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HESI Comprehensive Exam A with verified answers
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees - Correct answer B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D). When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L - Correct answer B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D). Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine - Correct answer A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D). The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen. - Correct answer B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t-PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation. - Correct answer B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D). When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F - Correct answer B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the primary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X-ray. - Correct answer C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D). A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations. - Correct answer A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A). A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A.Two-month-old who is unable to roll from back to abdomen B.Ten-month-old who cannot sit without support C.Nine-month-old who cries when his mother leaves the room
Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E). The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick. - Correct answer B Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D). An 8 - year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group. - Correct answer A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D). The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image? A.30ml B.15ml C.10ml D.5ml - Correct answer B Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL When assessing the laboratory findings of a 38 - year-old client with tuberculosis who is taking rifampin (Rifadin), which laboratory finding would be most important to report to the primary health care provider immediately? A.Orange-colored urine B.Potassium level, 4.9 mEq/L
C.Elevated liver enzyme levels D.Blood urea nitrogen (BUN) level, 12 mg/dL - Correct answer C Rationale: Rifampin can cause hepatoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider (C). Orange discoloration of the urine is an expected side effect of this medication (A). The potassium level (B) is normal. A BUN level of 12 mg/dL is within defined parameters (D). A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A.Increased hemoglobin and hematocrit levels B.Increased serum calcium level C.Decreased white blood cell (WBC) count D.Decreased triiodothyronine (T3) and thyroxine (T4) levels - Correct answer D Rationale: Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones (D). It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It is does not affect (A). (B) must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and (C) monitored. The nurse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A.Inhalation of powder form B.Handling of infected animals C.Spread from person to person through coughing D.Eating undercooked meat from infected animals E.Direct cutaneous contact with the powder - Correct answer A,B,D,E Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C). The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) A.Dark red vaginal bleeding B.Rigid boardlike abdomen C.Soft abdomen on palpation D.Complaints of severe abdominal pain E.Painless bright red vaginal bleeding - Correct answer A,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E). Which vital sign in a pediatric client is most important to report to the primary health care provider? A.Newborn with a heart rate of 140 beats/min B.Three-year-old with a respiratory rate of 28 breaths/min C.Six-year-old with a heart rate of 130 beats/min
feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time. A nurse performs an initial admission assessment of a 56 - year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A.Abdominal obesity B.Sedentary lifestyle C.History of hypoglycemia D.Hispanic or Asian ethnicity E.Increased triglycerides - Correct answer A,B,D,E Rationale: Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C). The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A.9:30 am B.10:30 am C.12:00 pm D.3:00 pm - Correct answer B Rationale: Regular insulin is short-acting and peaks between 2 and 3 hours after administration (B). The client is most at risk for a hypoglycemic reaction during the peak times. (A, C, and D) are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time. Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)?A.Reorient the client to surroundings. B.Assess blood pressure every 15 minutes. C.Determine if muscle soreness is present. D.Maintain a patent airway. - Correct answer D Rationale: The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway (D). Patients may be confused after ECT (A), but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority (B). Muscle soreness is an expected finding after ECT (C). The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. A. Drop prescribed number of drops into conjunctival sac. B. Wash hands and apply clean gloves. C. Place dominant hand on the client's forehead. D. Ask the client to close the eye gently. A. C, B, A, D B. B, C, A, D
C. A, B, D, C
D. A, C, B, D - Correct answer B Rationale: Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (B). Placing the dominant hand on the client's forehead (C) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (A); asking the client to close the eye gently helps distribute the medication (D). A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone (Risperdal). The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? A.Compliance with medication regimen B.Current thyroid-stimulating hormone (TSH) level C.Occurrence of mania or depression D.A 24 - hour diet and exercise recall - Correct answer A Rationale: Medication compliance (A) is most important for the treatment of psychotic disorders and, because Risperdal is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level (B) indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression (C) since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise (D) should also be assessed, but weight gain is a likely indicator of medication compliance. The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? A.Palpate for pitting edema. B.Provide meticulous skin care. C.Administer phosphate binders. D.Monitor serum potassium levels. - Correct answer D Rationale: Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening (D). One sign of fluid retention is pitting edema (A), but it is an expected symptom of renal failure and is not as high a priority as (D). (B and C) are common nursing interventions for CRF but not as high a priority as (D). A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A.Fever, elevated white blood count, elevated platelets B.Fatigue, weight loss and anorexia, elevated red blood cells C.Hyperplasia of the gums, elevated white blood count, weakness D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level - Correct answer C Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A.Accelerations in response to fetal movement B.Early decelerations in the second stage of labor C.Fetal heart rate of 130 beats/min between contractions
Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic assessment. The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? A.Surgical mask, clean gloves, and gown B.Properly fitted N95 respirator or mask C.Sterile gloves and gown D.Goggles, clean gloves, and gown - Correct answer B Rationale: The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A.Ammonia odor is noted when the catheter is emptied. B.240 mL of urinary output is produced in 12 hours. C.A 16 - French catheter was used for an adult female. D.Drainage system is hanging below the level of the bladder. - Correct answer B Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14 - to 18 - French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D). An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic. - Correct answer D Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety. Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A.States having difficulty with color perception B.Presents with opacity of the lens upon assessment C.Complains of seeing a cobweb-type structure in the visual field D.Reports the need to use a magnifying glass to see small print - Correct answer C Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention. Which intervention(s) should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A.Maintain bed rest for the first 6 hours after delivery. B.Palpate and massage the fundus to maintain firmness. C.Have client empty bladder if fundus is above umbilicus. D.Check perineal pad for color and consistency of lochia. E.Apply ice pack or witch hazel compresses to the perineum. - Correct answer B,D,E Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C). The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A.0. B.1. C. D.9 - Correct answer D Rationale:15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 ml = 9 mL Which data obtained during a respiratory assessment for a 78 - year-old client is most important to report to the primary health care provider? A.Auscultation of vesicular breath sounds B.Pulse oximetry reading of 89% C.Arterial Pao2 of 86% D.Resonance on percussion of the lungs - Correct answer B Rationale: An oxygen saturation lower than 90% indicates hypoxia (B). (A, C, and D) are all normal findings. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the family about signs and symptoms of hypoxia. B.Take the vital signs and obtain an O2 saturation level. C.Evaluate the need for tracheal suctioning. D.Revise the plan of care to include tracheostomy care. - Correct answer B Rationale: The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data (B). (A, C, and D) are all part of the nursing process and should not be delegated under the nurse's scope of practice.
C.Coarctation of the aorta D.Tetralogy of Fallot E.Transposition of the great vessels - Correct answer D,E Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C). A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A."I will not take my digoxin if my heart rate is higher than 100 beats/min." B."I should weigh myself once a week and report any increases." C."It is important to increase my fluid intake whenever possible." D."I should report an increase of swelling in my feet or ankles." - Correct answer D Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C). Which action by the nurse is consistent with culturally competent care? A.Treating each client the same regardless of race or religion B.Ensuring that all Native American clients have access to a shaman C.Understanding one's own world view in addition to the client's D.Including the family in the plan of care for older clients - Correct answer C The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views (C). Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity (A, B, and D). The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A."I know many women who have survived ovarian cancer." B."Let's talk about the treatments of ovarian cancer." C."In my opinion I would suggest getting a second opinion." D."Tell me about what you are feeling right now." - Correct answer D Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings (D). Giving false reassurance or personal suggestions are not therapeutic communication for the client (A, B, and C). A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B."You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C."For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D."I am legally required to document all of our conversations in the electronic medical record." - Correct answer C
Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client (D). A 45 - year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia - Correct answer C Rationale: Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A.Potassium level, 3.9 mEq/dL B.Creatinine level,1.1 mg/dL C.Sodium level, 125 mEq/L D.Calcium level, 9 mg/dL - Correct answer C Rationale: The normal serum sodium level is 135 to 145 mEq/L (C). This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. (A, B, and D) are all within normal parameters. The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individual(s)? (Select all that apply.) A.An Rh-negative woman who has had a miscarriage at 24 weeks B.The father of a baby of an Rh-positive fetus C.An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs' test D.An Rh-positive infant within 72 hours after birth E.An Rh-negative mother with a negative antibody titer at 28 weeks - Correct answer A,C,E Rationale: (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D). Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A.Limit fluids to prevent infection to the surgical site. B.Place the infant in the prone position. C.Provide a low-residue diet to limit bowel movements. D.Cover sac with a moist sterile dressing. - Correct answer B Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum (B). Fluids should be increased postoperatively to prevent dehydration (A). A high-fiber diet should be implemented to prevent constipation (C). After the repair, the sac is no longer exposed, so (D) does not apply.
The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.A client with nausea who needs a nasogastric tube inserted B.A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D.A client who is ready for discharge who needs discharge teaching - Correct answer A Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D). A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A.A 17 - year-old who is sexually active with numerous partners B.A 45 - year-old lesbian who has been sexually active with two partners in the past year C.A 30 - year-old cocaine user who inhales the drug and works in a topless bar D.A 34 - year-old male homosexual who is in a monogamous relationship - Correct answer A Rationale: (A) is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. (B) comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. (C), who free-bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected (D). The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? A.Uses descriptive words such as "gurgling" to describe breath sounds B.Records temperature 30 minutes before and after giving acetaminophen C.Charts some actions in advance of performing them D.Includes the client's response to an intervention - Correct answer C Rationale: Charting actions prior to implementing them is an example of fraudulent charting and the graduate nurse should receive further education (C). (A, B, and D) are appropriate charting examples. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A.Client will not demonstrate cross addiction. B.Codependent behaviors will be decreased. C.Excessive CNS stimulation will be reduced. D.The client will demonstrate an increased level of consciousness. - Correct answer C Rationale: Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described but do not have the priority of (C).
