HESI Remediation PN - #1

Which antimicrobial drugs are safe during breast-feeding? A:Penicillins B: Macrolides C: Tetracycline D: Cephalosporins C: Chloramphenicol

A , B , D Rationale: Penicillin's, macrolides, and cephalosporins are considered safe drugs during breast-feeding as they are least likely to affect the infant. Tetracycline and chloramphenicol should be avoided during breast-feeding.

A nurse is auscultating a client's heart sounds. Which valves close when the first heart sounds are produced? A) Mitral and Tricuspid B) Aortic and Tricuspid C) Mitral and pulmonic D) Aortic and pulmonic

A) Mitral and Tricuspid

After measuring the body temperature, the nurse documents a core temperature reading of 99 °F, but the actual oral route reading is 98 °F. Which route was used by the nurse for temperature measurement? A) Rectal B) Axillary C) Temporal D) Tympanic

A: Rectal

Which drug will most likely cause the client's eyelids to itch and eyes to burn as side effects? A. Ketorolac B. Ofloxacin C. Diclofenac D. Vidarabine

D. Vidarabine Vidarabine is an antiviral agent that causes sensitive reactions such as itching eyelids and burning eyes. The rest will not.

What situation would the student nurse know may predispose a toddler to a sense of shame and doubt? A) The caregiver's response is too harsh. B) The child is unable to establish companionship. C) The parents try to control the child and limit choices. D) The parents fail to establish a sense of trust in the child.

C) The parents try to control the child and limit choices.

Which nursing action is appropriate when assessing a pediatric client's arm circumference? A) Using specialized calipers for the measurements B) Having cloth tape available to measure the midpoint C) Recording the average of one measurement using two sites D) Measuring vertically along the posterior aspect of the upper arm

D) Measuring vertically along the posterior aspect of the upper arm Rationale: Arm circumference is an indirect measurement of muscle mass. The appropriate nursing action is to measure vertically along the posterior aspect of the upper arm to the acromial process and to the olecranon process. Specialized calipers are used to assess skinfold measurements. The nurse should record the average of at least two measurements at the same site.

A client is admitted to the hospital after sustaining a head injury. The nurse monitors for the most reliable sign of increased intracranial pressure, which is a slow: A) Rise in respiratory rate B) Narrowing of pulse pressure C) Decrease in the level of consciousness D) Increase in the diastolic blood pressure

C: Decrease in the level of consciousness. Decreasing LOC occurs because of the brain's acute sensitivity to hypoxia. The respirations usually are depressed because of brainstem compression. The systolic pressure increases and the diastolic pressure decreases, resulting in a widening, not narrowing, pulse pressure.

While communicating with a family that has been affected by interpersonal violence, the nurse asks what the family does for relaxation. Which realm of family life processes is the nurse trying to assess? A) Health B) Integrity C) Interactive D) Developmental

C: Interactive

A client has bright-red erythematosus macules and papules on the skin. What could be the diagnosis? A) Drug eruption B) Atopic dermatitis C) Contact dermatitis D) Nonspecific eczematous dermatitis

A: Drug eruption Atopic dermatitis is characterized by scaling and excoriation, due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. the client has been taking phenytoin for 10 years. when planning care for this client, what should the nurse do first? A) Place an airway and restraints at the bedside. B) Obtain a history of seizure type and incidence. C) Ask the client to remove any dentures and eyeglasses. 4 observe the client for increased restlessness and agitation.

B) Obtain a history of seizure type and incidence.

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? A) Calcium of 9.5 mg/dL (2.375 mmol/L) B) Potassium of 7.02 mEq/L (7.02 mmol/L) C) Bicarbonate of 22.8 mEq/L (22.8 mmol/L) D) Phosphorus of 4.1 mg/dL (1.3243 mmol/L)

B) Potassium of 7.02 mEq/L (7.02 mmol/L) Rationale: The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum bicarbonate is between 22 and 26 mEq/L or mmol/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what? A) Vesicular B) Bronchial C) Crackles 4) Rhonchi

C: Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

The nurse finds that a child has inattention, hyperactivity, and impulsivity upon assessment. Which medication would be beneficial for the child? A) Modafinil B) Doxapram C) Armodafinil D) Atomoxetine

D) Atomoxetine Rationale: Inattention, hyperactivity, and impulsivity in a child may indicate that the child has attention deficit hyperactivity disorder. Atomoxetine is a nonstimulant second-line drug used to treat attention deficit hyperactivity disorder (ADHD). Modafinil is a nonamphetamine stimulant used to treat shift-work sleep disorder (SWSD). Doxapram and armodafinil are nonamphetamine stimulants used to treat shift-work sleep disorder (SWSD).

