aHESI Fundamentals Practice Test Final 2 Questions and Answers, Exams of Nursing

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aHESI Fundamentals Practice Test Final 2 Questions and Answers

An adult is now alert and oriented following abdominal surgery. What position is most appropriate for the client? Semi-Fowler's Prone Supine Sim's - Correct answer A This position allows for greater thoracic expansion and puts less pressure on the suture line Following a craniotomy, the nurse positioned a client in low fowler's for which reason? To promote comfort To promote drainage from operation site To promote thoracic expansion To prevent circulatory overload - Correct answer B The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which action is least appropriate? Performing ROM exercise when bathing her Changing her position every two hours Suctioning the client supine and pulling the bed sheets tightly across her feet Placing her in the prone position for one hour three times a day - Correct answer C The sheets should not be drawn tightly across the feet as this may cause foot drop The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the nurse place the wheelchair? On the left side of the bed facing the foot of the bed On the right side of the bed facing the head of the bed Perpendicular to the bed on the right side Facing the bed in the left side of the bed - Correct answer A The client can then stand on the unaffected foot and pivot to sit down When caring for a client in hemorrhagic shock, how should the nurse position the client? Flat in bed with legs elevated Flat in bed Trendelenburg position Semi-Fowler's position - Correct answer A Mr. Landon is to have a tracheostomy performed. What is the top nursing priority? Shave the neck

Establish a means of communication Insert a Foley catheter Start an IV - Correct answer B Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal suctioning? Using a lubricant such as petroleum jelly Administering 100% oxygen before and after suctioning Making sure that the suction catheter is open or on during insertion Assisting the client to assume a supine position during suctioning - Correct answer B--To prevent hypoxia Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy? Use sterile tube each time and suction for 30 seconds Use sterile technique and turn the suction off as the catheter is introduced Use clean technique and suction for 10 seconds Discard the catheter at the end of every shift - Correct answer B Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take? Suction deeper to pick up secretions Gently withdraw suction tubing to allow suction or coughing out of mucous Remove the suction as quickly as possible Put the suction in and out several times to pick up secretions - Correct answer D During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and creates a pulling sensation. What is the best action for the nurse to take? Release the suction by opening the vent Continue suctioning to remove obstruction Increase the pressure Suction deeper - Correct answer A Warm compresses are ordered for an open wound. Which action is appropriate for the nurse? Use sterile technique when applying the dressing Leave the compresses on the area continuously, pouring warm solution on the area when it cools down Alternate warm compressed with cold ones Apply wet dressing, cover with dry dressing - Correct answer A

Beside the patient in his bed to avoid embarrassment. - Correct answer B An adult had an indwelling catheter removed, after she voids for the first time, the nurse catheterizes her as ordered and obtained 200 cc of urine. What is the best interpretation of this finding? The client: Is voiding normally Has urinary retention Has developed renal failure Needs an indwelling catheter - Correct answer B The nurse plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the nurse: Work on establishing a friendship with the patient Use humour to diffuse emotionally charged topics of discussion Sympathize with the patient when the patient shares sad feelings Demonstrate respect when discussing emotionally charged topics - Correct answer D The main purpose of the working phase of the nurse-patient relationship is to: Establish a formal or informal contract that adheres to the patient's problems. Implement nursing interventions that are designed to achieve expected patient outcome. Develop rapport and trust so the patient feels protected and initial plan can be identified. Clearly identify the role of the nurse and establish the parameters of the professional relationship. - Correct answer B A patient says, "I don't know if I'll make it through this surgery", which response by the nurse may block further communication? "You sound scared" "You think you will die." "Surgery can be frightening" "Everything will be alright" - Correct answer C A patient, who is to receive nothing by mouth (NPO) in preparation for bronchoscopy says "I'm worried about the test and I can't even have a drink of water." What is the best response by the nurse? "Lets talk about your concerns regarding the test". "I'll see if the doctor will let you have some ice chips".

"The doctor will review the results of the test as soon as possible". "As soon as the test is over, I'll get you whatever you would like to drink". - Correct answer A Which are components of a complete health history? Select all that apply. Chief complain History of the present illness Past medical/surgical history Family, personal, and social history Review of systems Physical exam - Correct answer A-E, physical exam is not part of the health history Following amputation of a lower extremity, a patient with prosthesis, should be educated by the nurse to Wear the prosthesis daily, but remove immediately when discomfort is experienced Adjust the fit of the prosthesis by wearing a heavier sock to insure a tight fit To put the prosthesis on immediately upon rising in the morning and keep it on all day To apply oil or lotion to the stump before applying prosthesis - Correct answer C When preparing a client for a blood transfusion, the nurse should consider for which of the following? (Select all that apply) Blood typing and cross-matching must be completed prior to a blood transfusion Clients with type A should only receive Type A blood but may receive type O in an emergency clients with type B blood should only receive type B blood, but may receive type A in an emergency Clients with type AB blood are "universal recipients" and should only receive type AB blood but may, in an emergency receive all four types of blood - Correct answer A, B, D During a skin assessment, a client asks a question about what the skin does. The nurse's response would be based on the knowledge that the functions of the skin include (Select all that apply.) Temperature regulation Sensory perception Identification Protection - Correct answer All answers are correct The skin regulates temperature through changes in its blood flow and through sweating. The skin provides sensory information through its nerve endings. Fingerprints allow for identification of individuals. The skin and mucous membranes are the first line of defense against injury and invasion of microorganisms. Which of the following is an ABNORMAL finding when observing Water Sealed Chest Drainage for proper functioning? Bubbling initially with coughing and deep inspiration

