Hesi Final Exam Test 1
Part of the RN role involves delegation of client assignments. Which of the following is an appropriate delegation for a nursing assistant? Care for a client requiring colostomy irrigation. Care for a client who requires a urine specimen collected. Care for a client with difficulty swallowing food and fluids. Care for a client receiving continuous tube feeding.
Care for a client who requires a urine specimen collected. The nurse must delegate tasks by determining the assignment based on the skill level of subordinate staff. The most appropriate in this situation would be to collect the urine specimen. Colostomy irrigation and tube feedings are not permitted skills for unlicensed staff. The client with difficulty swallowing is at risk for aspiration.
All of the following are appropriate guidelines in terms of nutrition and feeding for an infant EXCEPT: check all answers that apply Fluoride supplementation may be needed at about 6 months of age, depending on the infant's intake of fluoridated tap water. At 12 months of age, eggs can be given. Avoid microwaving baby bottles and baby food. Mix any necessary medications with formula.
Mix any necessary medications with formula. This would not be an appropriate guideline. Never mix food or medications with formula. Also avoid adding honey to formula, water, or other fluid to prevent botulism.
The type of angina that may occur at rest and results from a coronary artery spasm is which of the following? check all answers that apply stable angina Prinzmetal's angina preinfarction angina intractable angina
Prinzmetal's angina Prinzmetal's angina is also called variant angina or vasospastic angina. It results from coronary artery spasm. Attacks may be associated with ST-segment elevation noted on the electrocardiogram. stable angina Prinzmetal's angina preinfarction angina intractable angina
Your patient has been prescribed a bronchodilator for her asthma along with a corticosteroid to reduce inflammation. Which of the following is NOT a corticosteroid? check all answers that apply Salbutamol Beclomethasone dipropionate Fluticasone propionate Flunisolide Budesonide
Salbutamol Salbutamol is a bronchodilator. All of the other choices are corticosteroids.
Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following? This type of action may cause extreme pain. This type of action will delay healing. This type of action may cause venous thrombosis. This type of action may pop the prosthesis out of the socket.
This type of action may pop the prosthesis out of the socket. This question asks for the primary reason for this advice. The primary reason is that this type of action may pop the prosthesis out of the socket.
The gray-blue discoloration of the flanks seen in hemorrhagic pancreatitis is which of the following? check all answers that apply Turner's sign Murphy's sign Cullen's sign Trousseau's sign
Turner's sign Turner's sign is a gray-blue discoloration of the flanks seen in acute hemorrhagic pancreatitis. Cullen's sign is a bluish discoloration of the abdomen and periumbilical area also seen in acute hemorrhagic pancreatitis.
The ethical principle that is most closely related to the concept of free will is which of the following? check all answers that apply beneficence autonomy justice fidelity
autonomy Autonomy is a state of being self-regulating, self-defining, and self-reliant. A person, therefore, has the free will to dictate his own thoughts and actions.
The nurse develops a teaching plan for a client who has a 5 cm laceration of the arm. Which of the following is an appropriate learning outcome? the client's wound is healing and there is no infection present the nurse provided instructions to the client the nurse discusses with the client resources available the identification of the signs and symptoms of a wound infection
the identification of the signs and symptoms of a wound infection. The nurse should expect the client to be able to identify the processes involved in normal wound healing, identify the signs and symptoms of an infection of the wound, show that he or she can use wound cleansing equipment and know when, where and the time to return to the physician for a follow up appointment. Further, the client's wound is healing and there is no infection present, is an incorrect answer choice as this represents a nursing goal of wound care. Then, the nurse provide instructions to the client and the nurse discusses with the client resources available are examples of teaching methods the nurse uses to teach the client regarding wound care.