Which developmental milestone related to feeding does a nurse anticipate for a 36-month-old client? Select all that apply. A) Using a straw to drink B) Drinking well from a cup C) Chewing with the mouth closed during meals D) Beginning to use a fork by holding it in the first E) Spilling small amounts of food when using a spoon

D) Beginning to use a fork by holding it in the first E) Spilling small amounts of food when using a spoon Rationale: The nurse would anticipate the 36-month-old toddler to use a fork by holding it in the fist and spilling small amounts of food when using a spoon. The nurse would anticipate the 24th-month-old toddler to use a straw to drink liquids. The 15-month-old toddler is expected to drink well from a cup. Chewing with the mouth closed during meals is an expectation for the 24-month-old toddler.

The nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment finding is important? A) Slowed pulse rate B) Increased blood pressure C) Persistent muscular twitching D) Continuous trickling of blood

D) Continuous trickling of blood

Why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler? A) The extent of dehydration is based on these measurements. B) These measurements are used as the baseline for future growth. C) The management of dietary needs is based on height and weight. D) The values are used to calculate fluid replacement and medication dosages.

D) The values are used to calculate fluid replacement and medication dosages.

Which nursing assessment is important to recognize to determine the causative factors in a client with a history of spontaneous abortions ? A. Use of sex hormones B. Use of contraceptive pills C. Presence of heart problems D. History of alcohol consumption

D. History of alcohol consumption Rationale: Alcohol consumption during pregnancy may cause fetal abnormalities and increase the risk of spontaneous abortions. The presence of heart problems may not cause spontaneous abortions. The use of sex hormones in pregnancy may cause fetal abnormalities. Contraceptive pills may inhibit the ovulation process, but they rarely affect the embryo.

The parents of a toddler tell the nurse the family has been living in a very old building. The nurse should carefully assess the child for the irreversible effects of possible lead poisoning by focusing on the what? A) Urinary system B) Skeletal system C) Hematologic system D) Central nervous system

D: Central nervous system Rationale: nerves cells do not regenerate; once neurologic damage has occurred, changes are irreversible. changes in the urinary, skeletal, and hematologic systems are reversible with treatment.

Which antiinfective agent may lead to blindness if not used correctly by the client in prescribed amounts? A) Bromfenac B) Natamycin C) Trifluridine D) Gentamicin

D: Gentamicin Rationale: Gentamicin is an antiinfective agent that can lead to blindness if not used in prescribed amounts. The nurse should instruct clients to take this only as prescribed, because bacterial and fungal eye infections may worsen rapidly and can lead to blindness if not treated adequately. Bromfenac is a nonsteroidal antiinflammatory (NSAID) agent and does not lead to blindness. Natamycin is an antifungal agent and trifluridine is a topical antiviral agent; both do not cause blindness.

Which assessment data would cause the nurse to initiate treatment for a potential aspirin overdose for a toddler-age child who presents in the emergency department (ED)? A: Emesis B: Nausea C: Tinnitus D: Ecchymosis D: Hypoventilation

A , B , B Rationale: Ecchymosis (blood or bleeding under the skin due to trauma of any kind) is a late symptom associated with a chronic aspirin overdose. Hyperventilation would support the initiation of treatment for an aspirin overdose.

A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem? A) Moro B) Plantar C) Babinski D) Stepping

A) Moro Rationale: A difficult birth because of broad fetal shoulders may result in a fractured clavicle, as evidenced by a knot or lump, limited arm movement, and a unilateral Moro reflex . Plantar reflex is unrelated to a difficult birth caused by a fetus with broad shoulders. Babinski reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders. Stepping reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders.

