NURSING 420 HESI EXAM -2018

1. A patient who is 32 weeks gestation is experiencing dark, red vaginal bleeding and the nurse determines the FHR to be 100 bpm and her abdomen is rigid and boardlike. What action should the nurse take first? A. Admini ...

1. A patient who is 32 weeks gestation is experiencing dark, red vaginal bleeding and the nurse determines the FHR to be 100 bpm and her abdomen is rigid and boardlike. What action should the nurse take first? A. Administer O2 per face mask B. Abdominal manipulation C. vaginal manipulation D. Abdominal exam Answer: A Explanation: The nurse should immediately notify the healthcare provider and no abdominal or vaginal manipulation or exams should be done. Administer O2 per face mask and monitor for bleeding at IV sites and gums due to the increased risk of DIC. 2. A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain. What is the difference between abruptio placentae and placenta previa? A. abruptio placentae: painless bright red bleeding occurring in the third trimester B. abruptio placentae: occurs in the 2nd trimester C. placenta previa: occurs in the 2nd trimester D. placenta previa: painless bright red bleeding occurring in the third trimester Answer: D Explanation: The nurse must use knowledge base to differentiate between abruptio placentae (dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain) from placenta previa (painless bright red bleeding occurring in the third trimester). 3. A nurse must use knowledge base to differentiate between abruptio placentae (dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain) from placenta previa (painless bright red bleeding occurring in the third trimester). What assessments should be done in case of a patient suspected of abruptio placentae or placenta previa? A. abdominal or vaginal manipulation B. Leopold’s maneuvers C. internal monitoring D. Monitor for bleeding at IV sites and gums due to the increased risk of DIC Answer: D Explanation: Patients with abruptio placentae or placenta previa (actual or suspected) should have NO abdominal or vaginal manipulation. NO Leopold’s maneuvers. NO vaginal exams. NO rectal exams, enemas, or suppositories. NO internal monitoring. 4. A patient suspected of abruptio placentae or placenta previa should be monitorized for bleeding at IV sites and gums due to the increased risk of DIC. What isn’t DIC related to? A. cervical carcinoma B. fetal demise C. infection/sepsis D. pregnancy-induced hypertension Answer: A Explanation: DIC is related to fetal demise, infection/sepsis, pregnancy-induced hypertension (Preeclampsia) and abruptio palcentae. Cervical carcinoma is related to Podophyllin. 5. A patient which has been diagnosed with CVA has symptoms of aphasia, right hemiparesis, but no memory or hearing deficit. In what hemisphere has the patient most probably suffered a lesion? A. Left B. Superior left side C. Inferior right side D. Right Answer: D Explanation: A patient with a diagnosis of CVA presents with symptoms of aphasia, right hemiparesis, but no memory or hearing deficit has suffered a lesion in the left hemisphere. 6. A patient brought to the emergency room has the following symptoms: hypertension, , bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia. What will the patient be diagnosed with in this case? A. spinal shock B. increased ICP C. cerebral vascular accident D. autonomic dysreflexia Answer: D Explanation: The symptoms of autonomic dysreflexia are hypertension, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia. 1. If a child is on oral iron medication, the family should be thought by the nurse how it should be administered. Out of the following options, what oral iron administration advice is inappropriate? CONTINUED.....