Hesi Practice Questions 1
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A "What are the voices saying?" B "Which medication works best?" C "When do you hear voices?" D "How do you cope with the voices?"
A "What are the voices saying?"
Which intervention Is most important for the nurse to include in the plan of Care for a client who is 12 hours post-thyroidectomy ? A Resume antithyroid drug therapy. B Prepare to administer radioactive iodine treatments. C Anticipate and monitor for hypothermia. D Maintain a semi-Fowler position.
A Resume antithyroid drug therapy.
A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Sterile vaginal exam revealing 3cm dilation C. Biophysical profile results showing oligohydramnios D. Fetal heart tones located in upper right quadrants
D. Fetal heart tones located in upper right quadrants
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation
D. Oxygen saturation
While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?
Place a portable toilet next to the bed
A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone (Narcan) per PNR protocol b. Initiate seizure precautions c. Obtain a serum drug screen d. Instruct the family about withdrawal symptoms.
b. Initiate seizure precautions
A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? 1. Discuss the importance of continuing the usual at-home activities 2. Encourage the family to plan daily activities to keep the client busy 3. Have friends and family visit the client at a welcome party. 4. Instruct family to monitor the client's choice of television programs.
1. Discuss the importance of continuing the usual at-home activities
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?
1000, 1600, 2200, 0400
A client with cirrhosis of the liver having numerous, liquid, incontinent stools, and continues to be confused. After reviewing the clients laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. IV Human albumin b. Lactulose c. Furosemide d. Loperamide
b. Lactulose
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care? A) Have the client vocalize the instructions provided B) Ensure that someone will stay with the client for 24 hours C) Speak clearly and face the client for lip reading D) Provide written instructions for eye drop administration
A) Have the client vocalize the instructions provided
The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A) Keep the nails trimmed short B) Apply baby lotion to the skin twice daily C) Bathe the child with bath oil D) Allow the child to wear only 100% cotton clothing
A) Keep the nails trimmed short
What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy." B. "The dressing over my incision feels like it is too tight C. "I'm most comfortable when the head of the bed is raised" D. "This IV infusion makes me urinate more often than usual"
A. "When I get out of bed quickly, I feel a little dizzy."
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin
A. Culture for sensitive organisms
The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest expansion C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute
A. Diminished breath sounds over the trocar insertion site
The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.
A. Provide high protein snacks
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling and edema D. Monitor abdominal girth E. Increase oral fluid intake to 1,500 mL daily
A. Report serum albumin and globulin levels C. Note signs of swelling and edema D. Monitor abdominal girth
Upon the return of a client from surgery after an open reduction of a femur fracture, the nurse notes a small bloodstain on the cast and marks it. Four hours later the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A) Access the site by cutting a window in the cast B) Call the health care provider C) Outline the new spot then continue monitoring D) Record the findings in the client's record
C) Outline the new spot then continue monitoring
A patient who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breast are swollen, warm and tender on palpitation. Which instruction should the nurse provide?
Apply ice to the breast for comfort
An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture sputum, urine, burn wound, and all intravenous access sites. C Implement central line-associated bloodstream infection (CLABSI) protocols. D Evaluate daily serum electrolytes and hydration status.
B Culture sputum, urine, burn wound, and all intravenous access sites.
Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A) Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B) Avoid administration of oxygen at high levels for extended periods. C) Increase oxygen rate during sleep to compensate for slower respiratory rate. D) Oxygen is less toxic when it is humidified with a hydration source.
