Download HESI EXAM QUESTIONS WITH CORRECT ANSWERS 2025 and more Exams Nursing in PDF only on Docsity!
HESI EXAM QUESTIONS WITH CORRECT ANSWERS 2025
A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) Collect multiple site screening culture for MRSA Call healthcare provider for a prescription for linezolid (Zyrovix) Place the client on contact transmission precautions Obtain sputum specimen for culture and sensitivity Continue to monitor for client sign of infection. - Correct answer a. Collect multiple site screening culture for MRSA c. Place the client on contact transmission precautions e. Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D) based on the client's history is a wound infection. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? Empty the device every 8 hours and change the dressing daily ensure sterility Extended the transparent film dressing only to edge of wound to prevent tension. Ensure the transparent dressing has no tears that might create vacuum leaks Use an adhesive remover when changing the dressing to promote comfort. - Correct answer Ensure the transparent dressing has no tears that might create vacuum leak Rationale: The nurse should ensure that the VAC transparent film is intact, without tears or loose edges C) because a break in the seal resulting in drying the wound and decreasing the vacuum. The vacuum-assisted closure (VAC) device uses an open sponge in the wound bed, sealed with a transparent film dressing and tube extrudes to a suction device that exert negative pressure to remove excess wound fluid, reduce the bacterial count and stimulate granulation. The VAC is changed every other day or third day, not (A) depending on the stage of wound healing and emptied when full or weekly. The transparent wound dressing should extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight seal. Adhesive removers leave a reduce that binder transparent film adherence (D) The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? Increase fluid intake to 3,000 ml/daily Administer O2 at 5L/mint per nasal cannula Maintain the client in a semi Fowler's position Provide frequent rest period. - Correct answer Increase fluid intake to 3,000 ml/daily
Rationale: The plan of care should include an increase in fluid intake (A) to liquefy and thin secretions for easier removal of thick pulmonary secretion which facilitates airway clearance. (B) should be implemented for signs of hypoxia (C) implemented to facilitate lung expansion, and (D) implemented for activity intolerance, but these interventions do not have the priority of (A) 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? Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. - Correct answer Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24 - hour urine specimen. Discarding even one voided specimen invalidate the test. The nurse is preparing to administer a histamine 2 - receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? Neutralize hydrochloric (HCI) acid in the stomach Decreases the amount of HCL secretion by the parietal cells in the stomach Inhibit action of acetylcholine by blocking parasympathetic nerve endings. Destroys microorganisms causing stomach inflammation. - Correct answer Decreases the amount of HCL secretion by the parietal cells in the stomach Rationale: B correctly describe the action of histamine 2 receptor antagonist in helping to prevent peptic ulcer disease. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness? Body max index (BMI) between 20 and 24 Blood pressure reading less than 120/80 mm Hg Hemoglobin A1C (HbA1C) reading less than 7% Self-reported glucose levels of 120 - 150 mg/dl. - Correct answer Hemoglobin A1C (HbA1C) reading less than 7% Rationale: Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood glucose to rise slowly after a meal. The best indicator of acarbose effectiveness is a serum hemoglobin A1 no greater than 7%, an indication of glucose level over time. Acarbose has no effect on pain or blood pressure. Self-reported glucose levels of 120 - 150 reflect the blood sugar at the time taken and are not the best indicator of drug effectiveness. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? a. Antibiotics b. Anticoagulants c. Antihypertensive Anticholinergics - Correct answer Antibiotics
assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? d. Delirium e. Depression f. Dementia Psychotic episode - Correct answer Delirium Rationale: The client's clinical findings-polypharmia, urinary tract infection, and possible fluid imbalance are the most common causes of cognition and memory impairment, which is characteristic of delirium. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula Initiate bag- valve mask ventilation. Begin cardiopulmonary resuscitation - Correct answer a. Prepare medication reversal agent b. Check oxygen saturation level c. Apply oxygen via nasal cannula Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary. The nurse is planning preoperative teaching plan of a 12 - years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? Give the child syringes or hospital mask to play it at home prior to hospitalization. Include the child in pay therapy with children who are hospitalized for similar surgery. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Provide doll an equipment to re-enact feeling associated with painful procedures - Correct answer Provide a family tour of the preoperative unit one week before the surgery is scheduled Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? Explain the temporary burning of the IV site may occur. Assess IV site frequently for signs of extravasation Apply a topical anesthetic of the infusion site for burning Monitor capillary refill distal to the infusion site. - Correct answer Assess IV site frequently for signs of extravasation
