HESI

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches:

6 months Rationale: Around 6 months of age infants are able to swallow independently of sucking, and a cup may be introduced. Introducing a cup at 4 months is inappropriate because the infant does not have the ability to swallow independently of sucking at this age. Between 9 and 12 months of age, infants can swallow four or five times consecutively and hold and carry a cup to the mouth; introduction of a cup at the age 6 of months makes weaning easier at 9 to 12 months of age. Sixteen months is too late to introduce a cup; by this time the child has teeth and sucking on a bottle will promote the development of caries, as well as a preference for milk over solid foods.

Why does a nurse encourage continued health care supervision for a pregnant woman with pyelonephritis?

Antibiotic therapy should be administered until the urine is sterile. Rationale: Health care supervision requires treatment with an appropriate antibiotic until two cultures of urine are negative; recurring pyelonephritis often leads to preterm birth. Preeclampsia is not preceded by specific infections. Pelvic inflammatory disease is associated with infections of the genital, not the urinary, tract. A low-protein diet inhibits fetal development and is contraindicated during pregnancy.

A nurse is assessing a multipara who had a spontaneous vaginal birth 2 hours ago after 6 hours of labor. What should the nurse do first after reviewing the vital signs, performing a physical assessment, and transcribing the practitioner's prescriptions?

Assist the client to the bathroom. Rationale: The uterus should be approximately 2 cm below the umbilicus immediately after birth and rise to 1 cm above the umbilicus within 12 hours. This client's uterus is above the umbilicus and deviated to the right, indicating a full bladder. The client should be assisted to the bathroom so that she may try to urinate. A boggy uterus and saturated perineal pad indicate that the full bladder is interfering with the ability of the uterus to contract. Emptying the bladder allows the uterus to contract and return to the midline below the umbilicus and slows lochial flow. Massaging the fundus will be ineffective if the urinary bladder is full. After the bladder is empty it should be palpated. If the uterus is still boggy, then it should be massaged. Increasing the rate of administration of oxytocin (Pitocin) rate is inappropriate without a practitioner's prescription. If the uterus remains boggy after the bladder is emptied and the uterus is massaged, the practitioner should be called. It is not necessary to notify the practitioner of the clinical findings. However, if the uterus remains boggy after the bladder is emptied and the uterus is massaged, the practitioner should be called for a prescription to increase the rate of the IV oxytocin (Pitocin).

A client with a thromboembolic disorder is receiving a continuous intravenous infusion of heparin 1000 units per hour. There are 25,000 units of heparin in 500 mL of 5% dextrose solution. At how many milliliters per hour should the nurse set the rate on the electronic infusion control device? Record your answer using a whole number. ___ mL/hr

20

What clinical finding does the nurse expect when assessing a client with abruptio placentae?

Boardlike abdomen Rationale: Extravasation of blood at the placental separation site into the myometrium causes a tetanic boardlike uterus. The uterus is rigid because it is filled with blood and clots. Painless bleeding is associated with placenta previa; abdominal pain and uterine tenderness occur with abruptio placentae. In abruptio placentae the bleeding is not bright red; usually it is a port wine color.

When assessing a client with Grave's disease (hyperthyroidism) the nurse expects to identify a history of:

Diaphoresis Rationale: Increased basal metabolic rate, increased circulation, and vasodilation result in warm, moist skin. Menorrhagia, dry, brittle hair, and sensitivity to cold are associated with hypothyroidism.

A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say?

Tell the mother, "I'm sorry, but I need to ask you to stay in the waiting area." Rationale: In many states a minor who is self supporting and living away from home, providing military service, married, pregnant, or a parent is considered a emancipated minor. The emancipated minor assumes most responsibilities before the age of 18 years. An emancipated minor is entitled to confidentiality in dealings with health care providers.

A nurse is caring for a newly admitted client with a diagnosis of Graves disease. In preparing a teaching plan, the nurse anticipates which diet will be prescribed for this client?

high-calorie diet Rationale: Because of the individual's increased metabolic rate, a high-calorie diet is needed to meet the energy demands of the body and prevent weight loss. Sodium is not restricted because clients with hyperthyroidism perspire heavily and lose sodium. Gastrointestinal motility is increased and does not require the additional stimulus of increased roughage. Modification of dietary consistency is unnecessary.

The nurse is assigned to care for an infant in the newborn nursery who is 24 hours old. During assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches:

5 to 7 mg/dL Rationale: Jaundice in a newborn first becomes visible when the serum bilirubin level reaches 5 to 7 mg/dL. Jaundice will not be visible at a serum bilirubin level of less than 5 mg/dL.