B) Avoid administration of oxygen at high levels for extended periods.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and? A) Increased retention of albumin in the vascular system B) Decreased colloidal osmotic pressure in the capillaries C) Fluid shift from interstitial spaces into the vascular space D) Reduced tubular reabsorption of sodium and water
B) Decreased colloidal osmotic pressure in the capillaries
A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? A. "You have become dehydrated from the nausea. You will need to rest and increase fluid intake" B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms" C. A urine specimen will be needed to determine what kind of infection you have developed" D. use insulin per sliding scale until the nausea resolves, and then resume your oral medication
B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms"
The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a- Fruity breath odor b- Polyphagia c- Diaphoresis d- Polydipsia
c- Diaphoresis
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers B. Children usually resume their toileting behaviors when they leave the hospital C. A potty chair should be brought from home so he can maintain hi
B. Children usually resume their toileting behaviors when they leave the hospital
When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements
B. Give a dose of regular insulin as prescribed
a clent with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? A. Orange juice B. Regular insulin C. NPH insulin D. Repeat blood sugar level
B. Regular insulin
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperatue D. Erythrocytes, hemoglobin, and hematocrit
B. Serum potassium, calcium, and phosphorus
An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. Phobia B. Addiction C. Obsession D. Compulsion
D. Compulsion
The parents of a 6 year old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A. Provide a list of alternative activities that are less likely to cause the child to experience fatigue B. Explain that their child is too young to understand the risks associated with swimming C. Encourage the parents to allow the child to continue attending swimming lessons with supervision
C. Encourage the parents to allow the child to continue attending swimming lessons with supervision
In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin
C. Glucose
The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)
C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)
Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A A client is walking the halls at night rubbing his hands together. B A family member expresses concern about their relative "picking" at the NG tube. C A 16-year-old boy swung his fist at the nurse. D A disoriented client removed the mesh wrapped IV line for the second time.
D A disoriented client removed the mesh wrapped IV line for the second time.
The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take? A Inform the mother that toilet training is slower for boys. B Refer the mother to a community parent education program. C Suggest that the mother consult a pediatric nephrologist. D Provide disposable training pants while calming the mother.
D Provide disposable training pants while calming the mother.
An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. History of smoking over the past 6 months B. Sleep patterns during the previous few weeks C. Activity level prior to onset of symptoms D. Recent compliance with prescribed medications
D. Recent compliance with prescribed medications
During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives
D. Three year history of taking oral contraceptives
The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
Medication port
While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?
T4 levels in newborns
A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse
Total calcium 5.0 mg/dl
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
Weight bearing exercise
The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? a) Blurred Vision b) Headache c) Lack of appetite d) Urinary frequency e) Chills and fever f) Swollen hands
a) Blurred Vision b) Headache f) Swollen hands
An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? a) Obtain a prescription for an anticholinergic medication b) Determine how many hours declined slept last night c) Administer the PRN prescription for severe anxiety d) Watch the thyroid cartilage move while the client swallows
a) Obtain a prescription for an anticholinergic medication
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a) Recommend weigh bearing physical activity b) Reduce intake of foods high in vitamin D c) Decrease intake of foods high in fat d) Minimize heavy lifting and bending.
a) Recommend weigh bearing physical activity
A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) a) Topical corticosteroid. b) Topical scabicide. c) Topical alcohol rub. d) Transdermal analgesic. e) Oral antihistamine
a) Topical corticosteroid e) Oral antihistamine
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a) Altered consciousness within the first 24 hours after injury. b) Cushing reflex and cerebral edema after 24 hours c) Fever, nuchal rigidity and opisthotonos within hours d.) Headache and pupillary changes 48 hours after a head injury
a)altered consciousness
Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? a- Decreased abdominal girth b- Increased blood pressure c- Clear breath sounds d- Decrease serum albumin.
a- Decreased abdominal girth
The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis? a- I couldn't get my son's socks and shoes on this morning" b- My son has been on amoxicillin/clavulanate for 2 days for an ear infection c- My son has had a red rash over his entire body for the past 4 days. d- I couldn't get my son calm down and sleep last night.
