active tuberculosis would be to assure the safety of other clients, visitors, and staff by implementing airborne precautions. The health care provider would be notified, but this can be done after airborne precautions are started because implementation of infection control measures does not require a prescription by the health care provider. The nurse would plan to check the client's lung sounds, but this can be done after airborne precautions, including the use of an N95 mask by the nurse when assessing the client. The public health department will need to be notified so that contacts of the client can be tested and treated, but this can be done any time during the client's hospitalization.

After the nurse has instructed a client with active tuberculosis (TB) on self-care at home, which client statement indicates understanding of the teaching? 1 "I will plan to stop drinking alcohol during treatment." 2 "Once the cough and fever go away, I can stop the medication." 3 "While taking this medication I will stop all my other medications. 4 "I will make sure no visitors enter my home until I have finished treatment."

1, The medications used for treatment of TB can be toxic to the liver, and other substances that are hepatotoxic (such as alcohol) should be avoided during TB treatment to decrease the risk for liver damage. The medications must be taken for 6 months or longer to complete therapy; treatment should not be discontinued when symptoms subside. A client's health care provider will review current medications and let the client know if any should be stopped while being treated for TB, although most medications are safe to take with the medications used to treat TB. Most clients who are taking medications are not contagious after several weeks of treatment. A client who has started TB treatment and has had negative sputum cultures is not contagious and may return to usual activities such as having visitors, although the client will need to continue treatment for at least 6 months.

When educating a client with interstitial cystitis, which foods would the nurse mention are bladder irritants? Select all that apply. One, some, or all responses may be correct. 1 Milk 2 Nuts 3 Citrus fruit 4 Aged cheeses 5 Soy-containing foods 6 Green, leafy vegetables

2 3 4, Nuts, citrus fruits, and aged cheeses irritate the bladder of some individuals. Milk, soy-containing foods, and green, leafy vegetables are not likely to irritate the bladder.

Which medications inhibit tumor necrosis factor-alpha (TNF)-a in clients treated for rheumatoid arthritis (RA)? Select all that apply. One, some, or all responses may be correct. 1 Anakinra 2 Infliximab 3 Abatacept 4 Etanercept 5 Golimumab

2 4 5, Biologic response modifiers (BRMs) are the substances that modify immune responses by either enhancing an immune response or suppressing it. Infliximab, etanercept, and golimumab are BRMs used in the treatment of RA to inhibit tumor necrosis factor (TNF)-a. Anakinra is an interleukin-1 receptor antagonist used in the treatment of RA. Abatacept is a selective T-lymphocyte costimulator modulator (T-cell inhibitor) used in the treatment of RA.

The nurse is teaching a client with an acute exacerbation of ulcerative colitis about an appropriate diet. Which food selected by the client indicates that the dietary teaching is effective? 1 Orange juice 2 Scrambled eggs 3 Vanilla milkshake 4 Creamed potato soup

2, Low-fiber and lactose-free foods are recommended during acute exacerbations. Eggs are low-residue and less irritating to the colon than the other foods. Orange juice is high in fiber and contains cellulose, which is not absorbed and irritates the colon. Milk, found in the vanilla milkshake and creamed potato soup, contains lactose, which is irritating to the colon.

The nurse is obtaining a health history from a client with human immunodeficiency virus (HIV) with a low viral load who has been asymptomatic for years. Which statement by the client indicates the need for additional education on the disease process? 1 "I inform all my partners of my HIV-positive status." 2 "I should not skip any doses of antiretroviral medication." 3 "I occasionally have oral sex without the use of protection." 4 "I have never shared or reused any of my diabetic supplies."

3, Clients who are HIV positive, even those with very low or absent viral loads, need to be instructed to practice safe sex. This includes using protection in all sexual encounters, including oral sex. Clients will be instructed to inform all partners of HIV-positive status, ensure they do not skip doses of antiretroviral medication, and never share or reuse needles.

When a client is seen in the emergency department with sudden onset severe dyspnea, coughing, and wheezes, which prescribed treatment would the nurse administer first? 1 Inhaled corticosteroid 2 Normal saline infusion 3 Albuterol per nebulizer 4 Intravenous methylprednisolone

3, The client symptoms suggest acute asthma attack or anaphylaxis. Inhaled bronchodilators like albuterol act within a few minutes to relax bronchospasm, decrease bronchiolar inflammation, and dilate bronchioles. Inhaled corticosteroids are not rapidly acting and can be given after inhaled bronchodilators. Normal saline would be needed, but the nurse would not wait to give the bronchodilator while infusing saline. Intravenous corticosteroids like methylprednisolone take several hours to be effective and would not be the priority treatment.

After change-of-shift report, which client would the nurse assess first? 1 A client with possible lung cancer who is scheduled for bronchoscopy 2 A client with left pleural effusion who is scheduled for a thoracentesis 3 A client with hospital-acquired pneumonia and decreased breath sounds 4 A client with an acute asthma exacerbation and 85% oxygen saturation

4, A client with an oxygen saturation of 85% requires immediate assessment and interventions to improve oxygenation, such as administration of prescribed rapid-acting bronchodilators and administration of higher oxygen concentrations. There is no data indicating that the client who is scheduled for bronchoscopy needs any urgent interventions. The client with a pleural effusion does not have symptoms that indicate any need for urgent assessment or interventions. Decreased breath sounds would be expected in a client with pneumonia and are not an indicator of a need for immediate assessment.

Which assessment finding by the clinic nurse who is caring for a client with chronic bronchitis is most important to communicate to the health care provider? 1 Rhonchi with expiration 2 Prolonged expiratory phase 3 Heart rate 96 beats per minute 4 Temperature 101.8°F (38.8°C)

4, Because chronic bronchitis is a risk factor for pneumonia, the nurse would report the client's fever to the health care provider and anticipate further actions such as a chest x-ray and initiation of antibiotic therapy. Clients with chronic bronchitis have thick respiratory secretions and may chronically have rhonchi and coarse crackles. A prolonged expiratory phase of respiration is common in clients with chronic obstructive pulmonary diseases because of air trapping. A heart rate in the high normal range is common in clients with chronic obstructive pulmonary disease as a compensatory mechanism for low oxygen saturation.

Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1 Chest tube insertion 2 Aggressive diuretic therapy 3 Administration of beta-blockers 4 Positive end-expiratory pressure (PEEP)

4, Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.