RN EXIT HESI 3
In preparing for a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?
Enable clients to become active participating in controlling the disease process
A women just learned that she was infected with H. Pylori. Based on this finding which health promotion practice should the nurse suggest?
Encourage screening for peptic ulcer
A male clients lab results include a platelet count of 105,000. Based on this finding the nurse should include which action in the clients POC?
Encourage use of electric razor
The nurse notes a depressed client has been more withdrawn and non-communicative during the past 2 weeks. Which intervention is most important to include in the updated POC.
Engage the client in a non-threatening conversation
After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the HCP immediately and received several prescriptions. What action should the nurse take first?
Epinephrine
A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a program designed to address this problem?
Establish trust with community leaders and respect cultural family values
Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first
Evaluate both clients pain using pain scale
The nurse is assessing an older adult with Type 2 DM. Which assessment finding indicates that the client understands long term control of DM?
The hemoglobin A1C was 6.5
What client should the nurse assess frequently because of the risk of overflow incontinence?
A confused client who frequently forgets to go to the bathroom
The nurse working in the psychiatric clinic has phone messages from several clients. Which should the nurse return first?
A family member of a client with dementia who has been missing for 5 hours
A neonate with a congenital heart defect is demonstrating s/sx of HF. Which interventions should the nurse include in the infants POC? (SATA)
-Give O2 at 6Lpm -evaluate heart rate for effectiveness of cardio tonic medications -use high energy formula 30 calories/oz at 3 hours feeding via soft nipples -ensure interrupted and frequent rest periods between procedures
While monitoring a client during a seizure, which interventions should the nurse implement? Select all that apply
-Move obstacles away from the client -Monitor physical movements -Observe for patent airway -Record the duration of the seizure
Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.
-Prepare medication reversal agent -Check oxygen saturation -apply oxygen via nasal cannula
During change of shift, the nurse reports that a male client who had abdominal surgery yesterday is increasingly confused and disoriented. He wandered into the other client rooms saying that there are men in his room trying to hurt him. Because of continuing disorientation and the clients multiple attempts to get out of bed, soft restraints were applied at 0400. In what order should the nurse implement these interventions?
1. Assess clients skin and circulation 2. Evaluate the clients mentation and determine need for restraints 3. Assign UAP to remove restraints and remain in client room 4. Contact clients surgeon and HCP
The nurse is caring for a 4 year old child who becomes unresponsive as their heart rate decreases to 40 bpm. BP 88/70, Spo2 70% on 100% oxygen via non-rebreather. In what sequence, from first to last, should the nurse implement these actions?
1. Start chest compressions with assisted manual ventilation 2. Administer epinephrine 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia
The pt experiences a gas tank fire when riding his motorcycle, he is admitted to ER with full-thickness burns to all surfaces of the lower extremities. What percentage of body surface area should the nurse document in the EMR?
36%
When developing a teaching plan for a client newly diagnosed type 1 DM, the nurse should explain that an increased thirst is an early sign of DKA, which action should the nurse instruct the client to implement if this sign of DKA occurs?
Give a dose of regular insulin per sliding scale
While undergoing hemodialysis a client c/o dizziness. They are alert and oriented but skin is cool and clammy. HR 128 RR18 BP 90/60. Which intervention should the nurse implement first?
Elevate the clients legs and feet
A client receives a new prescription for simvastatin 5 mg daily at bedtime. What action should the nurse take?
Administer the medication as prescribed with a glass of water
A client diagnosed with calcium kidney stones has a hx of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the HCP attention?
Allopurinol
Based on principles of asepsis, the nurse should consider which circumstance to be sterile? a. One inch- border around the edge of the sterile field set up in the operating room b. A wrapped unopened, sterile 4x4 gauze placed on a damp table top. c. An open sterile Foley catheter kit set up on a table at the nurse waist level d. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
An open sterile foley catheter kit set up on a table at the nurses waist level
The nurse assesses a client with new onset diarrhea. It is important for the nurse to question the client about recent use of which medication?
Antibiotics
An older adult is admitted with dx of possible CVA. He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?
Ask the wife to stop and assess the pt ability to swallow.
Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the clients arm?
Assess IV site frequently for signs of extravastation
A client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in discharge teaching?
Avoid all isometric exercises, but walk regularly
A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? A. Administer antiemetic agents. D. Bivalve the cast for distal compromise. C. Provide high- calorie, high-protein diet. D. Begin parenteral antibiotic therapy.
Begin parenteral ATB therapy
The mother of a child with cerebral palsy asks the nurse if her Childs impaired movements will worsen as the child grows. Which response provides the best explanation?