a- I couldn't get my son's socks and shoes on this morning"
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? Select all that apply. a. Flat affect b. Frequent drooling c. Frequent syncope d. Blurred vision e. Occasional nocturia
a. Flat affect c. Frequent syncope d. Blurred vision
An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? a. Multiple organ dysfunction syndrome (MODS) b. Disseminated intravascular coagulation (DIC) c. Chronic obstructive disease. d. Acquired immunodeficiency syndrome (AIDS)
a. Multiple organ dysfunction syndrome (MODS)
A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? a. Reduced level of pain b. Full volume of pedal pulses c. Granulating tissue in foot ulcer d. Improved visual acuity
a. Reduced level of pain
While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavior
a. State it is unacceptable to undress during interview
A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26
a. The client has asymmetrical chest wall expansion
A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is the priority? a) Check the skin on the sacrum for skin breakdown b) Auscultate the lungs for atelectasis c) Inspect the pin sites for signs for infection d) Perform a neurovascular check for circulation
d) Perform a neurovascular checks for circulation
Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood cells b. Obtain blood and sputum cultures. c. Infuse 1000 ml normal saline d. Titrate oxygen to keep o2 saturation 90%
a. Transfuse packed red blood cells
A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? a) Ask a chemotherapy-certified nurse to administer the Zofran b) Administer the Zofran after flushing the saline lock with saline c) Hold the scheduled dose of Zofran until the client awakens d) Awaken the client to assess the need for administration of the Zofran.
b) Administer the Zofran after flushing the saline lock with saline
The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? a) Do not read without direct lighting for 6 weeks. b) Avoid straining at stool, bending, or lifting heavy objects. c) Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d) Limit exposure to sunlight during the first 2 weeks when the cornea is healing.
b) Avoid straining at stool, bending, or lifting heavy objects.
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? a) Neutralize hydrochloric (HCI) acid in the stomach b) Decreases the amount of HCL secretion by the parietal cells in the stomach c) Inhibit action of acetylcholine by blocking parasympathetic nerve endings. d) Destroys microorganisms causing stomach inflammation
b) Decreases the amount of HCL secretion by the parietal cells in the stomach
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) a) Take an additional dose for signs of hyperglycemia b) Recognize signs and symptoms of hypoglycemia. c) Report persist polyuria to the healthcare provider. d) Use sliding scale insulin for finger stick glucose elevation. e) Take Glucophage with the morning and evening meal.
b) Recognize signs and symptoms of hypoglycemia. c) Report persist polyuria to the healthcare provider. e) Take Glucophage with the morning and evening meal.
A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? a) Gastric output of 900 mL in the last 24 hours b) Serum potassium level of 3.1 mEq/L or mmol/L (SI) c) Increased blood urea nitrogen (BUN) d) 24-hour intake at the current infusion rate.
b) Serum potassium level of 3.1 mEq/L or mmol/L (SI)
A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a) Immune antibodies attack pancreatic beta cells resulting in no insulin b) The body cells develop resistance to the action of insulin. c) Body organs produce less insulin and more glucagon d) The liver produces excess glucose in response to excess glycotrophic hormones
b) The body cells develop resistance to the action of insulin.
The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly
b. Affirm that the client should arise slowly from the chair
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? a. Digestive problems b. Amenorrhea c. Electrolyte imbalance d. blood disorder
b. Amenorrhea
A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a. Explain that it may take several weeks for the medication to be effective b. Confirm the desired effect of the medication has been achieved. c. Notify the health care provider than a change may be needed. d. Evaluate when and how the medication is being administered to the client.
b. Confirm the desired effect of the medication has been achieved.
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Sed rate (ESR) b. Hemoglobin c. Calcium d. Osmolality
b. Hemoglobin
An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? a. Hygiene-self-care deficit b. Imbalance nutrition c. Disturbed sleep pattern d. Self-neglect
b. Imbalance nutrition
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Pain scale rating at 9 on a 0-10 scale b. Last menstrual period was 7 weeks ago c. Reports white curdy vaginal discharge d. History of irritable bowel syndrome IBS
b. Last menstrual period was 7 weeks ago
A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) a. Check urine for ketones b. Measure blood glucose c. Monitor vital signs d. Assessed level of consciousness e. Obtain culture of wound
b. Measure blood glucose c. Monitor vital signs d. Assessed level of consciousness
A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? a. Jaundice skin tone b. Muffled heart sounds c. Pitting peripheral edema d. Bilateral scleral edema
b. Muffled heart sounds
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a. Replace the IV site with a smaller gauge. b. Redress the abdominal incision c. Leave the lights on in the room at night. d. Apply soft bilateral wrist restraints.
