HESI Remediation Study Questions "Nursing Interventions"

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client?

"Take a deep breath when I tell you, and hold it while I remove the tube."

transsphenoidal hypophysectomy

A transsphenoidal hypophysectomy is a surgical procedure that removes tumors from the pituitary gland through the nose and sphenoid sinus

A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in a client with diabetes mellitus who has gastroenteritis. Which is the appropriate nursing intervention?

Encourage the client to take 8 to 12 oz of fluid every hour while awake Small amounts of fluid may be tolerated, even when vomiting is present. The nurse would encourage liquids containing glucose and electrolytes every hour. The remaining options will not provide the adequate intake needed by the client with diabetes mellitus.

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which source of complete proteins to maximize the availability of essential amino acids?

Meats Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

Peritonitis

is the term for inflammation of the peritoneum. The tissues can become inflamed if they're exposed to irritating or infected body fluids. This usually happens when something inside leaks or breaks. Infection is the most common cause of peritonitis, and it can be very dangerous.

A client calls the nurse at the clinic and reports experiencing a sensation as though the affected leg is falling asleep ever since the vein ligation and stripping procedure was performed. The nurse would make which response to the client?

"Your primary health care provider needs to be contacted to report this problem."

The nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which interventions would the nurse take when performing the irrigation? Select all that apply.

1. Position the client with the affected side down after the irrigation. 2. Warm the irrigating solution to a temperature that is close to body temperature. 3. Direct a slow, steady stream of irrigation solution toward the upper wall of the ear canal. During the irrigation, the client sits upright with a towel on the shoulder to capture water that drains from the ear. The ear to be irrigated is tilted to the side because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution would be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client would lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse would question which primary health care provider (PHCP) prescription documented in the client's medical record?

Administer 30 mL of milk of magnesia (MOM). Appendicitis would be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the primary health care provider's prescriptions for the client. Which prescription would the nurse question?

Ambulation four times daily Medical interventions during the acute phase of Ménière's disease include using diazepam as prescribed to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator (nicotinic acid) also will be prescribed. The client will remain on bed rest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

After hypophysectomy, a client complains of being thirsty and having to urinate frequently. What is the initial nursing action?

Assess urine specific gravity. A urine specific gravity test is checked after a hypophysectomy (pituitary gland surgery) because the pituitary gland produces antidiuretic hormone (ADH), which regulates urine concentration; therefore, a change in ADH levels following surgery can indicate a potential complication called "central diabetes insipidus," where the body produces too little ADH, leading to the excretion of large volumes of dilute urine, which can be detected by a low urine specific gravity

A client received 5 units of insulin aspart subcutaneously just before eating lunch at 12:00 p.m. The nurse would assess the client for a hypoglycemic reaction at which times?

Between 1:00 and 3:00 p.m. Insulin aspart is a rapid-acting insulin. Its onset of action is 15 minutes; it peaks in 1 to 3 hours, and its duration of action is 3 to 5 hours. Hypoglycemic reactions are most likely to occur during peak time.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Change the dressing Serosanguinous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and would be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The PHCP does not need to be notified.

A client who has undergone gastric surgery to remove a tumor has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action would the nurse take initially?

Check the suction device to make sure it is working. After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse would never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse needs to call the surgeon, who would do this repositioning under fluoroscopy.

The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate?

Contact the surgeon After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the surgeon needs to be notified immediately.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

Deflate the cuff on the tube. Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. Which items would be the most appropriate choice for this client to meet nutritional needs?

Graham crackers and warm milk The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals, and calories. Foods or beverages that contain caffeine, such as cocoa, coffee, tea, or colas, are prohibited because they can precipitate a hypertensive crisis.

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse would next assess the client for which finding?

Increased calf circumference The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.

The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question?

Indomethacin Indomethacin is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Digoxin is a cardiac medication. Furosemide is a loop diuretic. Propranolol hydrochloride is a beta-adrenergic blocking agent. Digoxin, furosemide, and propranolol are not contraindicated in clients with gastric disorders.

The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgment of the pacing catheter?

Limiting both movement and abduction of the right arm In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Therefore, the remaining options are incorrect.

A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention would the nurse implement initially?

Mineral Oil Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. Antibiotic eardrops and corticosteroid ointment are not initial nursing actions.

A nurse is reviewing the primary health care provider's prescriptions for a client diagnosed with hypothyroidism. Which medication prescription would the nurse question and verify?

Morphine sulfate Medications are administered very cautiously to the client with hypothyroidism because of altered metabolism and excretion and depressed metabolic rate and respiratory status. Morphine sulfate would further depress bodily functions. Hormone replacement with levothyroxine sodium, a thyroid hormone, is a component of therapy. Stool softeners, such as docusate sodium, are prescribed to prevent constipation. Acetaminophen can be taken.

The nurse is caring for a client who is 2 days postoperative from abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin based on capillary blood glucose testing 4 times a day. A carbohydrate-controlled diet has been prescribed, but the client has not been eating. On entering the client's room, the nurse finds the client to be pale and diaphoretic. Which action is appropriate at this time?

Obtain a capillary blood glucose level and quickly perform a focused assessment. Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and quickly perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the AP to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis?

Oxygen Saturation Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action would the nurse take?

Speak at normal tone and pitch, slowly and clearly. Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse would speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

A client who has been exercising in a gymnasium stops to measure the pulse and places the fingers over both carotid arteries simultaneously. The nurse exercising nearby is correct when cautioning the client to check the pulse on only one side, primarily for which reason?

The heart rate and blood pressure could drop. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. Although the information in the remaining options may be correct, these are not the primary reasons.

The nurse is reviewing the procedure for performance of an electrocardiogram (ECG). Which action by the nurse indicates understanding of the correct position for the V1 lead when performing a 12-lead electrocardiogram?

The lead is placed on the fourth intercostal space right sternal border.

A 56-year-old adult client with heart failure is receiving digoxin. The nurse is auscultating the apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action would the nurse take?

Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. digoxin increases contractility but slows heart rate

pheochromocytoma

a rare tumor that grows in the adrenal glands, causing the body to produce too much epinephrine and norepinephrine aka high blood pressure

Serosanguineous drainage

a thin, watery fluid that's a combination of blood and serum, or the liquid part of blood. It's a normal part of the healing process for wounds and incisions, and usually appears as a light pink to red fluid.