HESI Review

The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions?

• "I will avoid lying down after a meal."

A client comes to the clinic for evaluation. The client tells the nurse, "I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor." The client hands the nurse a printout of what the client found. Which response by the nurse would be mostappropriate?

• "Tell me more about where you found this information that you gave me."

The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence

"How safe do you feel in your home?" Explanation: The act of screening for intimate partner violence is a key intervention to help open doors for at risk women to discuss ways to improve their safety and well-being. Asking clients how safe they feel in their home open is an open-ended, nonjudgmental way to elicit perceptions of safety. Asking if a partner is excited about a pregnancy is not a good screening question because many couples are not excited to learn of an unplanned pregnancy. However couples with healthy relationships eventually adjust. Having an arrest record and gun ownership do not automatically equate to having a history of violence.

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should

take measures to ensure privacy during the counselor's visit.

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic.

A 2-year-old is being seen in the outpatient department for a minor injury. The nurse places the child on the examining table, and the child begins to scream and cry. No attempts comfort the toddler are effective. Which is the nurse's best action?

Allow the parents to hold the child in their lap for assessment.

A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's

Apical pulse

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibiotic therapy with ampicillin. Before administering this drug, the nurse must take which action?

Ask the client if she has any drug allergies.

What is the priority nursing intervention in the postictal phase of a seizure

Assess the client's breathing pattern.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply.

Assess the client's skin integrity. • Maintain alignment. • Assess client's neurological function. Question 74 proper bod

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

The nurse is caring for a client with type 2 diabetes who has been admitted with hyperglycemia. What is the most important consideration when developing a teaching plan for this client?

Assess what the client already knows, then identify learning needs.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

to clear secretions from the tubing

The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client?

Enlist the help of a hospital interpreter; ask the son to translate if none is readily available.

When developing the preoperative teaching plan for a 14month-old child with an undescended testis who is scheduled to have surgery, which method is most appropriate?

Explain to the parents how the defect will be corrected.

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What should the nurse do?

Explore his or her own feelings about the issues of anencephaly and organ donation

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first

Institute droplet precautions.

The nurse is teaching an adolescent how to self-administer insulin. Which of the following is a priority for the nurse to emphasize about insulin administration?

Insulin injections are administered in subcutaneous tissue.

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?

Monitor fetal heart tones.

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?

Report the incident to risk management.

The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used

Review medical record and medical orders for graduated compression stockings. • Identify the client and explain procedure. • Place the client in supine position. • Apply powder or lotion to legs. • Turn the stocking inside out and ease the stocking over the foot and heel. • Smoothly pull the stocking over the ankle and calf.

A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child's vaccinations?

Review nationally published immunization guidelines.

A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases?

Serum bicarbonate of 28 mEq/L

A client with rheumatoid arthritis tells the nurse, "I know it's important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which response by the nurse would

Take a warm tub bath or shower before exercising. This may help with your discomfort

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need something else." What should the nurse should tell the client to do?

Take the medication at mealtime.

The parent asks the nurse about a 9-year-old child's apparent need for between-meal snacks, especially after school. What information should the nurse include in the teaching plan

The child should help with preparing the snacks

A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer?

Transfer board

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

What does the pain feel like?

An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for taking the metformin before the procedure?

Withhold the metformin.

Which client should the nurse assess first?

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency

Which mediation can the nurse administer through a nasogastric (NG) tube?

acetaminophen

Question 88 A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate:

aggression.

The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output?

altered level of consciousness and thready pulse

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement?

assault

In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position?

below the umbilicus on the left side.

A client has been prescribed corticosteroids. The nurse would also anticipate an order for

blood glucose checks every 6 hours. Explanation: Corticosteroids cause elevated blood glucose levels; insulin may be necessary to maintain normal blood glucose levels. Corticosteroids can cause edema, but fluid restrictions are generally unnecessary unless the client also has renal or cardiac disease.

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers?

coercion as a result of the trusting relationship

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

elevated ST segment

When caring for a client receiving haloperidol, the nurse should assess for which problem?

extrapyramidal symptoms

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?

extravasation

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response

• "Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." What should the nurse do?

• Allow the client to see and hold the baby for as long as she desires.

Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

• Evaluate the client for voluntary admission to a mental health facility.

A client tells the nurse that she doesn't have funds to buy diapers and formula. The nurse should refer this client to a

• social worker.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"

"Test your blood glucose every 4 hours." Explanation: The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles."

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad

- Clients level of consciousness - A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad.

A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept?

-"False labor contractions are usually felt in the abdomen."

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting

15 g of a simple carbohydrate.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby?

Express a small amount of breast milk.

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?

Gradually eliminate one feeding at a time."

Which nifedipine-related side effect should the nurse be most concerned with when caring for a new stroke admissions

Hypotension

A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She's been in bed for a week and is not eating or showering. She told me that she didn't want to kill herself, but it's not like her to do nothing for herself. She won't even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason

The behaviors may reflect passive suicidal thoughts

A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or their part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over their body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client

The client's body image is real to the client.

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client:

The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." Question 61 An agitated, confused client

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."

A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This action is an example of:

false imprisonment.

Which of the following observations by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?

formula in the client's mouth during the feeding, and increased cough

The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client:

has a known history of sexually transmitted disease.

While taking an admission history, a client tells a nurse that they were a former IV drug abuser. Which test would be most important for this client to undergo?

hepatitis C virus test

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS

identifying who will be responsible for making client care decisions

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

lung auscultation and measurement of vital capacity and tidal volume

A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time?

pregnancy loss

A 2 1/2-year-old child and his 2-month-old sibling are brought to the clinic by their father, who explains that the older child says "no" whenever asked to do something. The nurse should explain that the negativism demonstrated by toddlers is frequently an expression of which characteristic?

pursuit of autonomy

Which of the following clients should the nurse assess first?

the client who is a child with stridor and nasal flaring

A nurse is preparing to administer an I.V. containing dextrose 10% in 1⁄4 normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

• I.V. tubing with a volume-control chamber

A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene

• Initiate a unit policy involving staff nurses, certified nurse- midwives, and physicians in teaching clients before labor induction.

A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse?

• Instruct the client to go to an emergency room for an urgent assessment.

What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked?

• Lead the client to his room and help him dress if he needs assistance.

The team leader has noticed a sharp increase in medication errors associated with IV antibiotic administration over the last 2 months. The group that could offer resources for tracking medication errors and improving care outcomes is the:

• Quality Improvement and Risk Management Department

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

• granulocytopenia

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

• The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.

A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply

• Use the hospital code for HIV when documenting care. • Ask all family members, except the client's significant other, to wait outside when she's educating the client.

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification means

• carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

A client has been taking fluoxetine, 40 mg daily at 0900 for 1 week. The client states he feels nervous and has had diarrhea. What interpretation does the nurse make about the client's symptoms?

• important, probably suggesting a decrease in dosage or change to another medication

A client with diabetes is taking insulin lispro injections. At what time should the nurse advise the client to eat?

• within 10 to 15 minutes after the injection.