hesi evolve questions (iv therapy, pain management, physiological questions, & immune system)
While providing care for four clients with human immunodeficiency virus (HIV) infections, the nurse notes newly developed clinical manifestations. Which client's condition would the nurse be able to delay reporting to the primary health care provider until unit rounds are made within the next 24 hours? - client A: burning, itching, & discharge from eyes - client B: blood in urine - client C: yellow discoloration of the skin - client D: nausea and vomiting accompanied by abd pain
client A: burning, itching, & discharge from eyes (47% nationwide answered correctly)
A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client reports persistent pain 1 week later. Which statement indicates the cause of the posttherapeutic neuralgia? - damage to the nerves - untreated major depression - scarring in the area of the rash - continued presence of the skin rash
damage to the nerves (83% nationwide answered correctly)
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? - cyanosis - bradycardia - mental confusion - distended neck veins
mental confusion (rationale: decreased O2 to the vital centers in the brain results in restlessness and confusion) (55% nationwide answered correctly)
The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? - preoxygenate the client before suctioning - employ gentle suctioning as the catheter is being inserted - loosen the client's secretions before suctioning by instilling saline - ensure that the cuff of the tracheostomy is inflated during suctioning
preoxygenate the client before suctioning (87% nationwide answered correctly)
Which would the nurse do first if an allergic reaction to a blood transfusion occurs? - shut off the infusion - slow the rate of flow - administer an antihistamine - call the health care provider (HCP)
shut off the infusion (95% nationwide answered correctly)
Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? - respiratory acidosis - respiratory alkalosis - respiratory compensation - respiratory decompensation
respiratory alkalosis (rationale: hyperventilation causes excess amounts of CO2 to be eliminated) (74% nationwide answered correctly)
Which action by a client taking immunosuppressant medication for rheumatoid arthritis indicates to the nurse the need for additional teaching? - has bloodwork for complete blood cell count (CBC) obtained - performs frequent hand washing - attends crowded sporting events - implements a home exercise program
attends crowded sporting events (rationale: clients taking immunosuppressant medications need to avoid crowds and people who are sick) (87% nationwide answered correctly)
The nurse identifies 12 mm of induration at the site of a client's tuberculin purified protein derivative (PPD) test. Which rational would the nurse use to explain this test? - the test result is negative and would not require any follow-up - the result indicates a need for further tests and a chest x-ray - the skin test is a screening method and you now need a Tine test - this skin test is inconclusive and requires repeat testing in 6 weeks
the result indicates a need for further tests and a chest x-ray (84% nationwide answered correctly)
A client with tuberculosis asks the nurse about the communicability of the disease. Which response would the nurse use? - "Tuberculosis is not communicable at this time." - "Untreated active tuberculosis is communicable." - "Tuberculosis is communicable during the primary stage." - "With the newer long-term therapies, tuberculosis is not communicable."
"Untreated active tuberculosis is communicable." (81% nationwide answered correctly)
Which dietary changes would the nurse suggest to the client with diarrhea associated with human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. - "Eat more fatty food." - "Eat much less roughage." - "Drink two cups of coffee daily." - "Eat more spicy and sweet food." - "Drink plenty of fluids between meals."
- "Eat much less roughage." - "Drink plenty of fluids between meals." (69% nationwide answered correctly)
Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. - "I can contract HIV by participating in oral sex." - "I can contract HIV by eating from used utensils." - "HIV is contracted by using contaminated needles." - "I can contract HIV by using the bathroom of a person who is HIV positive." - "Babies can contract HIV because of contact with maternal blood during birth."
- "I can contract HIV by participating in oral sex." - "HIV is contracted by using contaminated needles." - "Babies can contract HIV because of contact with maternal blood during birth." (71% nationwide answered correctly)
When would the client have a tuberculin skin test with purified protein derivative (PPD) read? - 1 week - within 12 hours - 24 to 48 hours - 48 to 72 hours
48 to 72 hours (rationale: it takes 48-72 hours for antibodies to respond to the antigen and form an indurated area) (80% nationwide answered correctly)
The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? - limit suctioning with catheter to 30 seconds - apply suction only after the catheter is inserted - lubricate the catheter with saline before insertion - use a sterile suction catheter for each suctioning episode
apply suction only after the catheter is inserted (rationale: the negative pressure from suctioning removes O2 and secretions. it should only be applied only after the catheter is inserted and is being withdrawn) (56% nationwide answered correctly)
Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? - ensuring patent airway - administering intravenous (IV) fluids - monitoring level of consciousness - protecting the client from injury during seizures
ensuring patent airway (rationale: the priority of the nurse because a client may lose consciousness during a seizure) (60% nationwide answered correctly)
A client with active tuberculosis is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions. Which nursing intervention would the nurse implement at this time? - ensure regular visits by staff members to meet the client needs - explore what the airborne precautions mean to the client - report the situation to the infection control nurse immediately - reteach the concepts of airborne precautions to the client.