A primigravida asks the nurse, "I've got this blotchy skin on my face, my nipples are darker, and there's this dark line down the middle of my stomach. What causes that?" The nurse explains that the gland that causes these expected changes during pregnancy is the:

Anterior pituitary gland Rationale: Hypersecretion of melanocyte-stimulating hormone (MSH) from the anterior pituitary gland causes darkened pigmentations during pregnancy. MSH is not secreted by the adrenal glands, thyroid gland, or posterior pituitary gland.

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding indicates a need for more frequent monitoring?

Ascending weakness Rationale: The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Localized seizures are not a characteristic of Guillain-Barré syndrome. Skin desquamation is not a characteristic of Guillain-Barré syndrome. Deep tendon reflexes are absent with Guillain-Barré syndrome.

Nursing care specific to a child with Wilm's Tumor, also known as nephroblastoma, includes:

Avoid unnecessary handling of abdomen Rationale: Unnecessary handling of the abdomen can cause spreading of the tumor. Measuring the abdominal girth is unnecessary as treatment, such as surgery, radiation, and chemotherapy, must be done. A kidney transplant is not usually necessary as the remaining kidney is generally normal. Palpating the mass may cause the tumor to spread.

While assessing a newborn, the nurse visualizes and palpates a generalized, soft, edematous area of the scalp on the occiput. What does the nurse suspect?

Caput succedaneum Rationale: Pressure against the fetal head during labor can cause localized trauma, which results in edema that is not confined within the suture lines of the skull. The edematous area is usually generalized and on the occiput. Hydrocephalus occurs when the ventricles in the brain fill with cerebrospinal fluid as a result of a congenital malformation such as stenosis of the aqueduct of Sylvius. In the newborn it manifests as an enlarged head with a bulging anterior fontanel; the head circumference is more than 1½ inches (4 cm) larger than the chest circumference. Pressure against the fetal head during labor can cause a collection of blood beneath the periosteum from ruptured blood vessels; this does not cross the suture line and is not generalized. Subdural hematoma is not palpable; the neonate will demonstrate signs of increased intracranial pressure.

A nurse in the birthing unit assesses a primigravida who is at 42 weeks' gestation. Fluid is leaking from her vagina, and she is complaining of back pain. Which conclusion is supported by the data collected?

Cesarean birth is anticipated Rationale: A floating fetal head in a primigravida at 42 weeks' gestation who is in early labor is suggestive of cephalopelvic disproportion, because engagement in primigravidas usually occurs before labor starts. A cesarean birth should be anticipated. A Nitrazine test is performed on leaking vaginal fluid to determine whether it is amniotic fluid; a positive result indicates that the mother's membranes have already ruptured and amniotomy (artificial rupture of membranes) is unnecessary. The mother is in the first stage of labor (onset of regular contractions to full dilation), not the second stage of labor (from full dilation of the cervix to the birth of the fetus). Early decelerations and a fetal heart rate of 140 beats/min are expected and do not indicate a problem.

During a home visit a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is unresponsive to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that intervention by an appropriate community resource is indicated. The nurse should make a referral to the:

Child Protective Services Rationale: All states have laws about obligatory reporting of child abuse to local authorities. This responsibility is delegated by the state to an appropriate local agency such as Child Protective Services. A staff member of the agency investigates allegations of child abuse and recommendations are made to protect the child's welfare. The clinic treats the client medically, but other agencies handle child abuse and other social problems. The hospital probably will not admit the child unless an immediate medical incident requires it. The bureau of the handicapped is concerned with equipment and supplies required for the individual with a disability.

A client at 35 weeks' gestation who has had no prenatal care arrives in labor and delivery and is found to be 20 percent effaced and 2 cm dilated, with her membranes intact and contractions 3 minutes apart. The nurse notices some ruptured blisterlike vesicles in the genital area. What should the nurse's next action be?

Contacting the health care provider about the need for a cesarean birth Rationale: Transmission of genital herpes simplex virus (HSV-2) to the newborn can occur during vaginal delivery when active lesions are present. Blindness, brain damage, or death could result if early measures are not taken. The priority is informing the health care provider of the presence of active genital herpes lesions so preparations for a cesarean birth may be made. The nurse would not want to enhance contractions; instead the nurse will begin preparations for a cesarean birth as soon as possible.

A client who has had a myocardial infarction experiences a noticeably decreased pulse pressure. What does this indicate to the nurse?

Decreased force of contraction Rationale: A direct relationship exists between systolic blood pressure and the force of left ventricular contraction. An increased blood volume, not a decreased pulse pressure, is indicated by hypertension. Hyperactivity of the heart is indicated by dysrhythmias and tachycardia. A decreased pulse pressure indicates decreased cardiac sufficiency.

