HESI V4 FrmRN2u

A 59 yr old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition? He is in a coma, and ...

A 59 yr old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition? He is in a coma, and has a very poor prognosis At a community health fair, a 50 yr old woman tells the nurse she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? Ask the woman if she also performs monthly breast self-exams Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication? Complaints of shortness of breath on exertion A college student who is Dx with a vaginal infection and vulva irritation describes the vaginal discharge as having a “cottage-cheese” appearance. Which prescription should the nurse implement first? Instill the first dose of nystatin (Mycostatin) vaginally per applicator A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding the nurse should anticipate implementing which action? Administer a retention enema of Kayexalate The nurse manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? A 35 year-old with Lupus erythematosus A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? Inspire deeply and slowly over 3 to 5 seconds The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? “the medication will help you think more clearly” A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, he tells her that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. Action? Instruct the client to eat his breakfast and take the Zithromax two hours after eating What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? Treat sexual partner(s) concurrently A primagravida at term comes to the prenatal clinical and tells the nurse that she is having contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 seconds with mild intensity by palpation. Action? Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour HESI V4 FrmRN2u Which instruction should the nurse provide to an elderly client taking an ACE inhibitor and a calcium channel blocker? Change positions slowly Assessment findings of a 3-hr old newborn include: axillary temperature of 97.7, HR of 140 with a soft murmur, and irregular RR 42. Based on these findings; action? Record the findings on the flow sheet A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement? Search all personal belongings An experienced nurse tells the nurse manager that working with a new graduate is impossible because the new grad will not listen to suggestions. The new grad comes to the nurse manager describing the senior nurses’ attitude as challenging and offensive. Action best for NM to take? Ask the nurses to meet with the nurse manager to identify ways of working together Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock? Ineffective tissue perfusion The nurse offers diet teaching to a female college student who was Dx with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? Combine several legumes and grains such as beans and rice to form complete proteins The nurse is triaging clients from a train wreck. A client has multiple open wounds, a BP of 90/50, and Pulse of 112. Which triage tag color should the nurse place on this client? Red Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)? Monitor serum creatinine levels A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data? Breath sounds A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with the client, which information is most important? The nurses’ feelings about this client Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia? A middle-aged male client in renal failure following an unsuccessful kidney transplant While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. Action? Measure the length of the apneic periods HESI V4 FrmRN2u The nurse is preparing to administer the 0700 dose of