HESI Extra Credit Module 9 Exam

HESI Extra Credit Module 9 Exam Extra Credit HESI Module 9 1. Questions 1. 1.ID: 9477047208 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the a ...

HESI Extra Credit Module 9 Exam Extra Credit HESI Module 9 1. Questions 1. 1.ID: 9477047208 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution Correct Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477054249 A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? A. Notify the surgeon Correct B. Continue the assessment Extra Credit HESI Module 9 C. Check the client’s blood pressure D. Obtain a flashlight, gauze, and a curved hemostat A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula Correct D. Ensuring that the intravenous (IV) line is patent Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477051498 A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak Correct D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response Correct Awarded 2.0 points out of 2.0 possible points. 5. 5.ID: 9477055619 A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing Correct Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477047967 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied Correct C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477054269 Extra Credit HESI Module 9 A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter Correct Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477044479 A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the health care provider B. Check for kinks in the drainage system Correct C. Check the client’s blood pressure and heart rate Extra Credit HESI Module 9 D. Connect a new drainage system to the client’s chest tube Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477047216 A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client’s overall intake and output record Correct D. Administer a 250-mL bolus of normal saline solution (0.9%) Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477054279 A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client’s blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved Correct Extra Credit HESI Module 9 Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 9477047901 A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position Correct Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 9477052857 A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? A. The client’s vital signs Extra Credit HESI Module 9 B. The amount of drainage C. The client’s lung sounds D. The chest tube connections Correct Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9477055641 A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges Correct Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 9477054227 A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment Correct D. Oxygen saturation monitor 15. 15.ID: 9477052847 A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting Correct Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 9477050283 A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth Correct D. Complaints of feeling sweaty. Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 9477047248 A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? A. Ensuring that the client has voided Correct B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours Extra Credit HESI Module 9 Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 9477045874 A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway Correct B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 9477045891 A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% Correct D. 100% Extra Credit HESI Module 9 Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9477052876 A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply. A. Hematocrit 30% (0.30) Correct B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) Correct D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L) Awarded 2.0 points out of 2.0 possible points. 21. 21.ID: 9477052865 A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client’s medical history? A. Pancreatitis B. Pacemaker insertion Correct C. Type 1 diabetes mellitus D. Chronic airway limitation Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 9477047238 A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat Correct B. Semi-Fowler C. Side-lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 9477051477 A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? A. Administering a laxative B. Encouraging fluid intake Correct C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours 24. 24.ID: 9477043192 A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. “I didn’t shampoo my hair.” Correct B. “I ate breakfast this morning.” C. “I didn’t take my anticonvulsant today.” D. “It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.” Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 9477049148 Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL (101.2 μmol/L) B. 4.4 mg/dL (262 μmol/L) Correct C. 8.9 mg/dL (529.9 μmol/L) D. 12.8 mg/dL (762.1 μmol/L) Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 9477051424 A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the health care provider the development of fever or redness and heat at the site Correct Extra Credit HESI Module 9 Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 9477044448 A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot Correct D. A positive test is a normal result and does not mean that the client is infected with HIV 28. 28.ID: 9477047259 A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy Correct C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 9477044498 A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood Correct C. Avoiding the administration of opioid analgesics Extra Credit HESI Module 9 D. Having the client ambulate in the room and hall for short distances Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 9477050216 A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time Correct Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 9477047283 A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish Correct 32. 32.ID: 9477044488 Extra Credit HESI Module 9 A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding Correct B. Renal colic C. Infection at the site D. Increased temperature 33. 33.ID: 9477049161 A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg Correct Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 9477054237 A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones Correct D. Specific gravity of 1.018