explore what the airborne precautions mean to the client (57% nationwide answered correctly)
A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother? - if she has ever kissed the baby and how - if the mother is breast-feeding her baby - when the baby last received antibiotics - how long she has been caring for the baby
if the mother is breast-feeding her baby (93% nationwide answered correctly)
The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products?- stay with client during first 15 minutes of infusion - flush packed red blood cells with 5% dextrose and 0.45% normal saline - remove the intravenous catheter if a blood transfusion reaction occurs - administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle
stay with client during first 15 minutes of infusion (rationale: a severe reaction usually occurs with the infusion of the first 50 mL of blood) (83% nationwide answered correctly)
Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction? - stop the blood transfusion immediately - report to the primary health care provider - recheck identifying tags and numbers on the client - maintain a patent intravenous (IV) line with saline solution.
stop the blood transfusion immediately (rationale: an incompatible blood transfusion can result in an acute hemolytic reaction) (98% nationwide answered correctly)
Which nursing intervention is the priority when the nurse notices that the client has a blood pressure of 90/70 mm Hg and a heart rate of 50 beats per minute while the nurse is performing nasotracheal suctioning? - administer intravenous fluids to the client - report to the primary health care provider - stop the suctioning procedure immediately - administer 100% oxygen manually to the client
stop the suctioning procedure immediately (rationale: nasotracheal suctioning can result in vagal stimulation and bronchospasm. vagal stimulation can result in hypotension, bradycardia, heart block, vtach, or other dysrhythmias and require immediate intervention) (78% nationwide answered correctly)
The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? - hypoxemia - hypocapnia - compensated metabolic acidosis - uncompensated respiratory acidosis
uncompensated respiratory acidosis (78% nationwide answered correctly)
Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? - use standard precautions - employ airborne precautions - plan interventions to limit direct contact - discourage long visits from family members
use standard precautions (84% nationwide answered correctly)
Which nursing intervention indicates misinformation when providing care for clients with the human immunodeficiency virus (HIV) infection? - "I will ask the client to avoid exposure to new infectious agents." - "I will ask the client about intake of supplemental vitamins and micronutrients." - "I will ask the client to avoid involvement in community activities." - "I will ask the client if he or she is up to date with recommended vaccines."
"I will ask the client to avoid involvement in community activities." (rationale: they may feel isolated and lonely so they should be involved) (79% nationwide answered correctly)
Which instruction would the nurse include when teaching a client with human immunodeficiency virus (HIV) about self-management? - "Limit your daily fluid intake to 2 liters daily." - "Eat more roughage daily with your meals." - "Rinse your mouth with normal saline after every meal." - "Maintain a 4- to 5-hour gap between each meal."
"Rinse your mouth with normal saline after every meal." (rationale: a patient with HIV should maintain proper oral care to improve their appetite and rinse with sterile water or normal saline several times a day to maintain proper oral hygiene) (65% nationwide answered correctly)
A client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS." Which response would the nurse use? - "Repeated phlebotomies may be able to rid you of the virus." - "You may be cured of AIDS after prolonged pharmacological therapy." - "Perhaps you should have worn condoms to prevent contracting the virus." - "There is no cure for AIDS, but there are medications that can slow down the virus."
