Hesi exit v1 2022

The nurse completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalusWhich assessment evidence that the child is experiencing increased intracranial pressure (ICP) ...

The nurse completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalusWhich assessment evidence that the child is experiencing increased intracranial pressure (ICP) Ans- Sluggish and unequal pupillary responses A client with acute pancreatitis is admitted with severe , piercing abdominal pain and an elevated serum amylase . Which additional information is the client most likely to report to the nurse ? Ans- Abdominal pain decreases when lying supine A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospitalWhich information is most important for the nurse to provide the parents prior to discharge? Ans- Instructions about how much fluid the child should drink daily . To auscultate for a carotid bruitthe nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location) AnsAfter receiving report on an inpatient acute care unit, which client should the nurse assess first? AnsThe client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity A teenager presents to the emergency department with palpitations after vaping at a partyThe client is anxious, fearful, and hyperventilatingThe anticipates the developing which acid base imbalance? AnsRespiratory alkalosis A with dyspnea is being admitted to the medical unitTo best prepare for the client's arrival, the nurse should ensure that the client's bed is in which ? Ans- Picture with the bed sitting up The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the admission assessment is relevan to the nurse's plan for taking the blood pressure reading? (Select all that apply) Ans- Blurred vision Flat affect Frequent syncope While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values ? Ans- Culture for sensitive organisms. A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near - drowning incident While providing to the child , the nurse begins with brother who rescued the child from the swimming pool and initiated resuscitation The nurse notices the older boy becomes withdrawn when asked about what happened Which action should the nurse take ? Ans- Ask the older brother how he felt during the incident A male client with cirrhosis has jaundice and prunitus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take ? Ans- Encourage the client to use cooler water and apply calamine lotion after soaking An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department ED) respiratory distressThe healthcare provider prescribes furosemide IVWhich therapeutic response to furosemide should the nurse expected in the with acute HF? Ans- Reduced reload Which intervention should the nurse include in the plan of care for a child with tetanus? Ans- Minimize the amount of stimuli in the room An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? AnsHad a cold and ear infection for the past two days A client with a prescription for " do not resuscitate ( DNR ) begins to manifest signs of impending death . After notifying the family of the client's status , what priority action should the nurse implement ? AnsThe client's need for pain medication should be determined. Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus Ans- Blood glucose monitoring A client who gave birth 48 hours ago has decided to bottle feed the infantDuring the assessment, the nurse observes that both breasts are swollen, warm and tender on palpationWhich instruction should the nurse provide? Ans- Apply ice to the breast for comfort The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that ap