When is the first dose of Hep B given? - Correct answer In the hospital at birth An adult has just died. How should the nurse prepare the body for transfer to the mortuary? Leave the body as is, no prep needed Bathe the body and put ID tags on it Remove dentures before bathing body Position the body with its head down and arms folded on its chest. - Correct answer B A patient has decreased cardiac output following a surgery. What will the nurse likely see in this patient? Decreased urine output Increased urine output Flushing of the skin Hyperventilation - Correct answer A The nurse counts an adult's apical heart beat at 110 beats per min. The nurse describes this as asystole bigeminy tachycardia bradycardia - Correct answer C A client as an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following? Gallbladder disease Liver disease Myocardial infarction Skeletal muscle injury - Correct answer C AST is an enzyme released in response to tissue damage. AST rises 24 hours after an MI. It will also rise with liver and skeletal muscle injuries An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following? blood clots Ecchymotic areas jaundice infection - Correct answer B A prothrombin time test should be performed regularly on persons who are taking which medication? Heparin

Warfarin Phenobarbital Digoxin - Correct answer B Which prothrombin time value would be considered normal for a client who is receiving warfarin? 12 seconds 20 seconds 60 seconds 90 seconds - Correct answer B The nurse is caring for a client who is receiving heparin. What drug should be readily available? Vitamin K Caffeine Calcium gluconate Protamine sulfate - Correct answer D- The antidote for heparin Vit K is antidote for Coumadin During the admission interview, a client who is admitted for a cardiac catheterization says, "Every time I eat shrimp I get a rash". What action is essential for the nurse to take at this time? Notify the physician Ask the client if they get a rash from any other foods Instruct the dietary department not to give the client shrimp Teach the client the dangers of eating shrimp and other shellfish - Correct answer A When a client returns from undergoing a cardiac cath, it is most essential for the nurse to Check peripheral pulses Maintain NPO Apply heat to the insertion site Start range of motion exercises immediately - Correct answer A An adult who is receiving heparin asks the nurse why it cannot be given by mouth. The nurse responds that heparin is given parenterally because it is destroyed by gastric secretions It irritates the gastric mucosa It irritates the intestinal lining Therapeutic levels can be attained more therapeutically - Correct answer A--Because of this it is given either subq or IV

Decrease in respiratory rate Increase in respiratory rate Yellow tinged sputum Auscultation of crackles throughout the lungs - Correct answer Pink-tinged frothy sputum Increase in respiratory rate Auscultation of crackles throughout the lungs The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? Place the client in high-Fowler's position Lie the client flat Place client in prone position Place client in Semi-Fowler's - Correct answer A A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? With the head of the bed elevated no more than 15 degrees At a 30 - 45 Degree angle Lying flat High-Fowler's - Correct answer A A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink- tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? Wheezes Scratching Crackles Air - Correct answer C Blood flows to the ______ atrium from the superior and inferior vena cavae - Correct answer right Blood flows from the right atrium to the right ventricle via the_______ valve - Correct answer tricuspid Blood flows from the right ventricle to the lungs for ____________________ - Correct answer oxygenation Blood flows from the _____ to the left atrium - Correct answer lungs

Blood flows from the left atrium via the ______ valve to the left ventricle - Correct answer mitral Blood flows from the ____ ventricle to the aorta and then to the systemic circulation - Correct answer left The nurse is caring for a client who has had a recent myocardial infarction involving the left ventricle. Which assessment finding is expected? a. Faint S1 and S2 sounds b. Decreased cardiac output c. Increased blood pressure d. Absent peripheral pulses - Correct answer B The myocardium is the layer responsible for the contractile force of the heart. Damage to this layer can result in decreased cardiac output. This most likely would result in decreased blood pressure and strength of peripheral pulses. Absent peripheral pulses would be caused by an arterial occlusion. S1 and S2 most likely would not be affected. The nurse is assessing a client following a myocardial infarction. The client is hypotensive. What additional assessment finding does the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min - Correct answer A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial (SA) node. This results in an increase in heart rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg? a. Increased cardiac output b. Hypertension

Evaluate for a pulse deficit. c. Assess the client's medications. d. Administer 1 mg of atropine. - Correct answer C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine to be needed