Brain damage with CP is not progressive but does have a variable course
A child with heart failure is receiving Lassie and has serum potassium level of 3.0. Which assessment is most important for the nurse to obtain?
Cardiac rhythm and heart rate
A client 24 hr post op from exploratory laparotomy is c/o being starving since not eating "real food" since the procedure. Prior to advancing their diet, which intervention should the nurse implement?
Check bowel sounds
The charge nurse in a CCU is reviewing client conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer?
Chronic liver failure with hemoglobin of 10.1 and slight bilirubin elevation
An older pt with type 2 DM reports leg pain when walking short distances, which is relieved by rest. Which client behavior indicates an understanding of the teaching to promote circulation?
Completely stop cigarette use
A mother brings her 3 yo to the ER and tells the nurse that he has had an upper respiratory infection for the past 2 days. Assessment of the client shows a rectal temperature of 102 and he is drooling and becoming increasingly restless. What action should the nurse take first?
Contact HCP and obtain tracheostomy tray
A client with hyperthyroidism is receiving propranolol. Which finding indicates that the medication is having the desired effect?
Decrease in pulse
An elderly man is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother who died 50 years ago. The nurse reviews the multiple prescriptions he is taking and assessed his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that this client is experiencing what condition?
Delirium
Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity?
Distal pulse intensity
The health care provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type 2 DM. Which information provides the best indicator of the drug's effectiveness?
Hemoglobin A1C reading less than 7%
What is the priority nursing action when initiating morphine therapy via an intravenous patient controlled analgesia pump?
Initiate the dosage lockout mechanism on the PCA pump
When providing diet teaching for a client with cholecystitis, which types of food choices should the nurse recommend to the client?
Low fat
A 60 yo asks the nurse about hormone replacement therapy as a means to prevent osteoporosis. Which factor in the clients history is a possibly contraindication for the use of HRT?
Mother and sister have hx of breast cancer
A client with a hx of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?
Muffled heart sound
A client with hx of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking and stopped smoking one month ago after his brother died. Which intervention is most important for the nurses to include in the clients POC?
Observe for changes in LOC
In early septic shock, what is the primary cause of hypotension?
Peripheral vasodilation
A client with a CVA should request a speech therapy referral if the client exhibits which finding?
Persistent coughing while drinking
A pt with rheumatoid arthritis starts a new prescription for etanercept subcutaneously once weekly. The nurse should emphasize reporting what problem to the HCP?
Persistent fever
When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? a. Prepare to administer atropine 0.4 mg IVP b. Gather emergency tracheostomy equipment c. Prepare to administer lidocaine at 100 mg IVP d. Place cardiac monitor leads on the client's chest.
Place cardiac monitor leads on the clients chest
The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?
Protect joint function
The nurse is planning a preoperative teaching plan for a 12-year-old who is scheduled for surgery. To help reduce the child's anxiety, which action is the best for the nurse to implement?
Provide a family tour of the preoperative unit one week before the surgery is scheduled
A 56 year old man shares with the nurse that he is having difficulty making decisions about terminating life support for his wife. What is the best initial action of the nurse?
Provide an opportunity for him to clarify his values related to the decision
The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?
Recommend weight bearing activity
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 line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?
Redress the abdominal incision
At 1615, the nurse reviews the clients medical record. Based on data contained in the record, which action should the nurse take before assisting get client with ambulation?
Remove sequential compression devices
A UAP reports that the client's right hand and fingers spasm when taking the blood pressure in that arm. After confirming the presence of spasms, what action should the nurse take first?
Review the clients serum calcium level
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?
Review the staff nurse job description to ensure that is is clear, accurate, and recurrent
A pt receives a thrombolytic medication following an MI. When the client has a bowel movement, what action should the nurse implement?
Send stool to the lab for a guiac test
When assessing a 6 mo infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?
Sitting upright
Which assessment finding for a client who is experiencing pontine myelinolysis should report to the HCP?
Sudden dysphagia
The nurse is assisting a new mother with infant feedings. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breast feeding?
Supplemental feedings with formula
The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?
Tell the staff to keep all clients and visitors in the client rooms with the doors closed
The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack. The clients Glasgow come scale score is 9. What information is most important for the nurse to determine?
The clients previous GCS score
A client is being discharged home after tx for HF. What instruction should the nurse include in the discharge teaching?
Weigh every morning
The nurse receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborns survival?
heat loss
An adult male client is admitted to the ER following a MVA and sustained a head injury. What assessment data would provide the earliest indication that the client is experiencing increased ICP?
lethargy
