Practice HESI 1
Which data would the nurse use to determine a client's score on the braden scale to predict a client's risk for developing pressure injuries? select all
-anorexia -hemiplegia (paralysis of one side of the body) -history of diabetes -urinary incontinence age is not used in the Braden scale
Which intellectual factor would the nurse consider as a dimension when gathering data for a client's health history?
-attention span it wouldn't be primary language bc this is a social dimension
On the first day of the month, a primary health care provider prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25mg once a day to be titrated in increments of 25mg every other day
Day 13
The medication prescribed for an infant is to be given IM. Which site will the nurse select for administration?
Vastus Lateralis
A client in the ICU tells the nurse, "no matter how much you try, I will not be able to recover. No one can change my destiny." Which religion might the nurse expect the client to practice?
Islam
When preparing to assess a client with active tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room?
N95 respiratory mask -the patient would be on airborne precautions
A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take?
instruct the client to splint the wound with a pillow when coughing
When preparing to give medications to a client, the nurse notes a prescription for digoxin 2.5mg by mouth daily. The digoxin is supplied as 0.125 mg tablets. Which action would the nurse take?
consult with the primary health care provider -a dose of 2.5 mg is excessive and the prescription should be questioned
A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing?
disenfranchised (loss that is not a socially recognized relationship; ie. abortion or pet)
Which would the nurse incorporate into the plan of care for the older adult experiencing chronic pain?
exercise -exercise and client teaching are important nonpharmacalogical activities for older adults with chronic pain
Which is the FIRST activity of daily living that the nurse would assist in teaching a developmentally disabled 8 year old child?
self-feeding -the steps for acquiring the skills needed to fulfill ADLs should progress in the same order as they do for a child who is not mentally challenged
An older client who has been on bed rest for a few hours reports feeling light-headed immediately after sitting up on the side of the bed. Which action is BEST for the nurse to take?
-help the client. sit on the edge of the bed for a few minutes
After the nurse teaches a client with coronary artery disease about healthy food choices, which dietary choices by the client indicate that the teaching was effective? select all
-olive oil (unsaturated fat) -whole grain bread -vegetables and fruits
Which information will the employee health nurse include when teaching about ways to prevent transmission of influenza in the workplace? select all
-sneeze or cough into the upper sleeve -use alcohol based hand sanitizers after blowing the nose -turn the head away from others when coughing or sneezing
As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse as a leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply.
-surgical procedure -name of surgeon -explanation of possible risks
The RN is teaching the student nurse about various sites for assessing body temperature. Which statement made by the student nurse is/are correct?
-the axilla is recommended to measure body temp in unconscious clients -the tympanic membrane is a preferred site of measuring body temperature in infants -the temporal artery is a preferred site of thermometer placement to measure rapid changes in core temp
Which statement made by an older adult MOST strongly supports the nurse's conclusion that the client has an impacted stool?
"I haven't had a bowel movement for several days."
Which statements by the nursing student indicate the need for further teaching about managing a pandemic disaster? select all
-"a 'worried well' population will help enhance the available health care resources." -"conducting public information campaigns is a relatively inefficient method of managing a pandemic"
The nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? select all
-"i should drink at least 6 glasses of water daily" -"i can include bran muffins in my breakfast daily" -"i will walk ever day as part of my exercise regimen"
The nurse is assessing a client with arthritis. Which statement made by the client indicates a precipitating factor?
"i run for 30 minutes every day; this exercise increases my pain." precipitating factor in an activity or factor that worsens symptoms
The student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the RN?
"palliative care is the same as hospice care."
Which statement would the nurse use to instruct the female client about obtaining a urine specimen?
"with the enclosed towelettes wipe your labia from front to back before collecting the specimen"
Which findings from the client's history would be symptoms of insomnia disorder? select all
-fatigue -early morning awakenings -reduced concentration -irritability
A primary health care provider prescribes three stool specimens for occult blood for a client who reports blood-streaked stools and a 10lb weight loss in 1 month. To ensure valid test results, which instruction would the nurse give to the client?
avoid eating red meat before testing -red meat can react w reagents used in the test and can cause false-positive results
Which action would the nurse do when collecting a 24-hour urine specimen?
check to verify whether a preservative is needed
Which category of isolation would the nurse implement for a client who is positive for C. diff?
contact precautions
Which information would the nurse document in the medical record regarding a client's reported allergies? select all
medication names, type of allergic reactions, epinephrine use for allergic reaction -it is not necessary to report the date of reactions or family history of allergies
The nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. Which action would the nurse take when caring for this client?
monitor O2 saturation levels when the client is eating
Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)?
move the patient to a private room
Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%?
non-rebreather mask -non rebreather delivers up to 90% at 10-15L/min; face tent is 30-50% at 4 to 8 L/min; Venturi is 24-50% at 4-10 L/min; nasal cannula is 24-45% at 2-6 L/min
Which criteria would the nurse consider when determining if an infection is a health care-associated infection?
occurred in conjunction with treatment for an illness
At which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter?
port on the tubing
Which approach would the nurse use for an older adult client with Alzheimer disease who frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause?
provide nursing care when the client is receptive; encouraging the client to talk about feelings may be of limited help
The nurse assists a client who had bariatric surgery to become more mobile. Which complication is the nurse attempting to prevent?
pulmonary embolism -immobility contributes to venous stasis, which can cause DVT and pulmonary embolism
While supervising the LPN, the RN observes that the LPN is about to dispense an incorrect dose of medication. Which action by the RN would be the priority?
question the dosage so that the LPN will identify the error.
Which action would the occupational health nurse take after a tuberculin skin test (TST) on a nurse working in the emergency department revealed an 11mm induration?
schedule the nurse for a chest x-ray. (induration of 10mm or greater is a positive test result in employees of high-risk settings)
