HESI V5 / NURSING MISC / DOWNLOAD AND SCORE GRADE A
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HESI V5 A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? • Allow the client to us... e a bedpan. • Explain the fetal head is descending. • Perform a sterile vaginal exam. < • Assist the client to the bathroom. • The nurse assesses a 78-‐year-‐old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? • Dyspnea, cough and fatigue. < • Hepatomegaly and distended neck veins. • Pain over the pericardium and friction rub. • Narrowing pulse pressure and distant heart sounds. • A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-‐time caretaker for a 22-‐year-‐old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? • Teach the client to problem-‐solve for herself and establish her own priorities. • Schedule a home visit in the afternoon to assess the son and client’s role as caregiver. • Provide feedback to the client about her atonement for guilt about her son’s impairment. • Acknowledge the client’s stress and suggest that she consider respite care. < • The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client’s telemetry pattern shows a second-‐degree heart block with a ventricular rate of 50. What action should the nurse take? • Administer the Toprol immediately and monitor the client carefully until the heart rate increases. • Provide the dose of Toprol as scheduled and assign a UAP to monitor the client’s BP q30 minutes. • Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern. < • Give the Toprol as scheduled if the client’s systolic blood pressure reading is greater than 180. [Show More]
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