SEM 2 HESI QUIZ
A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?
A nonrebreathing mask is used when the client requires higher oxygen concentrations and the condition is worsening. If the nonrebreathing mask does not improve oxygen saturation, the next steps to improving gas exchange and oxygenation are intubation and mechanical ventilation.
Which sedative-hypnotics are used to treat insomnia effects associated with a panic disorder? Select all that apply.
Alprazolam and clonazepam are examples of benzodiazepines, a class of sedative-hypnotics used to treat clients with insomnia effects associated with panic disorders. Phenelzine is a monoamine oxidase inhibitor used to treat panic disorders and promote sleep.
The nurse is preparing discharge instructions for a client who was prescribed enalapril for treatment of hypertension. Which instruction is appropriate for the nurse to include in the client's teaching?
Do not change positions suddenly.
A client had a bypass graft because of an abdominal aortic aneurysm. Postoperative prescriptions include measurements of the client's abdominal girth. Which serious problem may be indicated by an increasing abdominal girth?
During the first 24 hours after surgery, a sudden increase in abdominal girth most likely is graft related and needs to be investigated.
An adolescent visits the allergy clinic because of seasonal environmental allergies, and blood is drawn for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress?
Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions.
A severely depressed male client responds to therapy and with the help of the staff begins to set some daily objectives. Which behavior most indicates improvement in this client?
Initiation of interactions demonstrates that the depressed person is attempting to change behavior patterns.
What type of trauma center would the nurse consider to be most appropriate for a client who survived an accidental fire and has multiple injuries?
Level II trauma centers provide care to the most injured clients. Level III trauma centers stabilize clients with multiple injuries. Level I trauma centers provide a full continuum of trauma services for all clients. Level IV provides advanced life support and basic trauma client stabilization.
What is the effect of parathyroid hormone on bones? Select all that apply.
Parathyroid hormone increases bone breakdown, which increases serum calcium levels. Parathyroid hormone increases net release of calcium and phosphorus from bone into the extracellular fluid.
Which physical change noted by the nurse during a growth and developmental assessment for a 7-year-old client would necessitate further action?
Pubescent changes are not anticipated for a 7-year-old school-age client; this finding would lead the nurse to assess in more depth.
A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed?
Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration
Which safeguards should the school nurse teach parents to assess for prior to allowing school-age clients to participate in athletic programs? Select all that apply.
Safeguards prior to participation in athletic programs include a physical examination every two years, the use of appropriate equipment, and participating in warm-up exercise prior to physical activity. A life-long enjoyment of fitness and the development of basic motor skills are goals related to the participation in athletic programs, not safeguards.
A client at 30 weeks' gestation is admitted to the hospital with a diagnosis of low-lying placenta previa with slight vaginal bleeding. The client is stabilized, and bleeding ceases. What is the nurse's primary focus when providing discharge teaching about care at home for this client?
Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.
Which nursing care should be provided to a client who has undergone unilateral adrenalectomy?
Temporary glucocorticoid replacement therapy is needed for a client who has undergone a unilateral adrenalectomy.
The nurse assesses a client for orthostatic hypotension. The results are:Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider?
The assessment findings do not indicate postural hypotension (decrease of more than 20 mm Hg of systolic pressure or more than 10 mm Hg of the diastolic pressure).
A school-aged child is to receive a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs?
The child is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications.
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?
The first stage of labor is from zero cervical dilation to full cervical dilation (10 cm). The second stage is from full cervical dilation to delivery. The prodromal stage is before cervical dilation begins. The transitional phase is the first stage of labor, from 8 cm of dilation to 10 cm of dilation.
On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. What would the nurse determine that these laboratory results may be related to?
The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood.
During a group discussion of the local news, a client asks how the nurse feels about the events in question. What is the best response by the nurse?
The nurse should answer briefly but then redirect the conversation to keep the focus on the client.
A client with an antisocial personality disorder is remanded to the inpatient psychiatric unit for approximately 1 week. The client refuses to discuss any problems with the nursing staff, and so the team decides to use a confrontational approach. One morning the nurse asks the client how things went the day before. The client says, "I didn't do much. I watched TV and read a little." What is the most appropriate confrontational response by the nurse?
The response "It doesn't sound to me like you've been doing much work on the problems that brought you into the hospital" confronts the client with the fact that the client has not been working on personal problems.
A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach?
The vaccination is scratched into the skin using a bifurcated needle.
After a client gives birth, which physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled?
When the placenta separates from the uterine wall, it tears blood vessels, resulting in a gush of blood from the vagina. The uterus should become firm when the placenta begins to separate.