You are assessing a child who has been diagnosed with Duchenne muscular dystrophy. Which of the following would NOT be an indicator of this disease? Gowers sign increasing clumsiness vomiting (usually in the morning) waddling gait
vomiting (usually in the morning) There are a number of assessments that you might make in a patient with Duchenne muscular dystrophy. Vomiting is not one of them. The child may have a waddling gait, increasing clumsiness and muscle weakness, Gower sign (difficulty rising to standing position), delayed cognitive development, elevated CPK and SGOT/AST among other signs.
The nurse is obtaining an infant's chest circumference. The nurse should align the tape measure with the lower section of the chest with the center of the chest in line with the nipples directly above the abdomen and transverse to the chest against the center of the chest in line with the child's arm
with the center of the chest in line with the nipples nter of the chest in line with the nipples. To gain the most accurate measurement of the infant's chest, the nurse should position the tape measure at the center of the child's chest. Then the nurse should line the tape measure with the nipples and move the other side of the tape measure underneath the infant's to meet with the other end.
The RN is providing discharge instructions to a mother of a 3-year-old child who has undergone an orchiopexy to correct cryptorchidism. Which of the following statements made by the mother would indicate further teaching is necessary? "I'll give him medication so he'll be comfortable." "I'll check his voiding to be sure there is no problem." "I will let him decide when he wants to return to his play activities." "I will check his temperature."
"I will let him decide when he wants to return to his play activities." Vigorous activities should be restricted for 2 weeks following this type of surgery to allow for healing and prevent injury. Normal 3- year-olds want to be active, therefore, to prevent dislodging of the internal sutures, activity should be restricted. Monitoring the urine output, providing analgesics, and monitoring temperature are all important for the mother to be instructed upon.
The Glasgow Coma Scale score for a patient who opens his eyes when told to, moves away from a painful stimulus, and tells you the incorrect year is which of the following? check all answers that apply 10 15 12 8 11
11 The Glasgow Coma Scale rates eye opening response, motor response and verbal response. A patient who opens his eyes when told to, moves away from a painful stimulus, and tells you the incorrect year has a score of 11. Eye opening is rates from 1 - 4. Opening eyes when told to is a 3 on the scale. Motor response is rated from 1 - 6. Moving away from a painful stimulus is a 4 on the scale. Verbal response is rated from 1 - 5. Telling you the incorrect year rates a 4 on the scale. Therefore, the total score for this patient is 11.
You are teaching a class to encourage smokers to quit. You ask each person to write down how many packs they smoke per day and for how many years. The first person has smoked 2 packs per day for 12 years. How many pack-years would that amount to? 6 4 24 12
24 Smoking history is quantified in pack-years. To find this value, you would multiply the number of packs smoked per day by the number of years. In this woman's case she smoked 2 packs per day for 12 years. Her pack-years value is 24.
A nurse is caring for a patient who is in labor. The nurse has assessed a nonreassuring fetal heart rate manifesting as tachycardia unrelated to maternal variables. A pH blood sample is ordered. Which of the following fetal scalp pH values would indicate true acidosis? 7.25 7.15 7.30 7.35
7.15 Normal fetal scalp pH in labor is 7.25 to 7.35. If the value is below 7.2 this would indicate true acidosis. Therefore the 7.15 value would indicate true acidosis.
Pulmonary edema is a life-threatening event that can result from severe heart failure. If a client develops pulmonary edema which of the following actions is appropriate? check all answers that apply Place the client in a low-Fowler's position. Administer oxygen. Ensure that an intravenous access device is in place. Prepare for intubation if required.
Administer oxygen. Ensure that an intravenous access device is in place. Prepare for intubation if required. These are all appropriate actions. You should immediately place the client in high-Fowler's position, with the legs in a dependent position, to reduce pulmonary congestion and relieve edema.
Which of the following statements about antineoplastic medications is NOT accurate? check all answers that apply Antineoplastic medications kill or inhibit the reproduction of neoplastic cells. Antineoplastic medications are only used to decrease life-threatening complications. The effect of antineoplastic medications may not be limited to neoplastic cells. Usually only one medication is used in order to increase the therapeutic response. Chemotherapy dosing is usually based on total body surface area and type of cancer.