What must the nurse assess first when planning to promote mother-infant attachment? A) Mother-infant interaction B) Mother-father interaction C) The infant's physical status D) The mother's ability to care for her infant

A) Mother-infant interaction

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? A) Red B) Black C) Green D) Yellow

A) Red Rationale: The nurse would use a red tag for a client who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions. A green tag is used for a client with minor injuries that do not require immediate treatment. A yellow tag is used for a client who has major injuries requiring treatment.

A client who had surgery for a resection of the colon and the formation of a colostomy is to be discharged in several days. What is a primary nursing intervention for this client? A) Determine the client's ability to care for the colostomy B) Show the client how to change the abdominal dressing C) Encourage the client to care for the colostomy without assistance D) Teach the client about the special precautions concerning the diet

A: Determine the clients ability to care for the colostomy. Rationale: The client's feelings, knowledge, and skills concerning caring for the colostomy must be assessed before discharge.

Which assessment finding should the nurse identify as a physical readiness cue for a toddler-age client related to toilet training? A) Having regular bowel movements B) Willing to invest the time needed C) Telling a parent that the diaper is wet D) Expressing a willingness to please parents

A: Having regular bowel movements

After interacting with a preschooler, the nurse concludes that the child has normal development according to Fowler's spiritual development. Which behavior of the child supports the nurse's conclusion? A) The child imitates the adults as they pray. B) The child does not exhibit any spiritual behavior. C) The child accepts the existence of a supreme power. D)The child questions the religious practice and its benefits.

A: The child imitates the adults as they play Rationale: A preschooler is in the intuitive-projective stage of Fowler's spiritual development, and would imitate the others as they pray and perform other religious activities.

A pregnant woman who is past her due date is hospitalized for a labor induction. Which drug should be administered to the client? A) Clomiphene B) Menotropins C) Dinoprostone D) Choriogonadotropin alfa

C) Dinoprostone Rationale: Dinoprostone is a prostaglandin that stimulates uterine contractions to promote the progression of labor. The rest are fertility drugs used to increase the likelihood of conception in an infertile woman.

The fetus of a client in labor is found to be at +1 station. Where did the nurse locate the fetus's head? A) On the perineum B) High in the pelvis C) Just below the ischial spines D) Slightly above the ischial spines

C) Just below the ischial spines

A nurse is assessing a toddler with plumbism (lead poisoning). Which organ system is of most concern because of the condition's irreversible effects? A) Urinary B) Skeletal C) Nervous D) Hematologic

C) Nervous

While completing an assessment, the nurse finds that a client has decreased thickness and excessive dryness of the epidermis. Which clinical finding is associated with this skin assessment? A) Skin tears B) Skin cancer C) Skin fragility D) Skin hyperplasia

C) Skin fragility

A client after a trauma has difficulty opening his or her eyes, has abnormal motor response, and speaks inappropriate words. What is the status of the client utilizing the Glasgow Coma Scale? Record your answer using a whole number

Answer: 8 The client having pain opening the eyes scores 2 points, abnormal motor response scores 3 points, and inappropriate words scores 3 points, which adds up to 8. A client scoring 8 points on the Glasgow Coma Scale after trauma requires medium priority

Which statements about sleep are correct? Select all that apply. A) Sleep involves three phases. B) Sleep is associated with healing. C) Sleep is a state of rest that occurs for a sustained period. D) Sleep restores a person's energy and feeling of well-being. E) Sleep is a cyclic physiologic process that alternates with shorter periods of wakefulness.

B , C , D

The nurse is providing post-procedure care to a client after an arthroscopy. What will be the nurse's priority while providing care to the client? A) Encouraging the client to perform exercises B) Elevating the affected extremity for 12 to 24 hours C) Assessing the neurovascular status of the client affected limb D) Administering analgesics as prescribed by the primary healthcare provider

C) Assessing the neurovascular status of the client affected limb

When a client develops steatorrhea, the nurse documents this stool as: A) Dry and rock-hard B) Clay colored and pasty C) Bulky and foul smelling D) Black and blood-streaked

C) Bulky and foul smelling Rationale: Bulky and foul smelling characteristics describe steatorrhea, which results from impaired fat digestion Steatorrhea: Oily stool