Rationale: Infiltration of a vesicant can cause severe tissue damage and necrosis, so the IV site should be assessed regularly for extravasation (B) of the chemotherapeutic agent. The client should be instructed to report any discomfort at the site (A). If pain and burning occur, the IV should be stopped and C is not indicated. Peripheral pulses, not D, provide the best assessment of perfusion distal to the infusion should the drug extravasate or infiltrate. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? Resume normal physical activity Drink electrolyte fluid replacement Give a dose of regular insulin per sliding scale Measure urinary output over 24 hours. - Correct answer Give a dose of regular insulin per sliding scale Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingerstick glucose level and self-administer a dose of regular insulin per sliding scale. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? Protect joint function Improve circulation Control tremors Increase weight bearing. - Correct answer a. Protect joint function Rationale: Primary goal in the management of rheumatoid arthritis is to protect and maintain joint function. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect Decrease in serum T4 levels Increase in blood pressure Decrease in pulse rate Goiter no longer palpable. - Correct answer Decrease in pulse rate Rationale: Beta blockers such as propranolol help control the symptoms of hyperthyroidism, such as palpitations or tachycardia, but do not alter thyroid hormone levels, B is not a desired effect in hyperthyroidism. Beta blocker do not impact the presence of a goiter. An older male client with type 2 diabetes mellitus reports that has experiences legs 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? Consistently applies TED hose before getting dressed in the morning. Frequently elevated legs thorough the day.
Sterile syringe is placed on sterile area as the nurse riches over the sterile field. - Correct answer c. An open sterile Foley catheter kit set up on a table at the nurse waist level Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1 - inch border (A). A sterile object become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface. An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Ask the UAP to take the blood pressure in the other arm Tell the UAP to use a different sphygmomanometer. Review the client's serum calcium level Administer PRN antianxiety medication. - Correct answer Review the client's serum calcium level Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented. A 56 - years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? Provide an opportunity for him to clarify his values related to the decision Encourage him to share memories about his life with his wife and family Advise him to seek several opinions before making decision Offer to contact the hospital chaplain or social worker to offer support. - Correct answer a. Provide an opportunity for him to clarify his values related to the decision A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? Weigh every morning Eat a high protein diet Perform range of motion exercises Limit fluid intake to 1,500 ml daily - Correct answer a. Weigh every morning should be instructed to weight each morning before breakfast with approximately the same clothing. A is not specifically to HF and fluid retention. A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? Schedule a colonoscopy within the next month. Encourage screening for a peptic ulcer. Screen all family member for hepatitis A
Eat small, frequent meals thought the day. - Correct answer b. Encourage screening for a peptic ulcer. Rationale: Helicobacter pylori is a gram- negative organism than can colonize in the stomach and is associated with peptic ulcers formation. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? Cardiac rhythm and heart rate. Daily intake of foods rich in potassium. Hourly urinary output Thirst ad skin turgor. - Correct answer Cardiac rhythm and heart rate Rationale: Hypokalemia is a side effect of potassium-wasting diuretics, such as Lasix, and manifest as muscle weakness, hypotension, tachycardia, and cardiac dysrhythmias, so changes in the child's heart rate and cardiac rhythm should be reported to the healthcare provider. Although BCD can affect the serum potassium level, the most important finding is the effect of hypokalemia on the child's cardiac rate and rhythm. The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? Encourage the client's family to visit more often Schedule a daily conference with the social worker Encourage the client to participate in group activities Engage the client in a non-threatening conversation. - Correct answer d. Engage the client in a non-threatening conversation. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? a. Headache Joint stiffness Persistent fever Increase hunger and thirst - Correct answer Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider. 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? The fasting blood sugar was 120 mg/dl this morning. Urine ketones have been negative for the past 6 months The hemoglobin A1C was 6.5g/100 ml last week No diabetic ketoacidosis has occurred in 6 months. - Correct answer c. The hemoglobin A1C was 6.5g/100 ml last week
Administer the analgesic as requested - Correct answer d. Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe, but should be treated with analgesics as indicated A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? Send stool sample to the lab for a guaiac test Observe stool for a day-colored appearance. Obtain specimen for culture and sensitivity analysis Asses for fatty yellow streaks in the client's stool. - Correct answer Send stool sample to the lab for a guaiac test Rationale: Thrombolytic drugs increase the tendency for bleeding. So, guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract. The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? Brain damage with CP is not progressive but does have a variable course CP is one of the most common permanent physical disability in children Severe motor dysfunction determines the extent of successful habilitation Continued development of the brain lesion determines the child's outcome. - Correct answer Brain damage with CP is not progressive but does have a variable course Rationale: CP is nonprogressive cerebral insult due to asphyxia, brain malformation, or toxicity, such as kernicterus. It is characterized by impair movement, posturing and may include perceptual, expressive and intellectual deficits, but the motor disabilities can vary as the child grows (A) and as interventions are implemented to prevent disuse complications. In early septic shock states, what is the primary cause of hypotension? Peripheral vasoconstriction Peripheral vasodilation Cardiac failure A vagal response - Correct answer Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? Allopurinol (Zyloprim) Aspirin, low dose Furosemide (lasix) Enalapril (vasote) - Correct answer Allopurinol (Zyloprim)