Antineoplastic medications are only used to decrease life-threatening complication. Usually only one medication is used in order to increase the therapeutic response. These statements are not accurate. Antineoplastic medications are used to cure, increase survival time, and decrease life-threatening complication. Usually several medications are used in order to increase the therapeutic response.
A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication is not taken, restraints will be applied and the medication will be given by injection. The nurse's statement constitutes which legal tort? Assault Battery Negligence Right to refuse care
Assault sault. Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standard of care. The client has the legal right to refuse care. In this situation, the correct action is to try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to client's refusing care.
In documenting a patient's medication, you inadvertently enter the wrong name for the medication. You immediately recognize the mistake. What is the most appropriate action to take? check all answers that apply Report the mistake to the nursing administration of the hospital. Erase the error and enter the correct information immediately. Use white-out to correct the error and enter the correct information immediately. Draw a single line through the entry, initial it and enter the correct name for the medication.
Draw a single line through the entry, initial it and enter the correct medication. It is not necessary to report the error to the nursing administration. Also, you should never erase or white out an entry. It is only necessary that you draw a single line through the mistake so as not to obliterate it completely and initial the mistake. Then you should correct it.
Which of the following should be the nurse's initial action immediately following the birth of the baby? Aspirating mucus from the infant's nose and mouth Drying the infant to stabilize the infant's temperature Promoting parental bonding Identifying the newborn
Drying the infant to stabilize the infant's temperature The nurse's first action should be to dry the baby and stabilize the infant's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Prompting parental bonding and identifying the neonate are appropriate after the baby has been dried.
Which of the following is typical of a fetus at week 16 of fetal development? check all answers that apply Fetus is 11.5 to 13.5 cm in length. Fetus has reflex hand grasp functions. Fetus is 100 g. Lanugo hair begins to develop.
Fetus is 11.5 to 13.5 cm in length. Fetus is 100 g. Lanugo hair begins to develop. These are all typical of a 16-week-old fetus. Reflex hand grasp functions occur at week 24.
You have a patient who has been diagnosed with asthma. You are teaching him the proper use of an inhaler. Which of the following would NOT be included in your instruction? Exhale completely. Use the bronchodilator before the steroid inhaler. If using a spacer, keep mouth open to bring in volume of air with misted medication. Wait at least one minute between inhaled doses (puffs).
If using a spacer, keep mouth open to bring in volume of air with misted medication. If using a spacer, the mouthpiece should be gripped in the mouth. If not using a spacer, the mouth should be kept open to bring in volume of air with misted medication. The other choices are correct instructions.
In establishing a teaching plan for a client who is in the first trimester of pregnancy, the nurse identifies a long list of topics to discuss. Which is most appropriate for the first visit? Asking the woman what questions and concerns she has about parenting Dealing with heartburn and abdominal discomfort Nutrition and activity during pregnancy Preparation for labor and delivery
Nutrition and activity during pregnancy. Nutrition and activity are important concerns from the first trimester onward. Labor and delivery is a third trimester concern, and parenting is of most concern in either the third trimester or post delivery. Heartburn and abdominal discomfort do not usually occur until the third trimester.
Which of the following is would indicate implied consent to a procedure? check all answers that apply The patient voluntarily submits to the procedure. The patient consents in writing. The patient orally consents. The patient consents orally and in writing.
The patient voluntarily submits to the procedure. When a patient voluntarily submits to the procedure, this indicates implied consent. Consenting in writing or orally is considered expressed consent.
A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend: petroleum jelly. a water-soluble lubricant. body cream or body lotion. less-frequent intercourse.
a water-soluble lubricant. water-soluble lubricant. A Water-soluble jelly should be used. Petroleum jelly, body creams, and body lotions are not water soluble. Less-frequent intercourse is an inappropriate response.
