1. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastronomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For whi
...
1. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastronomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
2. A nurse is caring for a client who has a terminal illness and is approaching death. The client’s respiration are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
3. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of protein?
4. A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device?
5. A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?
6. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should a nurse take?
7. A nurse enters a client’s room and finds her on the floor. The client’s roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about the incident?
8. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
9. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
10. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
11. A nurse is teaching a client and his family how to care for the client’s tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
12. A nurse is caring for a client who is postop following knee arthroplasty and requires the use of a thigh length sequential compression device. Which of the following actions should the nurse take?
i.
13. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
14. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
15. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
16. A nurse is admitting a client who has been having frequent tonicclonic seizures. Which of the following actions should the nurse add to the client's plan of care?
17. A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?
18. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
a.
19. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
20. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
21. A nurse in a longterm care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
22. A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's intake and output as 120 mL of fluid?
23. A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action?
24. A nurse receives report about a client who has 0/9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following action should the nurse take first?A nurse is caring for a client who is terminal diagnosis and whose health is declining. The client request information about advance directives. Which of the following responses should the nurse make?
25. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse removed IV catheter?
26. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
27. A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?
28. A client who is postoperative is verbalizing pain as a two on the pain scale of 0 to 10. Which of the following statements should the nurse identify as indication of the client understands the preoperative teaching she received about the pain management?
29. A nurse is caring for a child who has a prescription for a blood transfusion. The parents refuse the treatment due to religious believes. Which of the following action should the nurse take?
30. A nurse has an order to remove the sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following action should the nurse take?
a.
31. A nurse on a medicalsurgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
32. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over seven hours. The nurse should step infusion pump to deliver how many milliliters per hour?
33. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over seven hours. The nurse should step infusion pump to deliver how many milliliters per hour?
34. Undersize planning teaching for a group of adolescents who beach recently had surgical placement of an ostomy. Which of the following message to the nurse use as a psychomotor approach to learning?
35. A nurse is initiating a protective environment for a client who is in allogenic stem cell transplant. Which of the following precautions of the nurse plan for this client?
36. The middle adult client tells the nurse "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
37. A nurse is reviewing evidencebased practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
38. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
39. A nurse is admitting a client who is having in exasperation of heart failure. While planning this patient's care, when should the nurse initiate discharge planning?
a.
40. A nurse is performing a skin assessment of the patient client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as possible indications of the skin malignancy?
41. The charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
42. A nurse is administering 1 L of 0.9 sodium chloride to a client who is post operative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication of the treatment was successful?
43. A nurse is educating a client who has a terminal illness about her request to decline recipe cetacean and her living well. The client asked what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?
44. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
a.
45. A nurse is teaching a client who's left leg is in a cast about using crutches. Which of the following statements for the nurse identify as an indication of the client understands teaching?
46. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?
47. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
a.
48. A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses his treatment options and leave the clients room. When the nurse asked if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
49. A nurse is assessing a client reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain?
a. D – is your pain sharp or dull?
50. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?
51. A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse except to confirm the correct tube placement?
52. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirmed the fire, which of the following actions should the nurse take?
53. A nurses caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
a.
54. A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals signatures me the nurse legally witness (select all that apply)
55. A nurses caring for a client who is post operative and has signs of hemorrhagic shock. When the nurse notifies the surgeon he directors her to continute to measure the clients vital signs every 15 minutes and call him back in one hour. From a legal perspective which of the following actions should the nurse take next
a. B – Notify the nurse manager
56. A nurse is caring for a group of clients on a major medical surgical unit. Which of the following situations does the nurse demonstrates ethical principle and veracity?
57. A nurse is teaching a client about dietary management of hyper cholesterolemia. Which of the following foods should the nurse suggested the client add to his diet?
[Show More]
 HESI VI EXIT EXAM.png)
.png)