b. Redress the abdominal incision
An older adult client with systematic inflammatory response syndrome SIRS has a temperature of 101.8 Fahrenheit heart rate of 110 beats/ minutes and respiratory rate of 24 breaths/ minutes which additional finding is most important to report to the healthcare provider? a. capillary glucose reading b. Serum creatinine of 2.0mg/dL c. Blood pressure of 130/88 mmHg d. Hemoglobin of 12 g/dL
b. Serum creatinine of 2.0 mg/dL
A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Blood alcohol level of 0.09% b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) c. Six hours of sleep in the past three days. d. Weight loss of 10 pounds (4.5 kg) in past month.
b. Serum lithium level of 1.6 mEq/L or mmol/l (SI)
A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a. Elevate lower extremities while out of bed b. Teach family proper range of motion exercises. c. Maintain proper body alignment when in bed d. Encourage diaphragmatic breathing exercises.
b. Teach family proper range of motion exercises.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Evaluate the client for sleep disturbances b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. d. Assess the client for weakness and fatigue e. Note and report the client's food and liquid intake during meals and snacks.
b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. e. Note and report the client's food and liquid intake during meals and snacks.
The nurse is assigned to a client with parkinson disease. Which findings would the nurse anticipate? a. non intention tremors and urgency with voiding b. echolalia and a shuffling gait c. muscle spasms and a bent over posture d. intention tremor and jerky movement of the elbows
b. echolalia and a shuffling gait
After receiving report, the nurse can most safely plan to assess which client last? The client with... a) A rectal tube draining clear, pale red liquid drainage b) A distended abdomen and no drainage from the nasogastric tube c) No postoperative drainage in the Jackson-Pratt drain with the bulb compressed d) Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.
c) No postoperative drainage in the Jackson-Pratt drain with the bulb compressed
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication? a) Dilute the Dextrose in one liter of 0.9% Normal Saline solution. b) Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. c) Push the undiluted Dextrose slowly through the currently infusion IV. d) Ask the pharmacist to add the Dextrose to a TPN solution.
c) Push the undiluted Dextrose slowly through the currently infusion IV.
A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? a) Slow increasing intracranial pressure (ICP) b) Decerebrate posturing c) Rapid onset of decreased level of consciousness. d) Coup contrecoup signs
c) Rapid onset of decreased level of consciousness
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? a) Ask the UAP to take the blood pressure in the other arm b) Tell the UAP to use a different sphygmomanometer. c) Review the client's serum calcium level d) Administer PRN antianxiety medication.
c) Review the client's serum calcium level
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a) Serum ph of 7.45 b) Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c) Serum potassium of 3.0 mg/dl d) Gastric output of 100 ml in the last 8 hours
c) Serum potassium of 3.0 mg/dl
The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? a- Stares straight ahead without blinking b- Face does not convey any emotion c- Cries frequently during the interview d- Uses a monotone when speaking
c- Cries frequently during the interview
35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? a- Supplemental hormonal therapy will probably be unnecessary b- The thyroid will regenerate to a normal size within a few years. c- The client will be restricted from eating seafood d- The remainder of the thyroid will be removed at a later date.
c- The client will be restricted from eating seafood
The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a. An adult female who has been depressed for the past several months and denies suicidal ideations. b. A middle-age male who is in a depressive phase of bipolar disease and is receiving Lithium. c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist. d. An elderly male who tells the staff and other clients that he is superman and he can fly
c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist.
A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement? a. Encourage the client to be calm and relax for a little while b. Assist the client to identify stimuli that precipitates the activity. c. Allow time for the behavior and then redirect the client to other activities. d. Teach the client thought stopping techniques and ways to refocus.
c. Allow time for the behavior and then redirect the client to other activities.