When ascultating the heart, which of the following characteristics best describes the first heart sound in a client with tachycardia? splitting accentuated midstyolic click an opening snap
accentuated centuated. In clients who have tachycardia, the first heart sound is accentuated. The accentuation represents a high cardiac output, heart block and mitral stenosis. A splitting sound is heard during the second heart sound and may represent delayed emptying of the right ventricle. Further, midstyolic click is associated with conditions such as mitral valve prolapse. Then, an opening snap is associated with the opening sound in a stenotic mitral valve.
During auscultation of a child's chest, high pitched, fine crackle sounds are heard. This abnormal sound is also known as what? stridor sounds egophony sounds adventitious sounds posterior sounds
adventitious sounds ventitious sounds. Adventitious sounds are abnormal breath sounds. They indicate the presence of a disease. Crackles, rhonchi and friction rubs are types of adventitious sounds.
Which of the following characteristics or symptoms is more likely to be seen in hyperthyroidism than in hypothyroidism? check all answers that apply agitation heat intolerance weight gain diarrhea
agitation heat intolerance diarrhea These are all signs of hyperthyroidism. Hypothyroidism would have the opposite signs: lethargy, intolerance to cold, and constipation along with weight gain. Both diseases have many other signs and symptoms.
Your patient has had a uterine artery embolization to treat a fibroid tumor. She is being discharged and you will be giving her instructions for home care. Which of the following would NOT be a part of your instructions? alter diet to eliminate fiber call the health care provider if you run a fever of 101.1 degrees F or more do not use tampons for at least four weeks avoid straining during bowel movements
alter diet to eliminate fiber This patient would be told to eat a normal diet including fiber and fluids. All of the other choices are appropriate instructions. Other instructions may include: take prescribed medications as ordered; call the physician if she has bleeding, pain, swelling, hematoma at the puncture site, urinary retention or abnormal vaginal drainage; and refrain from using douches or having vaginal intercourse for at least four weeks.
A female client's gonorrhea culture is positive for gonorrhea. Which of the following actions should the nurse take? instruct the client to wait in the office for 25 minutes after the examination to allow the local anesthesia to wear off instruct the client to wait 24 hours before taking prescribed medication ask the client for the names of all of her sexual partners instruct the client to douche 5 hours after the procedure to get rid of the solution used for the culture
ask the client for the names of all of her sexual partners k the client for the names of all of her sexual partners. A gonorrhea culture is used to identify if an individual has gonorrhea by using a swab to obtain discharge from the cervix, throat, anus or urethra. For a positive result on the diagnostic test, the N. gonorrhea organism is present. For this test, the nurse should inform the client to not douche before the examination and douching is not recommended after the examination. The nurse should also obtain from the client a listing of all sexual partners that the client has had in order to contact them so the partners can receive treatment. This way the gonorrhea infection does not spread to other individuals.
In your state, screening for neural tube defects is mandated by law. You know that this test is highly associated with both false positives and false negatives reliability of results multiple gestations infections during pregnancy
both false positives and false negatives There are various techniques to determine fetal and maternal well-being. The screening for neural tube defects by testing either maternal serum alpha-fetoprotein (AFP) levels or amniotic fluid AFP levels is highly associated with both false positives and false negatives.
Which of the following would be considered a late sign of colorectal cancer? check all answers that apply blood in stool anemia cachexia abdominal mass
cachexia abdominal mass These are late signs along with guarding or abdominal distention. Blood in the stool is the most common manifestation of this cancer.
You have a patient with cardiomyopathy who presents with tachycardia, hypotension and a narrowed pulse pressure. The patient also has tachypnea and pulmonary congestion evidenced by crackles. This patient is most likely experiencing which of the following? check all answers that apply cardiogenic shock hypovolemic shock obstructive shock distributive shock
cardiogenic shock Cardiogenic shock occurs when either systolic or diastolic dysfunction of the pumping action of the heart results in reduced cardiac output. This patient shows typical signs of cardiogenic shock. Other signs of peripheral hypoperfusion include: cyanosis, pallor, diaphoresis, and diminished pulses.