Rationale: The effectiveness of allopurinol is diminished when aluminum hydroxide is used leading to an increased chance for gout flare ups. The healthcare provider should be alerted about the allopurinol interaction so any changes in medication regimen may be considered. 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? Cluster care to conserve energy Initiate contact isolation Encourage him to use an electric razor Asses him for adventitious lung sounds - Correct answer Encourage him to use an electric razor Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II Persistent coughing while drinking Unilateral facial drooping Inappropriate or exaggerated mood swings - Correct answer Persistent coughing while drinking Rationale: After a stroke, clients may experience dysphagia and an impaired gag reflex that is evaluated by a speech pathology team. Coughing while drinking results from impaired swallowing and gag reflex, so a referral to a speech therapist is indicated to evaluate the coordination of oral movements associated with speech and deglutination. Cranial nerves I and II are sensory nerves for taste and sight and do not require a referral to speech pathology. Unilateral facial drooping is associated with stroke but is not a focus of rehabilitation. D sre not addressed by speech therapy. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: Remove sequential compression devices. Apply PRN oxygen per nasal cannula. Administer a PRN dose of an antipyretic. Reinforce the surgical wound dressing. - Correct answer Remove sequential compression devices. Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted. Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? Sudden dysphagia Blurred visual field Gradual weakness
Prepare to administer atropine 0.4 mg IVP Gather emergency tracheostomy equipment Prepare to administer lidocaine at 100 mg IVP Place cardiac monitor leads on the client's chest. - Correct answer a. Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias 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? Replace the IV site with a smaller gauge. Redress the abdominal incision Leave the lights on in the room at night. Apply soft bilateral wrist restraints. - Correct answer b. Redress the abdominal incision Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client's sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm. An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? b. Lethargy Decorticate posturing Fixed dilated pupil Clear drainage from the ear. - Correct answer Lethargy Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? Prepare the client to independently treat their disease process Reduce healthcare costs related to diabetic complications Enable clients to become active participating in controlling the disease process Increase client's knowledge of the diabetic disease process and treatment options. - Correct answer c. Enable clients to become active participating in controlling the disease process Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A) To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?
Confirm that all the staff nurses are being assigned to equal number of clients. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. Analyze the amount of overtime needed by the nursing staff to complete assignments. - Correct answer b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity. The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? Supplemental feedings with formula Maternal diet high in protein Maternal intake of increased oral fluid Breastfeeding every 2 or 3 hours. - Correct answer Supplemental feedings with formula Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant's time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply. Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity Range of Motion Distal pulse intensity Extremity sensation Presence of exudate - Correct answer Distal pulse intensity Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment does not have the priority of determining perfusion to the extremity. 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? They can contribute to increased dependency They decrease the risk for joint trauma They promote muscle strength They diminish range of motion ability. - Correct answer They decrease the risk for joint trauma Rationale: Assistive devices of this kind are very beneficial in reducing joint trauma(B) caused by excessive twisting. These devices promote independence, rather that increasing dependency
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? e. Hypoglycemia Fluid balance Heat loss Bleeding tendencies - Correct answer Heat loss Rationale: Adequate thermoregulation is the nurse next priority. The newborn is at risk for significant heat loss due to a large surface area exposed to the environment, a thin layer of subcutaneous fat, and distribution of brow fat. Heat loss increases the neonate's metabolic pathway's utilization of oxygen and glucose. The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? Instruct the client's family member to stay in the visitor waiting area until further notice Tell the staff to keep all clients and visitors in the client rooms with the doors closed. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. Call the hospital operator to determine if the is indeed a real emergency or a fire drill. - Correct answer Tell the staff to keep all clients and visitors in the client rooms with the doors closed Rationale: The charge nurse should treat the alarm as an actual fire emergency and instruct all clients and visitors to stay in the clients' room with doors closed until otherwise notified. A should be anxiety producing. Visitors should remain in the rooms with the clients. C is only necessary if the location and severity of the fire make the unit unsafe for inhabitants and would only be implemented after other measures to control de fire had failed. D should not be done until after measures are taken to protect clients and visitors. 