Study HESI EAQ Final for Nursing 101

Regular cow's milk is avoided in infants during the first year of life because it is

too concentrated for an infant's kidneys to manage. It also increases the risk of milk product allergies and is also a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin. Most infants are not allergic to or intolerant of cow's milk.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

*Revising the will and planning a visit to a friend are realistic, productive, and constructive ways of using this time* Crying and talking openly about death are signs of depression. Going from healthcare provider to healthcare provider demonstrates disbelief, denial, or desperation. Refusing to follow treatments and stating that the client is going to die anyway indicates anger and hopelessness, not acceptance.

A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain?

"Can you describe your pain to me?" R: The nurse may ask the client to describe the pain or to point the area that hurts. It may help to assess the nature of the pain. Asking about effect on pain with movement may help to assess precipitating factors. The severity of a pain could be identified by asking the client to rate it on a scale from 0 to 10. The precipitating factors can be identified by asking the client about worsening of the pain with a particular activity.

The nurse is working with a female client who is from Southeast Asia that presents with general fatigue. The nurse asks the client if there is any reason for her fatigue. Which statements are most culturally consistent with a client from Southeast Asian culture? Select all that apply.

"I'm tired because I have less blood in my body." "I'm tired because my blood vessels are weak. "I'm tired because I haven't been eating right lately." R: Different cultures may have different explanations for sickness or fatigue. Many Southeast Asian women believe that fatigue occurs because of Ayurveda, or the balance of different energies in the body. This client may believe her fatigue is caused by low blood volume, weak blood vessels, or poor nutrition that has affected the body's balance. A European-American client is more likely to give a biomedical explanation for fatigue such as stress, family issues, or depression.

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume?

70 mL.

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is what? Select all that apply.

An elevated temperature of 101.3° F (38.5° C) is most indicative of a systemic infection. A WBC count of 8200/mm3 (8.2 X 109/L) is within the normal range of 5000 to 10,000/mm3 (5 to 10 X 109/L). Pedal edema is generally not related to an infectious process. Pale skin and nail beds may be related to an infectious process, but not necessarily.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation R: This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history?

Attention Span R: Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?

Expectoration of blood After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

Cheyne-Stokes respiration

In Cheyne-Stokes respiration, a client's breathing pattern is characterized by *progressively deeper and faster breathing*, that is, *hyperventilation* followed by *apnea*.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply.

Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiologic effect?

Local anesthesia R: Cold reduces the sensitivity of pain receptors in the skin. In addition, local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort. Local blood vessels constrict. Local cold applications do not depress vital signs. Local cold applications do not affect blood viscosity directly.

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care?

Participate in the bedside rounds The nurse should participate in bedside rounds with the healthcare team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse in the next shift. These bedside rounds provide patient-centered care as the nurse shares information about the client's condition, status of problems, and treatment plan for the next shift. The nurse can meet the client's family after obtaining firsthand information from the nurse completing the shift. The nurses review the client's medical reports and discuss treatment plans for the next shift after completing the bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report.

After changing a dressing that was used to cover a draining wound on a client with vancomycin-resistant enterococci (VRE), the nurse should take which step to ensure proper disposal of the soiled dressing?

Place the dressing in a red bag/hazardous materials bag.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Provide perineal care

the pressure exerted on the skin when a debilitated client is pulled up in bed without a draw sheet or when the client slides down in bed.

Shearing Force With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing tearing of the skin. *Using a draw sheet can reduce and minimize friction and shearing force*.

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be?

Stop the nurse from giving the injection *Alcohol deactivates the smallpox vaccine*. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.

used as an objective measurement of consciousness on a numerical scale. This scale assigns a numeric score for each area of neurologic status of the client. A higher score equates to a higher neurologic function.

The Glasgow Coma Scale (GCS) is

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by doing what?

The primary purpose of an oil-retention enema is to *lubricate the sigmoid colon and rectum*. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

What is an example of the critical thinking attitude of independent thinking in nursing practice?

To talk with other nurses to share ideas about nursing intervention R: Nurses talking to each other and sharing ideas about nursing interventions reflects independent thinking. Responsibility and authority require referring to a policy and procedure manual for reviewing steps of a skill. Humility involves recognizing the need for more information for making a decision. Curiosity is exploring and learning about clients to help make appropriate clinical judgment.

Which definition is involved in the caring process called knowing according to Swanson's theory of caring?

Trying to understand an event that has meaning in the life of another.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

Use draw sheets to pull up, transfer and position the client

Which are examples of high-reliability organizations? Select all that apply.

Which are examples of high-reliability organizations? R: Aviation, air traffic control, and nuclear power plants are examples of high-reliability organizations because they have to operate in hazardous conditions yet have very few adverse events. Cancer hospitals and state transportation agencies are not high-reliability organizations because they do not operate under hazardous conditions.

A client with dementia who feels highly anxious and confused believes that the current day is actually different than what it is. Which statement made by the nurse is an example of validation therapy?

Yes, today is the day that you just mentioned

The nurse finds that a client with bilateral oral swelling, pain, and trismus had undergone a surgical extraction of an impacted tooth five days ago. What type of nursing diagnosis does the documentation of acute pain refer to?

actual

Limiting head of bed elevation, repositioning, and range of motion are interventions that may prevent

pressure related injury verses shear injury.

to obtain the stroke volume

the cardiac output should be divided by pulse rate

A client complains to the nurse that a staff member did not respond to the client's call. The nurse politely reassures the client, and makes the client comfortable. The nurse speaks to the staff member about the incident and solves the problem. Which critical thinking attitude has the nurse demonstrated in this situation?

fairness - listening to both sides

Cardiac output is obtained by

multiplying the heart rate and the stroke volume.

Performance improvement focuses on analyzing and evaluating the current performance of healthcare workers in order to bring about a qualitative change. In the given situation, a new technique for performing sponge and instrument counts in the operating room is being analyzed in order to help understand the degree of qualitative change in the system. This is an example of a performance improvement. Quality improvement focuses on the continuous study and improvement of the processes of providing healthcare services to clients. Installing new call bells, conducting client teaching programs before discharge and speeding up the process of obtaining are examples of quality improvements.

true