When performing an assessment on a client with dementia, the RN must gather certain information. Which data gathered during the assessment indicates a manifestation associated with dementia? Absence of sundown syndrome. Presence of personal hygienic care. Confabulation. Improvement of sleeping.
confabulation Dementia has variant findings, from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. The client who uses confabulation is providing the fabrication of events or experiences to fill in memory gaps. As dementia progresses, the client will have episodes of wandering or sundowning.
In the management of pain there are several types of pharmacological interventions: NSAIDS, narcotic agonists and antagonists and narcotics. Which of the following drugs would be considered a narcotic? check all answers that apply dilaudid butorphanol nalbuphine acetaminophen
dilaudid Dilaudid is a fast-acting, potent narcotic. It may cause appetite loss. It takes effect within 30 minutes depending on the way it is administered. Butorphanol and nalbuphine fall into the narcotic agonist and antagonist type of pain management. Acetaminophen is a non-narcotic drug.
A burn that is dry, leathery, and possibly edematous is which of the following? check all answers that apply superficial, partial thickness first degree burn second degree burn full thickness burn
full thickness burn A full-thickness burn (third-degree burn) has a dry, leathery, and possibly edematous appearance. Its color is white to charred and there is little or no pain. The depth of the burn is to subcutaneous tissue and possible fascia, muscle, and bone.
A person's reaction to pain is subjective. It is influenced by certain factors. Which of the following are factors that may influence a patient's pain experience? check all answers that apply gender culture religion acute hypotension
gender culture religion A person's pain experience will be subjective. There are many factors that influence how a patient will feel and handle pain. Anxiety, culture, religion, and gender affect a patient's response to pain.
A young adult was told that he had a significant reaction to the Mantoux test. The nurse explains that this means he has active tuberculosis. had active tuberculosis has been exposed to tuberculosis is immunocompromised.
has been exposed to tuberculosis. A reaction to the Mantoux test for tuberculosis means the client has been exposed to the tuberculin bacillus. Further testing needs to be done to determine whether the disease is active or dormant. A positive reaction does not mean the client is immunocompromised, but clients who are immunocompromised have a high risk of tuberculosis.
You are assessing a 50-year-old African-American male who maintains an active lifestyle. When he asks you about his risk for hypertension you tell him that which of the following factors puts him at a higher risk? being over 45 years old having a low triglyceride level his lifestyle his race
his race Being over 65 years old may have an impact on his risk for hypertension. His active lifestyle and a low triglyceride level will not put him at risk for hypertension. The only correct choice here is race. African-Americans have an increased risk for hypertension.
The nurse obtains a health history from the following client. Which piece of data should alert the nurse to include infertility teaching in her discussion? circumcision as a newborn history of premature ejaculation history of measles at age 12 employment as an engineer
history of premature ejaculation Premature ejaculation is a possible cause of infertility. Circumcision, having the measles, and being an engineer do not affect fertility.
The nursing diagnosis deals with which of the following? check all answers that apply disease medical condition human response to health problems care plan
human response to health problems A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.
Your patient who is 12 weeks pregnant comes to the office for a routine checkup. Your patient asks if her pregnancy is high risk. You list the risk factors that contribute to a high risk pregnancy. This list would include which of the following? check all answers that apply hypotension malnutrition anemia a height of less than 60 inches Rh incompatibility
malnutrition anemia a height of less than 60 inches Rh incompatibility These are some risk factors involved in a pregnancy. Hypotension is not one of them. Other factors include but are not limited to: under age 17 or over 34, multiple gestations, medical diseases, and a history of family violence.
Nightmare disorder and sleepwalking would be classified as which type of sleep disorder? check all answers that apply dyssomnias parasomnias sleep architecture disorders sleep latency disorders
parasomnias Parasomnias are characterized by unusual or undesirable behaviors or events that occur during sleep/wake transitions, certain stages of sleep, or during arousal from sleep. Nightmare disorder and sleepwalking are classified as parasomnias. REM sleep behavior disorder and sleep paralysis are also parasomnias.
