HESI Volume 5 Questions and Answers.

HESI Volume 5 A client delivers a viable infant, but begins to have excessive uncontrolled vaginal Notifying the health care provider of the clients’ condition, what information is most An infant born to a heroin- ...

HESI Volume 5 A client delivers a viable infant, but begins to have excessive uncontrolled vaginal Notifying the health care provider of the clients’ condition, what information is most An infant born to a heroin-addicted mother is admitted to the neonatal care, unit. What behaviors can the to exhibit? A multigravida, full-term laboring client complains of “back labor”. Vaginal examination reveals that the client’s 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement? A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestational is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a b each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What A postpartal client complaisn that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? During a 26-week gestation prenatal exam, a client reports occasional dizziness What intervention is best for the nurse to recommend to this client? Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is the priority? A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy Which action should the nurse instruct the parents to take if the child begins to vomit? A client is receiving oxytocin (Pitocin ) to augment early labor. Which assessment is most important time the infusion rate is increases? An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds tachypneic, and hypotonic. What is the first action that the nurse should take? A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive Rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take? While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? When caring for a client who has acute respiratory distress syndrome (SRDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for dour days. What assessment is most important for the nurse to complete? A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? The client with which type of wound is most likely to need immediate intervention by the nurse? The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? Which breakfast selection indicated that the client understands the nurse’s instructions about the dietary management of osteoporosis? The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s diet restrictions. Which foods are contraindicated for this child? Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization’s budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse’s immediate attention? During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse’s decision to report this finding to the healthcare provider? A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? The nurse is teaching a client how to perform colostomy irrigations. When observing the client’s return demonstration, which action indicated that the client understood the teaching? An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices? A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke? The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn’s survival? The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for the treatment? A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client’s history is a possible contraindication for the use of HRT? A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is “starving” because he has had no “real food” since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two weeks. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first? After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? A male client experiences a gasoline talk fire when riding his motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom). Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Video The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) While removing a male postoperative client’s staples, the nurse observes that the client’s eyes are closed and his face and hands are clenched. The client states, “I just hate having staples removed.” After acknowledging the client’s anxiety, what action should the nurse implement? A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infants plan of care? (Select all that apply). A 6-year old child with infectious diarrhea is placed on a rehydration therapy Which action should the nurse instruct the parents to take if the child begins to vomit? A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse’s request, what action is best for the charge nurse to take? In making client care arrangements, which client is best to assign to the practical nurse (PN) working on the unit with the nurse? When assessing an adult make who presents at the community health clinic with a history of hypertension, the nurse notes that he has 2+ pitting edema on both ankles. He also has a history of gastroesophageal reflux disease (GERD) and depression. Which intervention is most important for the nurse to implement? A client with Alzheimer’s Disease (AD) is receiving trazodone (Desyrel), a recently prescribed antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? A 6-year old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings, which action should the nurse implement first? An older male client with Type 2 diabetes mellitus reports that he experiences leg pain when walking short distances and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? During a 26-week gestation prenatal exam, a client reports occasional dizziness What intervention is best for the nurse to recommend to this client? A client is receiving oxytocin (Pitosin) to augment early labor. Which assessment is most important at the time the infusion rate is increased? A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client’s admission history, he tells the nurse that he recently received vancomycin (vancocin) for a methicillin-resistant staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply). The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in his discharge teaching? A client with rheumatoid arthritis (RA) starts a new prescription for etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasis the importance of reporting which problem to the healthcare provider? When providing diet teaching for a client with cholecystitis, which types of food choices should the nurse recommend to the client? The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. What instruction should the nurse provide? Following an esophagogastroduodenoscopy (EGD), a male client is drowsy and difficult to arouse, and his respirations are slow and shallow. Which action should the nurse implement? (Select all that apply) In early septic shock states, what is the primary cause of hypotension? The nurse is planning the preoperative teaching plan for a 12-year-old child who is schedules for surgery. To help reduce this child’s anxiety, which action is best for the nurse to implement? When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? When assessing a 6-month-old infant, the nurse determined that the anterior fontanel is bulging. In which situation would the finding be most significant? An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator settings of tidal volume 600, FIO2, 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are: pH 7.31, PaCO2 60, PaO2 98%, HCO3 23. To normalized this client’s ABG findings, which action is required? Which assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity? The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decreased milk supply for the mother who is breastfeeding? A 56-year-old man shares with the nurse that he is having difficulty making a decision about terminating life support for his wife. What is the best initial action by the nurse? A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessments include: blood pressure 85/45 mm Hg, oral temperature 98.6 F, pulse 124 beats/minute, and respirations 22 breaths/minute. Based on these data, the nurse formulates the first portion of a nursing diagnosis as “Risk for injury”. What term best expresses the “related to” portion of the nursing diagnosis? A client is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complains of difficulty breathing. The nurse determined the client is tachypneic with absent breath sounds in the client’s right lung fields. Which additional finding indicates that the client developed a tension pneumothorax? The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long-term control of diabetes? When entering a client’s room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiates CPR and calls for assistance. Which action should the nurse take next? A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A male client’s laboratory results include a platelet count of 105,000/mm3. Based on this finding, the nurse should include which action in the client’s plan of care? A 13 year old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next? A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on data contained on the record, what action should the nurse take before assisting the client with ambulation? A client experiencing withdrawal from the benzodiazepines alprazolam (Xonax) is demonstrating severe agitation and tremors. What is the best initial nursing action? An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data wound provide the earliest indication that the client is experiencing increased intracranial pressure (ICP)? In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A client is schedules to receive an IV dose of onsansetron (Zofran) eight hours after receiving chemotherapy. The client has a saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose.(Enter numeric value only. If rounding is required, round to the nearest tenth) A 4 day postpartum client calls the clinic and reports that her nipples are so sore that she loves breastfeed her infant. What instruction is best for the nurse to provide?