A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? A.Orient the client to activities on the unit. B.Document suicide precautions on the shift report. C.Assign the client to a semiprivate room. D.Obtain a verbal no-suicide contract with the client. - Correct answer C Rationale: It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation. A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? A.Heart palpitations B.Leg cramps C.Nausea D.Tetany - Correct answer A Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency (A). (B and C) are also of concern but are not as life threatening. (D) is a symptom of hypocalcemia. A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A.Insert a large-bore IV for fluid resuscitation. B.Prepare to assist with maintaining the airway. C.Cleanse the wounds using sterile technique. D.Administer an analgesic for pain. - Correct answer B Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care (B). (A, C, and D) are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway. The nurse prepares to administer digoxin (Lanoxin), 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A.Discontinue the digoxin. B.Notify health care provider. C.Administer the digoxin. D.Reverify the digoxin level. - Correct answer C Rationale: A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should be continued to maintain a therapeutic range (C). The others actions are not indicated for a therapeutic range (A, B, and D). The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A.Usual prepregnant weight
Rationale: The nurse should allay their concerns by providing information about the procedure and answering questions (B). This action assists the couple in coping with the situation. (A) may offer false reassurance. (C) alone does not resolve the couple's fears. Although (D) may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely to be most helpful in calming their fears. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A.Fine crackles B.Wheezes C.Course crackles D.Stridor - Correct answer C Rationale: This sound is caused by air passing through airways that are intermittently occluded by mucus (C). Fine crackles are a series of short-duration, discontinuous, high-pitched sounds (A). Wheezes are continuous, high-pitched, musical or squeaking-type sounds (B). Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway (D). A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? A.CAGE questionnaire for alcoholism B.Addiction Severity Index C.Glasgow Coma Scale D.DSM multiaxial evaluation - Correct answer C Rationale: Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale (C), has the highest priority. (A) is useful in helping clients recognize their alcoholism. (B and D) are comprehensive assessments that should be completed after the acute phase is resolved. In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A.A consistent fasting blood sugar level between 80 and 85 mg/dL B.A 2 - hour postprandial level greater than 120 mg/dL C.Client reports taking a 30 - minute walk after dinner D.Client describes eating pattern of four to six meals daily - Correct answer Rationale: Two-hour postprandial levels greater than 120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value greater than 120 mg/dL (B) should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal (A). (C and D) are healthy behaviors for a women with gestational diabetes. When blood or blood products are administered, which task can be assigned to the licensed practical nurse (LPN)? A.Initiation of the blood product B.Obtaining vital signs after infusion has begun C.Assessment of client's condition prior to blood administration D.Evaluation of client's response after receiving blood product - Correct answer B Rationale: Blood and blood products must be initiated by the registered nurse (RN) (B); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. (A, C, and D) are all part of the nursing process and the scope of the RN.
A nurse is assessing a client with heart failure who has been prescribed digoxin (Lanoxin) for therapy. Which finding indicates an issue with the medication management? A.Regular heart rate of 88 beats/min B.Serum potassium level, 2.9 mEq/L C.Weight decreases by 1 lb daily D.Serum sodium level, 138 mEq/L - Correct answer B Rationale: A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low (B). (A, C, and D) are all expected findings when caring for a client with congestive heart failure. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? A.The pupils become equal and reactive to light. B.The right pupil constricts within 30 minutes. C.Bilateral visual accommodation is restored. D.The right pupil dilates after drop installation. - Correct answer D Atropine (Isopto Atropine) is a mydriatic drug, which causes pupil dilation and paralysis in preparation for surgery or examination (D). (A, B, and C) do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery. After assessing a 26 - year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A.Blood pressure, 159/98 mm Hg B.Hemoglobin A1c (HbA1c), 6% C.Creatinine level, 1.0 mg/dL D.Chronic sciatica - Correct answer A Rationale: A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke (A). (B and C) are within defined parameters, and (D) is not a recognized chronic complication of diabetes. Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? A.Nervousness B.Increased appetite C.Apical heart rate of 130 beats/min D.Insomnia - Correct answer C Rationale: The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders (C). (A, B, and D) are all expected findings that should also be reported but are not as critical. A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A.How the client examines her feet B.Which hypoglycemic medication she takes C.Who lives in the home with her D.How long she has had diabetes mellitus - Correct answer A