A woman 40 years of age is 28 weeks gestation and comes to the emergency room with painless, bright red bleeding of 1 1/2 hours duration. What condition does the nurse suspect this client has? Abruptio placenta Hydatidiform mole Placenta previa Prolapsed cord
placenta previa Placenta previa is characterized by painless bleeding in the third trimester. Abruptio is characterized by abdominal pain and a rigid abdomen with or without obvious bleeding. Shock develops rapidly in placenta abruptio. Hydatidiform mole is characterized by sever nausea and vomiting and the passage of grapelike vesicles. Prolapsed cord often occurs when the membranes rupture and is not characterized by bleeding. xdf
After a thyroidectomy, the nurse should monitor for signs of tetany which can be caused by trauma to the parathyroid gland. The signs of tetany include which of the following? check all answers that apply negative Chvostek's sign positive Trousseau's sign photophobia cardiac dysrhythmias
positive Trousseau's sign photophobia cardiac dysrhythmias All three of these are signs of tetany. A positive Chvostek's sign would also be a sign of tetany, along with carpopedal spasm, dysphagia, muscle and abdominal cramps, numbness and tingling of the face and extremities, wheezing and dyspnea, and seizures.
The nurse is caring for an African-American female patient who is 75 years old. The patient complains of a gradual loss of her peripheral vision. Examination has indicated increased IOP. Which of the following is the most likely cause of her symptoms? check all answers that apply subconjunctival hemorrhage primary closed-angle glaucoma primary open-angle glaucoma macular degeneration cataracts
primary open-angle glaucoma Primary open-angle glaucoma has a gradual onset of increased IOP due to blockage of drainage of the aqueous humor. The optic nerve undergoes ischemic damage resulting in permanent visual loss. It is the most common type of glaucoma and is most commonly seen in elderly patients, especially those of African background or diabetics.
Postoperative care for a woman following a mastectomy will include arm exercises to: strengthen the affected muscles. increase firmness in the remaining breast tissue. decrease pain as the surgical site heals. promote drainage after lymphatic disruption.
promote drainage after lymphatic disruption. A mastectomy includes the removal of lymph nodes. The recommended exercises will help promote drainage and prevent swelling. The exercises will not help strength muscles, increase breast firmness, or help with pain control.
You are assigned to instill eye medication in a patient's eye. All of the following are appropriate for this task EXCEPT: check all answers that apply instructing the patient to tilt the head backward, open the eyes, and look up pulling the upper lid upward before instilling the medication squeezing the bottle gently to allow the drop to fall into the conjunctival sac instructing the client to squeeze the eyes shut after instilling the medication
pulling the upper lid upward before instilling the medication instructing the client to squeeze the eyes shut after instilling the medication These are not appropriate measures. Pull the lower lid down against the cheekbone and instruct the client to close the eyes gently; not squeeze the eyes shut.
A patient's ability to implement his own decisions is the right to which of the following? check all answers that apply informed consent self-determination professionalism accountability
self-determination Self-determination is often used synonymously with autonomy. It means having a form of personal liberty to choose and implement one's own decisions, free from deceit, duress, constraint, or coercion.
You have a patient with Alzheimer's disease whose symptoms become more pronounced in the evening. You understand that this is known as which of the following? check all answers that apply sundowning secondary dementia confabulation hyperorality
sundowning Sundowning (also known as sundown syndrome) is the situation in which symptoms and problem behaviors of those with cognitive disorders become more pronounced in the evening. This may occur in both delirium and dementia.
In the male, which of the following indicates the first sign of puberty? hair under the arms testicular growth increase in height deepening of the voice
testicular growth In males, puberty starts sometime between 10 and 14 years of age. With boys, the first sign that indicates puberty is the testicles grows and the scrotum changes. Following this, boys start to have pubic and facial hair and hair under the arms. Also, they have a Deeping in the voice.