HESI FUNDAMENTALS - STUDY
An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client?
"It is important for you to get out of bed so that calcium will go back into the bone."
A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective? "The purpose of the test is to detect lesions in the brain." "The purpose of the test is to inject medication into the bone." "The purpose of the test is to examine the cerebrospinal column." "The purpose of the test is to provide information about the blood vessels."
"The purpose of the test is to provide information about the blood vessels."
Normal specific gravity of urine
1.010-1.030
The nurse is caring for a client with a diagnosis of lung cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 2000 mm3 (2.0 × 109/L) 5800 mm3 (5.8 × 109/L) 8400 mm3 (8.4 × 109/L) 11,500 mm3 (11.5 × 109/L)
2000 mm3 (2.0 × 109/L)
The nurse has administered diazepam 5 mg by the intravenous route to a client. The nurse should plan to maintain the client on bed rest for at least how long?
3 hours
The nurse is reviewing the laboratory test results for a client with a diagnosis of severe dehydration. The nurse should expect the hematocrit level for this client to be noted at which level? 60% (0.60) 47% (0.47) 45% (0.45) 32% (0.32)
60% (0.60) The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. Because hematocrit is measured as a proportion of red blood cells to a volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit level. In a client with dehydration, the nurse would expect to note that the hematocrit level is increased. Conversely, an increase in fluid can cause a decrease in the hematocrit level.
Normal serum protein level
6.4-8.3 g/dL
The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action?
Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
Buterol attachment
The nurse is reviewing the laboratory test results and notes that the prothrombin time (PT) is 7.0 seconds. The nurse understands that this PT value would be noted in which condition?
Deep Vein Thrombosis (DVT)
The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse should include which intervention in the nursing care plan?
Ensure that a gag reflex is present before allowing the client any oral intake.
which action should hte nurse implement when administering a prescroption drug that should be given on an empty stomach?
Give one hour before or two hours after a meal. Average transit time from stomach to duodenum is 2 hours.
The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? Glipizide Lisinopril Metformin Beclomethasone
Glipizide There are a number of medications that should be avoided, if possible, for the homeless person due to the safety risks. Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which presents a safety risk to the homeless person.
To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess?
Hepatitis B surface antigen (HBsAg)
A decreased Granulocyte count is indicative of...
Infection. Granulocytes are blood cells that destroy bacteria.
The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse?
Leaves the ulcer open to the air after the enzymatic agent is applied The wound should be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.
The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse should expect to delete which prescription on the client's care plan?
Maintain a clear liquid diet for 72 hours.
A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication? Injecting the medication slowly Massaging the area after removing the needle Inserting the needle at a 10- to 15-degree angle Making a circular mark around the injection site
Massaging the area after removing the needle
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
On the nonoperative side with the legs abducted
The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?
Prolonged bed rest The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.
The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review?
Prothrombin time (PT)
A client is experiencing chronic insomnia. The nurse interprets this to mean that which areas of the brain are involved?
Reticular activating system and cerebral hemispheres
The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply. Asthma Claustrophobia Sleep problems Bipolar disorder Aggressive behavior Attention-deficit hyperactivity disorder (ADHD)
Sleep problems Bipolar disorder Aggressive behavior Attention-deficit hyperactivity disorder (ADHD)
A client is brought into the emergency department folling a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
Stop code immediately
RN only tasks
T - teach A - assessment P - planning E - evaluating critical/complex pts, new admissions, fresh post-op, discharge, all medications, invasive procedures (centro-line, ports)
The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.
Tetany Hypotension Prolonged QT interval Positive Chvostek's sign
A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance?
The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.
A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?
Three sputum cultures are negative.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
Tolerance of exertion
A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position should the nurse place the client in for the procedure?
Upright and leaning forward with the arms on an over-the-bed table
A stool smear for culture needs to be obtained from a client. What steps should the nurse plan to implement when obtaining the specimen? Select all that apply.
Wearing sterile gloves Using a sterile container Sending the specimen directly to the laboratory Positioning the client in a dorsal recumbent position
metabolic alkalosis
a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids.
what does a right shift indicate?
an increased number of mature neutrophils
Hematocrit level of 60% is most likely found in clients with what diagnosis?
pernicious anemia
what risks present with metabolic alkalosis
tetany and seizures nurse should implement seizure precautions for client safety
A child is receiving edetate calcium disodium (calcium ethylenediaminetetraacetic acid [EDTA]) by intravenous (IV) infusion for the treatment of lead poisoning. The primary health care provider (PHCP) prescribes a blood level lead concentration measurement. Which action should the nurse take to obtain the blood specimen?
Stop the IV infusion for 1 hour before obtaining the blood.