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? Her mother and sister have a history of breast cancer - Correct answer Her mother and sister have a history of breast cancer 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? Discontinue intravenous therapy Obtain a prescription for a diet change Assess for abdominal distention and tenderness. Auscultate bowel sounds in all four quadrants - Correct answer Auscultate bowel sounds in all four quadrants The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A young man with schizophrenia who wants to stop taking his medication The mother of a child who was involved in a physical fight at school today. A client diagnosed with depression who is experiencing sexual dysfunction. A family member of a client with dementia who has been missing for five hours - Correct answer A family member of a client with dementia who has been missing for five hours
Rationale: safety is always the priority concern and the family member of the missing client with dementia needs assistance with contacting authorities as well as psychological support during this time. 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) Assess the client's skin and circulation for impairment related to the restrains Evaluate the client's mentation to determine need to continue the restrains Assign unlicensed assistive personnel to remove restrains and remain with client Contact the client's surgeon and primary healthcare provider - Correct answer 1. Assess the client's skin and circulation for impairment related to the restrains
- Evaluate the client's mentation to determine need to continue the restrains
- Assign unlicensed assistive personnel to remove restrains and remain with client Contact the client's surgeon and primary healthcare provide 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 days. 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? Put a cold cloth on his head and administer acetaminophen. Listen to lung sounds and place him in a mist tent. Notify the healthcare provider and obtain a tracheostomy tray Assist the child to lie down and examine his throat. - Correct answer Notify the healthcare provider and obtain a tracheostomy tray Rationale: This child exhibiting signs and symptoms of epiglottitis, a bacterial infection causing acute airway obstruction, so is the immediate action to take. 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? Epinephrine Injection, USP IV Diphenhydramine IV Albuterol (Ventolin) inhaler Methylprednisolone IV - Correct answer Epinephrine Injection, USP IV Rationale: Epinephrine should be administered immediately to open the airway and raise the blood pressure by vasoconstricting the blood vessels. All other medications should be administered after the epinephrine is given. Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?
Rationale: Moving this away from the client helps prevent to unnecessary injurie. Observing for the pt airway alert the nurse to provide airway assistance as soon as the seizure stop D and E provide the healthcare provider with an accurate description of the seizure activities. C inserting something on the mouth can obstruct may cause further airway obstruction and is contraindicated even if the client is biting the tongue. F may cause further injury and is contraindicated. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? Determine client's level current blood alcohol level. Observe for changes in level of consciousness. Involve the client's family in healthcare decisions. Provide grief counseling for client and his family. - Correct answer b. Observe for changes in level of consciousness. Rationale: Based on the client's history of drinking, he may be exhibiting sign of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? Report the results to the healthcare provider. Increase ventilator rate. Administer a dose of sodium carbonate. Decrease the flow rate of oxygen. - Correct answer Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate The mother of the 12 - month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? Perform CPT after meals to increase appetite and improve food intake. CPT should be performed more frequently, but at least an hour before meals. Stop using CPT during the daytime until the child has regained an appetite. Perform CPT only in the morning, but increase frequency when appetite improves. - Correct answer CPT should be performed more frequently, but at least an hour before meals. Rationale: CPT with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie.
Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie. - Correct answer Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie Rationale: B is limited in sodium, is high in fiber, and no additional fat is added through cooking, so it is the best choice for an antihypertensive meal. A high in sodium and cholesterol, which should be avoid. C is high in fat and caffeine which can elevate the BP D is high in sodium and cholesterol and includes caffeine. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? Fingerstick glucose assessment q6h with meals Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose Review with the client proper foot care and prevention of injury Do not contaminate the insulin aspart so that it is available for iv use Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management - Correct answer a. Fingerstick glucose assessment q6h with meals c. Review with the client proper foot care and prevention of injury e. Coordinate carbohydrate controlled meals at consistent times and intervals f. Teach subcutaneous injection technique, site rotation and insulin management Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse? Diarrhea and flatulence Abdominal cramps Muscle pain Altered taste - Correct answer Muscle pain Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? Ensure that the knot can be quickly released. Tie the knot with a double turn or square knot. Move the ties so the restraints are secured to the side rails. Ensure that the restraints are snug against the client's wrist. - Correct answer Ensure that the knot can be quickly released. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?