A neonate born at 39 weeks' gestation is small for gestational age. What commonly occurring problem should the nurse anticipate when planning care for this infant?

Hypoglycemia Rationale: Hypoglycemia is common in newborns who are small for gestational age because of malnutrition in utero; the nurse can detect this with a blood glucose test and notify the primary health care provider. Polycythemia, not anemia, is more likely to occur. Although a protein deficiency may occur, it is not life threatening at this time. Although hypocalcemia may occur, it is not as common as hypoglycemia.

A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks why she has to urinate so often. The nurse tells her that urinary frequency in the first trimester is:

Influenced by the enlarging uterus, which is still within the pelvis Ratinale: The uterus remains in the pelvis until the second trimester, placing pressure on the bladder. The fetus is in the uterus, but head descent occurs in preparation for delivery in the third trimester. Fetal waste products are minimal at this time and do not influence urinary frequency. Frequency is a physiological, not a psychological, sign of early and late pregnancy.

The family member of a client with newly diagnosed Guillain-Barre's syndrome comes out to the nurse's station and informs the nurse the client states he is having difficulty breathing. What is the first action the nurse should do?

Inform the family member the nurse will be in to assess the client. Rationale: The initial response for the nurse is to assess the client to ensure a patent airway. Guillain-Barre's syndrome will exhibit ascending paralysis and can impede respiratory function. The health care provider will be notified after the nurse has assessed the client. This is not a normal response to this disease so it is not correct to assure the family member of this. The nurse will not call a code until she has assessed the client.

A thallium scan is prescribed for a client with a history of chest pain. What information should the nurse include when explaining the purpose of the test to the client?

It assesses myocardial scarring and perfusion. Rationale: Thallium imaging is used to assess myocardial scarring and perfusion; necrotic or scar tissue does not extract the thallium isotope. The scan monitors action of the heart valves available from an echocardiogram or, if indicated, from a cardiac catheterization with an angiography. Visualization of the ventricular systole and diastole are determined by cardiac angiography. Identifying the adequacy of electrical conductivity is determined by an electrocardiogram (ECG).

What nursing intervention is anticipated for a client with Guillain-Barré syndrome?

Maintaining ventilator settings to support respiration. Rationale: Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated depending on the extent of the paralysis because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first?

Notify the client's health care provider of the results. Rationale: The nurse is most ethically and legally accountable for reporting diagnostic testing results to the client's health care provider, whether the results are normal or, more important, abnormal. Informing the client of the results is an incorrect action in this situation. Placing the results in the client's record and obtaining normal values of the results from the lab are acceptable actions for the nurse after notifying the health care provider of the abnormal results.

The health care provider prescribes propylthiouracil (PTU) for a client with the diagnosis of Graves' disease. What should the nurse teach the client when discussing the self-administration of this medication?

Observe for signs of infection Rationale: PTU may lower the white blood cell count, making the client prone to infection. Propylthiouracil does not cause hypocalcemia. Taking the drug through a straw is necessary with iodine preparations to prevent staining of the teeth; propylthiouracil does not contain iodine. Propylthiouracil does not cause photosensitivity.

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. What is most important for the nurse to include in a teaching program?

Outline ways that prevent physical trauma from occurring during a seizure. Rationale: The client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and should be taken with food. Seizures and seizure disorders are not similar; they vary greatly. Others should understand the condition and be taught how to help in case of a seizure.

A client with osteomyelitis is receiving antibiotic therapy via a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. The nurse concludes that this finding probably indicates that:

There was a problem with the obtaining of blood specimens. Rationale: Peak levels will always be higher than trough levels; therefore, it indicates some mix-up in the drawn samples. Increasing the dose is an appropriate action if the trough level were too low. Providing a dose in excess of the client's needs is an appropriate action if the trough level were too high, but not exceeding the peak. There is not enough information to determine if the antibiotic administered is adequate.

A client with a suspected placenta previa is to have a repeat sonogram at 16 weeks' gestation. What nursing intervention is needed to prepare for this procedure?

Ensuring that the client drinks two 8-oz glasses of water Rationale: A full bladder helps stabilize the uterus during sonography, allowing better visualization of the fetus; two full glasses of water, ingested about 1 hour before the test, will fill the bladder. Emptying the bladder is inadvisable because a full bladder supports the uterus and improves visualization. Because the procedure is noninvasive, it is unnecessary to cleanse the skin. An enema is contraindicated when placenta previa is suspected and will not improve visualization of the uterus anyway

A pregnant client with cardiac disease asks a nurse to clarify what she was told about making the birth easier for her. What should the nurse remind her is an option to facilitate birth?

