HESI Extra Credit Module 10 Exam

Extra Credit HESI Module 10 1. Questions 1. 1.ID: 9476932222 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client ad ...

Extra Credit HESI Module 10 1. Questions 1. 1.ID: 9476932222 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9476924021 Extra Credit HESI Module 10 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 9476934084 A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating Extra Credit HESI Module 10 C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9476926416 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours Correct Extra Credit HESI Module 10 Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9476930486 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) Correct B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9476924035 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9476930409 A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics 8. 8.ID: 9476930444 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes Awarded 2.0 points out of 2.0 possible points. Extra Credit HESI Module 10 9. 9.ID: 9476938114 A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness Correct C. Increased urine output Correct D. Chvostek sign E. Hyperactive deep tendon reflexes Awarded 2.0 points out of 2.0 possible points. 10. 10.ID: 9476922170 A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention Correct C. Trousseau sign Correct D. Skeletal muscle weakness E. Decreased deep tendon reflexes Extra Credit HESI Module 10 Awarded 2.0 points out of 2.0 possible points. 11. 11.ID: 9476938127 A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions Correct B. Checking the client’s pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client’s carotid pulse for 15 seconds Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 9476926427 A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: A. 1 inch B. 1½ inches (3.8 cm) C. 2 inches (5 cm) Correct D. 4 inches (10 cm) Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9476928659 The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2 Correct Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 9476924027 A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100 Correct Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 9476932260 A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse? Extra Credit HESI Module 10 A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm Correct Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 9476934050 A nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 9476928634 A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED Correct B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 9476934080 A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia Correct Awarded 1.0 points out of 1.0 possible points. Extra Credit HESI Module 10 19. 19.ID: 9476922101 The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. “I need to keep the sun off the radiation site.” B. “I can use over-the-counter cortisone cream on the radiation site if it gets red.” Correct C. “I need to be careful not to wash off the marks that the radiologist made on my skin.” D. “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.” Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9476928696 A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. Correct B. Visitors must remain at least 2 feet (61 cm) from the client C. A dosimeter badge must be placed on the client’s bedside stand. Extra Credit HESI Module 10 D. The client may be maintained in a semiprivate room as long as the client uses a commode. Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: 9476922197 A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request? A. “Short walks are OK.” B. “You need to stay in your room for now.” Correct C. “Yes, it’s fine to take a walk around the nursing unit.” D. “Do you think that a walk around the unit will tire you out?” Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 9476922140 A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client’s vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container Correct Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 9476932272 A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items: A. Within the client’s reach on the left side B. Within the client’s reach on the right side Correct C. Just out of the client’s reach on the left side D. Just out of the client’s reach on the right side Extra Credit HESI Module 10 Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 9476934043 A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids Correct C. Giving foods that are primarily liquid D. Placing food in the affected side of the client’s mouth Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 9476932211 A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to: A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field Correct D. Keep all objects in the impaired field of vision Extra Credit HESI Module 10 Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 9476934092 A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to: A. Sit in soft, deep chairs B. Rock back and forth to start movement Correct C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 9476932268 A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and immediately: A. Documents the event B. Notifies the healthcare provider C. Checks the client’s bladder for distention Correct D. Checks to see whether the client has a prescription for an antihypertensive Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 9476920117 A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately: A. Suctions the client B. Obtains a pulse oximeter C. Contacts the health care provider Correct D. Increases the rate of the client’s intravenous (IV) solution Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 9476926402 An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen Correct Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 9476932252 A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever Extra Credit HESI Module 10 B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough Correct Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 9476938123 A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client’s headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin) Correct Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 9476920127 A client is found to have AIDS. What is the nurse’s highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client Correct D. Identifying risk factors related to contracting AIDS with the client Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 9476928683 A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves: A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material