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh? A) Palpate the femoral artery B) Assess for a positive Homan sign C) Compress and release the client's toenails D) Instruct the client to flex and extend the knee

C) Compress and release the client's toenails

A nurse is assessing a client at 16 weeks' gestation. Where does the nurse expect the fundal height to be located? A) Above the umbilicus B) At the level of the umbilicus C) Half the distance to the umbilicus D) Slightly above the symphysis pubis

C: Half the distance to the umbilicus Rationale: Considering the growth of the fetus, this is the expected height of the fundus at 16 weeks' gestation. The height of the fundus in centimeters is approximately the same as the number of weeks of gestation if the woman's bladder is empty at the time of measurement. Above the umbilicus is where the fundus should be palpated from after 24 weeks' gestation until term. At the level of the umbilicus is where the fundus should be palpated at 22 to 24 weeks' gestation. Between 12 and 14 weeks' gestation, the uterus outgrows the pelvic cavity and can be palpated just above the symphysis pubis.

When monitoring a client 24 to 48 hours after surgery, the nurse should assess for which problem associated with anesthetic agents? A) Colitis B) Stomatitis C) Paralytic ileus 4) Gastrocolic reflux

C: Paralytic Ileus Rationale: After surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.

A client has a fever spike, but the client's body temperature returns to normal at least once a day. Which type of fever can be assessed in the client? A) Sustained B) Relapsing C) Remittent D) Intermittent

D) Intermittent

Which is a developmental milestone related to feeding that the nurse anticipates for a 24-month-old client? A) Using a straw to drink B) Drinking well from a cup C) Beginning to use a fork by holding it in the fist D) Spilling small amounts of food when using a spoon

A) Using a straw to drink Rationale: The nurse would anticipate that a 24-month-old toddler can use a straw to drink liquids. The 15-month-old toddler is expected to drink well from a cup. Beginning to use a fork by holding it in the fist and spilling small amounts of food when using a spoon are expectation for a 36-month-old.

The nurse is examining a child living in foster care who has not had access to vision screening. The nurse suspects that the child is at high-risk of developing amblyopia. Which statement is true? A) The child is around 6 years of age and has untreated strabismus. B) The child is around 3 years of age and has uncorrected strabismus. C) The Hirschberg test performed on this child shows that the light falls symmetrically within each pupil D) The alternate cover test performed on this child shows that shifting the cover from one eye to the other causes the eye to move.

A: The child is around 6 years of age and has untreated strabismus. Rationale: In strabismus, or cross-eye, one eye deviates from the point of fixation. If strabismus is not detected and corrected by 4 to 6 years of age, blindness from disuse, known as amblyopia, may result. So, the 6-year-old child with untreated strabismus is at risk for developing amblyopia. If a 3-year-old child is found to have strabismus, there is still time to treat it so the child does not develop amblyopia. For the Hirschberg test, commonly used to detect misalignment, a flashlight or the light of the ophthalmoscope is shone directly into the client's eyes from a distance of about 40.5 cm (16 inches). If the eyes are orthophoric, or normal, the light falls symmetrically within each pupil. In the alternate cover test, occlusion shifts back and forth from one eye to the other and movement of the eye that was covered is observed as soon as the occluder is removed while the child focuses on a certain point. If normal alignment is present, shifting the cover from one eye to the other will not cause the eye to move. Neither of these two results indicates a high-risk of developing amblyopia.

Which Nursing Intervention Is Most Appropriate For A Client In Skeletal Traction A) Add and remove weights as the client desires B) Assess the pin sites at least every shift and as needed C) Ensure that the knots in the rope are tied to the pulley D) Perform range of motion to joints proximal and distal to the fraction at least once a day

B) Assess the pin sites at least every shift and as needed Rationale: The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are NOT tied to the pulley and move freely. The performance of ROM is indicated for all joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

A client in labor, dilated to 4 cm, is admitted to the birthing room. An electronic fetal monitor is applied. Which assessment should alert the nurse of the need to notify the primary healthcare provider? A) Contractions every 4 minutes that last 50 seconds B) Contractions every three minutes lasting 120 seconds C) Fetal heart rate accelerations at the beginning of a contraction D) Fetal heart rate decelerations to 110 beats/min before the peak of a contraction