Facilitating the birth with vacuum extraction Rationale: Vacuum extraction will decrease the workload of the heart during expulsion and permit a vaginal birth. Induction can increase cardiac workload. Many clients with cardiac disease are able to give birth vaginally when precautionary measures are instituted; it is preferable to avoid the secondary stress that surgery may impose. During the second stage of labor cardiac output may be increased; the client needs assistance to decrease the cardiac workload.

What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common?

Increased risk for respiratory complications Rationale: As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.

What age-related fear should the nurse expect when preparing a 4-year-old child for surgery?

Intrusive procedures Rationale: Intrusive procedures threaten the developing body image of the preschooler. The preschooler is more tolerant of strangers than is a younger child. Routines are important to the preschooler, but some deviations in structure of activities can be tolerated. The preschooler can tolerate short periods of separation from parents.

A client with a diagnosis of Graves disease refuses to have radioactive iodine (RAI) therapy, and a subtotal thyroidectomy is performed. What should the nurse do postoperatively to reduce the risk of thyroid storm?

Prevent infection at the surgical site. Rationale: Conditions such as trauma and infection can precipitate thyroid storm (thyroid crisis, thyrotoxic crisis). A high-calorie diet does not prevent crisis; it restores glycogen reserves depleted by an increased metabolic rate. Postoperative breathing exercises prevent respiratory complications, not thyroid storm. Learning how to support the neck after surgery limits tension on the suture line, thereby decreasing the risk of hemorrhage, not thyroid storm.

A client steps on a rusty nail, and the puncture site becomes swollen and painful. Tetanus antitoxin is prescribed. The nurse explains that the antitoxin is used because it:

Provides antibodies Rationale: Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of plasma cells, the precursors of antibodies. Passive, not active, immunity occurs. Passive immunity, by definition, is not long lasting.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in vitamin K and that should be avoided. What should the nurse include on the list? Select all that apply.

Spinach, Broccoli Rationale: The amount of vitamin K in spinach is 266 mcg/100 g; the recommended daily allowance of vitamin K is 80 mcg/100 g for men and 65 mcg/100 g for women when a person is receiving an oral anticoagulant. The amount of vitamin K in broccoli is 132 mcg/100 g. Fruit, including oranges, contains minimal vitamin K. Chicken breast is high in protein, not vitamin K. Sweet potatoes are high in vitamin A, not vitamin K.

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?

Suction the client's oropharynx. Rationale: A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway. Oxygen administration will be useless if the airway is not patent. Placing the client in the orthopneic position is unsafe for a client with Guillain-Barré syndrome. The client will be unable to maintain this position. Muscle weakness involves the lower extremities, progressing to the upper extremities and diaphragm.

Evidence-based nursing uses a variety of sources to support nursing practice. Which are sources of evidence-based practice? Select all that apply.

Theory, Research, Clinical Expertise Rationale: Evidenced-based nursing care uses information gleaned from theory, research, expert opinion, client history and physical examination, client preferences and values, and the clinical expertise of the nurse. Time/motion studies are not used as a basis of evidenced-based practice. Accepted nursing rituals are not used as a basis of evidenced-based practice.

Isoenzyme laboratory studies are prescribed for a client who is suspected of having a myocardial infarction. The nurse recalls that the most reliable early indicator of myocardial insult is:

Troponin I (cTnI) and troponin T (cTnT) Rationale: Troponin I and troponin T are proteins in the striated cells of cardiac tissue and are therefore unique markers for cardiac damage; elevations occur within one hour of a myocardial infarction (MI) and persist for 7 to 15 days. Serum AST levels begin to increase in 4 to 6 hours, peak at approximately 24 hours, and remain elevated for 3 to 4 days after an MI. Myoglobin is the oxygen-binding protein of striated muscle; although it rises within the first few hours after an MI, it lacks cardiac specificity. CK isoenzyme levels, especially the MB subunit, begin to rise within 3 to 6 hours, peak in 12 to 18 hours, and are elevated for 48 hours after the occurrence of an MI.

When assessing a client with Graves disease, the nurse expects to identify:

Weight loss, exophthalmos, and restlessness Rationale: Weight loss and restlessness occur because of an increased basal metabolic rate; exophthalmos occurs because of peribulbar edema. Constipation, dry skin, and weight gain are associated with hypothyroidism because of the decreased metabolic rate. Lethargy and weight gain are associated with hypothyroidism as a result of a decreased metabolic rate; forgetfulness is not related. Although weight loss and exophthalmos occur with hyperthyroidism, the client will be hyperactive, not hypoactive.