"There is no cure for AIDS, but there are medications that can slow down the virus." (rationale: it is an honest response that corrects the client's misconception about the effectiveness of the current antiviral medications) (97% nationwide answered correctly)
Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. One, some, or all responses may be correct. - diarrhea - anorexia - weight gain - hemoptysis - night sweats
- anorexia - hemoptysis - night sweats (54% nationwide answered correctly)
In which order would the nurse complete these steps when administering a blood transfusion? - check client identification before hanging unit of blood - change main line solution to normal saline - check primary health care provider's prescription - ascertain that intravenous catheter size is 18 or 20 gauge - obtain vital signs and history of transfusions
- check primary health care provider's prescription - obtain vital signs and history of transfusions - ascertain that intravenous catheter size is 18 or 20 gauge - change main line solution to normal saline - check client identification before hanging unit of blood (31% nationwide answered correctly)
Which clinical manifestations are associated with tuberculosis? Select all that apply. One, some, or all responses may be correct. - fatigue - nausea - weight gain - low-grade fever - increased appetite
- fatigue - nausea - low-grade fever (56% nationwide answered correctly)
The health care provider suspects a client has tuberculosis and prescribes a purified protein derivative (PPD) test, chest x-ray, and sputum culture. Prioritize implementation of the ordered interventions. - notify the Department of Health - institute airborne precautions - obtain a sputum specimen - have a chest x-ray performed - perform a PPD intradermal skin test
- institute airborne precautions - have a chest x-ray performed - perform a PPD intradermal skin test - obtain a sputum specimen - notify the Department of Health (29% nationwide answered correctly)
According to priority, in which order would the nurse perform care activities for a client with complete partial seizures? - maintaining airway - assessing vital signs - performing neurological checks - recording the time and duration of seizure
- maintaining airway - recording the time and duration of seizure - assessing vital signs - performing neurological checks (24% nationwide answered correctly)
The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do? - ask the client to take several deep breaths - instruct the client to cough before suctioning - administer 100% oxygen to the client - change the suctioning equipment to ensure sterility
administer 100% oxygen to the client (74% nationwide answered correctly)
A client develops bacterial meningitis. Which action is the priority nursing care? - monitoring for signs of intracranial pressure - adding pads to the side of the bed - administering prescribed antibiotics - administering glucocorticoids
administering prescribed antibiotics (48% nationwide answered correctly)
Which finding from cerebral spinal fluid would lead the nurse to associate with a diagnosis of bacterial meningitis? - increased protein - increased glucose - decreased specific gravity - decreased white blood cell count
decreased specific gravity (rationale: bacterial meningitis causes increased permeability of the blood-CSF barrier, resulting in increased protein in CSF) (54% nationwide answered correctly)
The nursing team is involved in providing effective pain management. Which task would be performed by the registered nurse (RN) in this case? - hygiene - taking and reporting of vital signs - administering oral pain medications - developing a treatment plan for the client's pain
developing a treatment plan for the client's pain (63% nationwide answered correctly)
The nurse is caring for a client with deep partial-thickness burns who is receiving an opioid for pain management. Which mode of medication administration is preferred for this client? - oral - rectal - intravenous - intramuscular
intravenous (77% nationwide answered correctly)
Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? - refraining from consuming fatty foods - refraining from consuming frequent meals - refraining from consuming high-calorie foods - refraining from consuming high-protein foods
refraining from consuming fatty foods (many AIDS clients become intolerant to fat due to the disease and antiretroviral meds) (85% nationwide answered correctly)
Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? - stop the blood transfusion and infuse saline - administer the prescribed antipyretic - obtain a prescription for an antihistamine - notify the blood bank about the symptoms
stop the blood transfusion and infuse saline (96% nationwide answered correctly)
The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? - the partial pressure of oxygen (PO2) value is 80 mm Hg - the partial pressure of carbon dioxide (PCO2) value is 60 mm Hg - the bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L) - serum potassium value is 4 mEq/L (4 mmol/L)
the bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L) (49% nationwide answered correctly)
A client had an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10 mm within 48 hours after planting. Which conclusion would the nurse make about the client's response to this diagnostic? - the client has contracted clinical tuberculosis - the client has passive immunity to tuberculosis - the client has been exposed to the tubercle bacillus - the client has developed a resistance to the tubercle bacillus
the client has been exposed to the tubercle bacillus (67% nationwide answered correctly)
Which diagnostic test result indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)? - level of immunoglobulin M (IgM) in the client's blood - the number of CD4+ T cells available - presence of antigen-antibody complexes - speed with which the virus invades the ribonucleic acid
the number of CD4+ T cells available (83% nationwide answered correctly)