CNA dutes
ADL's : ambulation, turning, bathing, changing linens, mouth care, feeding (except those at risk for aspiration, RN only), vital signs (stable patients), weights
Ascorbic Acid (Vitamin C)
can causes a false-negative in occult blood test
A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? Diaphoresis Pupillary constriction Increased urinary output Dry oral mucous membranes
dry oral mucous membranes
Third-space fluid
fluid that shifts into the interstitial spaces and stays there
Following myelography, how should the nurse plan to best position the client?
head slightly elevated
what does a left shift indicate?
increased immature band neutrophils. Suggests bacterial infection.
position for a colonoscopy procedure
left sims' position
The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? Holding a warm compress over the puncture site for 5 minutes Encouraging the client to open and close the hand rapidly for 2 minutes Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes
LPN duties
Can perform everything a CNA can, assist with stable patients (those with chronic issue w/predictable outcomes), gather data (listen to heart, lung, and bowel sounds), routine procedures (EKG, glucose, foley, wound care, ostomy), assist w/nursing interventions, but not develop them, give medication (not IV's, blood transfusions or blood products),
A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care?
Changing dressings frequently around the Penrose drain
The nurse is reviewing the laboratory test results for a client and notes that the albumin level is 3.0 g/dL (30 g/L). The nurse understands that this laboratory value would be noted in which condition?
Cirrhosis of the liver
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? Red, hard skin Serous drainage Purulent drainage Warm, tender skin
Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications?
Decrease in aspartate aminotransferase (AST)
The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions? Heart failure Addison's disease A severe burn injury Adrenal insufficiency
Heart failure The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A level of 150 mEq/L (150 mmol/L) would indicate hypernatremia. Hypernatremia is noted in such conditions as heart failure, Cushing's disease, dehydration, diabetes insipidus, diaphoresis, diarrhea, and hypovolemia. Hyponatremia would be noted in the conditions identified in the remaining options.
The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem?
Infection
The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure?
bed rest with head elevation no greater than 30 degrees
coneal reflex
blinking -
Cholchicine and Iodine
can cause a false-positive in occult blood test
A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client?
cleansing with warm tap water
what type of syringe is used to administer tb skin test?
small hypodermic syringe
The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. Stroke Pneumonia Sleep apnea Myasthenia gravis Obstructive lung disease Opioid analgesics, sedatives, anesthetics
stroke sleep apnea myasthenia gravis opioid analgesics, sedatives, anesthetics
The nurse is reviewing the surgeon's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? Atenolol Atorvastatin Cyclobenzaprine Conjugated estrogen
Atenolol beta-blocker (should not be stopped abruptly)
gullian-barre syndrome
ascending paralysis. watch for respiratory problems.
A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed?
supine, in semi-fowlers rationale: Placing the client in a semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps to prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions also are noted and recorded.
Which clients would most likely be at risk for developing third spacing? the client with cirrhosis the client with liver failure the client with diabetes mellitus the client with a minor burn injury the client with chronic liver disease
the client with cirrhosis the client with liver failure the client with chronic liver disease
The nurse is reviewing the laboratory test results for a client with a diagnosis of thrombocytopenia purpura. The nurse should expect the results for platelet aggregation to be at which level?
decreased The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentages of platelet aggregation. Decreased platelet aggregation may occur in persons with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.
The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform?
Assessing how often the client swallows Assessing how often the client swallows after nasal surgery is a priority action because this is a sign of bleeding. Checking vital signs and looking at the external packing for bleeding are important but not a priority for nasal surgery clients. Determining if the client can breathe through the unaffected nostril is an essential reasonable postoperative assessment.
The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value measures overall kidney function? Sodium levels Protein levels Blood uric acid levels Creatinine clearance levels
Creatinine clearance levels Creatinine clearance is a calculated measure of glomerular filtration rate and is the best indication of overall kidney function. The amount of creatinine cleared from the blood (e.g., filtered into the urine) is measured in the total volume of urine excreted in a defined period. The analysis compares the urine creatinine level with the blood creatinine level, and therefore, a blood specimen for creatinine must also be collected. Sodium levels are decreased in prerenal acute kidney injury. Increased levels of protein indicate glomerular disease, nephrotic syndrome, diabetic neuropathy, and urinary tract malignancies and irritations. Uric acid levels are increased in conditions such as gout or uric acid calculi.
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?
Headache, restlessness, and confusion When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias.
A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? Sodium Potassium Magnesium Phosphorus
Potassium The serum potassium level tends to rise with metabolic acidosis. This is because potassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte should be monitored closely while the client is treated.
A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. Leave the nasal cannula in place and have the ABG samples drawn. Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.
Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. rationale: This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the primary health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal.
A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that 3 enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the AP to do? Administer a Fleet enema. Administer an oil retention enema. Wait 30 minutes and then administer another enema. Stop administering the enemas until the primary health care provider (PHCP) is notified.
Stop administering the enemas until the primary health care provider (PHCP) is notified. Up to 3 enemas may be given when there is a prescription for enemas until clear. If more than 3 are necessary, the nurse should call the PHCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?
assessing for the return of the gag reflex (A - airway)
An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? An increase in pulse rate A drop in blood pressure Nerve and muscle damage Muscle fatigue in the extremities
nerve and muscle damage