In assessing a client with diabetes mellitus type 1, the nurse notes that the client's respirations have changed from 16 with normal depth to 32 and deep, and the client has become lethargic. What assessment data should the nurse obtain next? a. Arterial blood gases b. Core body temperature c. Blood glucose d. Oxygen saturation
c. Blood glucose
What action should the school nurse implement to provide secondary prevention to a school-age children? a. Collaborate with a science teacher to prepare a health lesson b. Prepare a presentation on how to prevent the spread of lice c. Initiate a hearing and vision screening program for first-graders d. Observe a person with type 1 diabetes self-administer a dose of insulin
c. Initiate a hearing and vision screening program for first-graders
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi-Fowler position with his arms at his sides. What action should the nurse implement? a. Reposition the client in a side-lying position and support his abdomen with pillows. b. Elevate the client's feet on a pillow while keeping the head of the bed elevated. c. Raise the head of the bed to a Fowler's position and support his arms with a pillow d. Place the client in a shock position and monitor his vital signs at frequent intervals
c. Raise the head of the bed to a Fowler's position and support his arms with a pillow
A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective? a. The nurse note that no pills remain in the prescription bottle. b. The client serum Depakote level is 125 mcg/ml c. The family reports a great reduction in client's maniac behavior d. The client denies any occurrence of suicidal ideation.
c. The family reports a great reduction in client's maniac behavior
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? a) A 34-year -old admitted today after an emergency appendendectomy who has a peripheral intravenous catheter and a Foley catheter. b) A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race. c) A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter. d) An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
d) An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? a) Transfer a client to another unit b) Monitor the central telemetry c) Perform the admission d) Assist cardiac nurses with their assignments
d) Assist cardiac nurses with their assignments
The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? a) Pulmonary embolus with an intravenous heparin infusion and new onset hematuria b) Myocardial infarction with sinus bradycardia and multiple ectopic beats c) Adult respiratory distress syndrome with pulse oximetry of 85% saturation. d) Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
d) Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a) Perform the drainage immediately after meals b) Instruct the client to breath shallow and fast c) Obtain arterial blood gases (ABG's) prior to procedure d) Explain that the client may be placed in five positions
d) Explain that the client may be placed in five positions
A client who is hypotensive is receiving dopamine, and adrenergic agonist IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a) Initiate seizure precautions b) Assess pupillary response to light hourly c) Monitor serum potassium frequently d) Measure urinary output every hour
d) Measure urinary output every hour
A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? a) Irrigate the indwelling urinary catheter. b) Prepare the client for external pacing. c) Obtain capillary blood glucose measurement. d) Titrate the dopamine infusion to raise the BP.
d) Titrate the dopamine infusion to raise the BP.
An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? a) Onset of mild confusion b) Pain score 8 out of 10 c) Pale, diaphoretic skin d) Weak palpable distal pulses
d) Weak palpable distal pulses
A male client who fell off a roof have right and left femur fractures and crushing injuries to both ankles. He is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pin on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vital signs are heart rate 130 beats/minute, respiration 32 breathes/minute, blood pressure 180/90 mmHg. Which interventions is most important for the nurse to implement? a) Request the healthcare provider to consider a different analgesic b) Evaluate the traction for amount of tension applied to each extremity c) Determine if client is experiencing cumulative effects of the total dosage d) Assess the extremities for signs of compartment syndrome q2 hours
d) assess the extremities for signs of compartment syndrome q2 hours
The nurse is caring for a 16 year old client with a femur fracture 14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious and oxygen saturation levels of 88%. IN immediately notifying the provider of these findings, the nurse recognizes the client is at risk for a) compartment syndrome b) atelectasis c) myocardial infraction d) fatty embolism
d) fatty embolism
During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? a. Urine ketones b. Urine albumin c. Serum protein d. Serum potassium
d. Serum potassium
Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client a. Have partner screened for human immunodeficiency virus b. Report a sudden onset arthralgia to the healthcare provider c. Decrease intake of high-fat-foods, caffeine, and alcohol d. Use two forms of contraception while taking this drug.
d. Use two forms of contraception while taking this drug.
A client with postpartum depression who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care? a. sleeps at least 6 hours per night b. consumes 3 meals and 1500 mL of fluid per day c. engages in one client to client interaction daily d. attends one group activity per day
d. attends one group activity per day