B) Contractions every three minutes lasting 120 seconds Rationale: Contractions occurring every three minutes for 120 seconds only leaves 60 seconds between contractions. These contractions are too frequent and prolonged for a client who is dilated only 4 cm. The client may become exhausted quickly, which will compromise the fetus. Contractions every 4 minutes that last 50 seconds, fetal heart rate acceleration at the beginning of a contraction, and fetal heart rate deceleration to 110 beats/min before the peak of a contraction are all expected findings and do not require further intervention.

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because of what characteristic of the scalp edema in caput succedaneum? A) Becomes ecchymotic B) Crosses the suture line C) Increases after several hours D) Is tender in the surrounding area

B) Crosses the suture line Rationale: Scalp edema that crosses the suture line is the clinical finding that differentiates between these two conditions. With caput succedaneum the swelling crosses the suture line, whereas in cephalhematoma it does not. Bruising may occur in either condition. The swelling diminishes; if the swelling increases, the newborn will need to be observed for signs of increased intracranial pressure. Pain is not associated with either condition

Postoperatively a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect the client is experiencing? A) Hypokalemia B) Hypocalcemia C) Thyrotoxin Crisis D) Hypovolemic Shock

B) Hypocalcemia Rationale: The signs and symptoms presented in the question indicate hypocalcemia. Injury to the parathyroid glands during a thyroidectomy results in a deficiency of parathormone, which decreases calcium levels in the blood. Hypokalemia is characterized by generalized weakness, a decrease in reflexes, shallow respirations, and cardiac dysrhythmias. Thyrotoxic crisis is characterized by tachycardia, hyperpyrexia, and an exacerbation of hyperthyroid symptoms. Hypovolemic shock is characterized by a weak, thready pulse and hypotension.

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? A) 20 to 40 breaths/min B) 30 to 60 breaths/min C) 60 to 80 breaths/min D) 70 to 90 breaths/min

B: 30 to 60 breaths/min Rationale: after respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a) stridor b) crackles c) wheezes d) friction rubs

B: Crackles Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal construction of obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

Which is a developmental milestone related to feeding that the nurse anticipates for a 15-month-old client A) Using a straw to drink B) Drinking well from a cup C) Chewing food with mouth closed D) Spilling small amounts of food when using a spoon

B: Drinking well from a cup

A nurse is caring for a 7-year-old child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma. The healthcare provider prescribes intravenous mannitol. The nurse monitors the child's intracranial pressure and urine output because mannitol belongs to which classification of diuretics? A) Loop B) Osmotic C)Potassium sparing D) Carbonic anhydrase inhibitor

B: Osmotic Rationale: Osmotic diuretics, such as mannitol, increase the osmotic pressure of glomerular filtrate and thus decrease absorption of sodium; they are used to treat cerebral edema and increased intraocular pressure. Loop diuretics, such as furosemide, inhibit resorption of sodium and potassium in the loop of Henle; they are used for heart failure and pulmonary edema. Potassium-sparing diuretics, such as spironolactone, interfere with sodium resorption in the distal tubules, thus decreasing potassium excretion; they are used to treat cirrhotic ascites and pulmonary edema. Carbonic anhydrase inhibitors, such as acetazolamide, increase sodium excretion by decreasing sodium-hydrogen ion exchange. They are used to treat seizure disorders and open-angle glaucoma.

A newborn who was delivered with the assistance of forceps sustains an injury that results in facial paralysis. What would the nurse state to the mother? A) The baby will have this condition for life. B) The newborn may need intensive physiotherapy. C) The condition usually subsides on its own in a few days. D)The newborn should not be allowed to cry because it can cause pain.

C) The condition usually subsides on its own in a few days. Rationale: A difficult delivery performed with forceps may result in facial paralysis, which may manifest as asymmetrical movements of the face, an inability to close the eyelid, and drooping of the corner of the mouth. This condition is self-limiting and may subside in few days. Physiotherapy is not indicated for the treatment of this condition. The parents should be informed that this condition is not painful.