Download Nursing Questions and Answers and more Exams Nursing in PDF only on Docsity!
HESI PREDITION END TEAM TEXT
A client with irritable bowel syndrome is recovering from surgery to create an ileostomy what foods should the nurse instruct the client to avoid to reduce the risk of food blockage - Correct answer Dried fruits & nuts Rationale: dried fruits and nuts can cause a blockage in the small intestine the client should be instructed to avoid these food items with an ileostomy A client with malnutrition is assessed for osteomalacia what data show the nurse review to determine their clients risk for this health problem - Correct answer Vitamin D levels Rationale: Malnutrition has widespread affects on various organ systems osteomalacia is defective mineralization of newly formed bones secondary to chronic deficiency of vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide the nurse with the most accurate information regarding this health problem The nurse has determine an adolescent client needs reinforcement education about prevention of a sickle cell crisis which instruction should the nurse include select all that apply - Correct answer Wear warm clothes outside in cold weather take your hydroxyurea (Droxia) daily as prescribed Drink at least eight 12 ounces glasses of water a day Get regular exercise but do not exercise so much that you become tired
Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle cell disease. it occurs when the micro circulation is obstructed by sickling of the red blood cells resulting in local tissue ischemia and severe pain. the three most common identify triggers for the development of a vaso-occlusive crisis are hypoxemia, dehydration, and body temperature changes The nurse is caring for a client with schizophrenia who has refused they are risperidone for the last week the client has been suspicious of nursing staff and periodically aggressive for the past three days today the client broke a chair in their room and is making verbal threats to the nurse and to other clients in the day wrong what is the first action the nurse should take - Correct answer Remove the other clients in nonessential staff from the day room Rationale: schizophrenia is a mental health disorder which causes hallucinations, delusions, disorder thought process and impaired behavior function. Safety for all staff clients and visitors is priority and potential violence situations A nurse who normally works on a post surgical care unit has been asked to float to the preoperative care unit what is the best response by the nurse - Correct answer I don't feel totally comfortable floating so I would like to be paired with a resource nurse for my shift Rationale: The nurse has acknowledged their discomfort with floating and has also identified a means of making a float shift nurse more comfortable and important part of a successful float shift and identifying using resources on the float unit including a partnership with a specific resource nurse for the shift to answer questions locate supplies etc.
education sheet does not reflect racial profiling stereotyping or inappropriate categorizing of the clients population The nurse is emptying the urinary collection bag for a client with history of HIV in which sequence sure the nurse perform the following actions after the urinary collection bag has been drained
- Correct answer Ensure urinary collection bag is placed below the clients bladder empty that your receptacle remove PPE Wash hands with soap & water Document amount of urine collected Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne illnesses in cases of hematuria healthcare professionals including nurses need to completely situational risk assessment prior to each client interaction to determine risk and choose the appropriate infection control strategy to minimize risk to themselves and their client population according to the CDC A GRANDSon is concern about the older clients happiness and so much time is spent talking about the past what should the nurse respond to the grandson - Correct answer Reminiscing is a common activity in older adults that helps them to stay connected Rationale: The nurse should explain that reminiscing is normal and common activity in older adults talking about the past helps older adult clients stay connected to other people by providing a topic of conversation even if they don't experience much during the day Family of an elderly Japanese woman is upset because the client has not received any pain medication the nurse explains that the client never complain about pain and did not write the pain and severe when assess what should the nurse manager do - Correct
answer Explain that in the Japanese culture people often show a stoic response to pain so that it is important to look for PHYSICAL clues Rationale: individuals of Japanese descent will not complain about pain as they do not want to dishonor themselves or their families some will either refuse pain medication when offered therefore it is important to look for physical clothes like (rocking, sweat on brows, elevated blood pressure) and input from the family when assessing for pain The nurse assessed audible expiratory wheezes over a clients lower lobes what should the nurse do first after completing this assessment - Correct answer Raise the Head of the bed to a 60° angle Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing the nurse should do is raise the head of the bed to a 60° angle in order to improve ventilation The nurse is flushing a clients peripheral intravenous catheter saline lock with sterile normal saline during the flush the nurse notes that resistance is met what action should the nurse take - Correct answer Remove the saline lock and re-insert in another site Rationale: The peripheral in a minute IV catheter device also known as a saline lock is a device flushed with saline and applied to a PICC to maintain IV access and patency. To maintain patency the lock should be flush with 3 mL of NS before and after each medication administered, after blood draw, and every 12 hours with the saline lock has been not been in use. While saline locks reduce the need to insert IV lines, they do have a risk and should be removed 72 hours after insertion to reduce the likelihood of infection
- chemotherapy for chronic leukemia w/ low WBC - Correct answer ANS: Client with metastatic liver cancer receiving IV morphine for pain. Rationale: The client with my tastic cancer of the liver being treated with IV morphine has the direct prognosis and would most probably benefit from hospice care although the other clients are diagnosed with cancer the health conditions are stabilized with treatment hospice would not be indicated for them at this time The nurse has inserted in indwelling urinary catheter into email client after the flow Of urine has started and the nurse has inserted additional length of tubing through the clients made us what should the nurse do - Correct answer Inflate the balloon with 10 mL of sterile water A client recovering from a CABG (coronary artery bypass surgery) asked the nurse why he has bandages on his legs which of the following should the nurse do to assist this client - Correct answer Remind the client that the veins from the surgery were harvest for the leg region Rationale: preoperative teaching Would have included the veins to be use for the surgery the nurse to remind the client of this teaching to explain the presence of the bandages at this time A client with community acquired pneumonia is admitted and started on IV vancomycin upon assessment the client reports itching in the nurse observes skin changes. After stopping the infusion which action should the nurse implement first - Correct answer Obtain a blood pressure Rationale: Community acquired pneumonia is a lung infection most often caused by streptococcus pneumonia. vancomycin is a
powerful antibiotic commonly used to treat community acquired pneumonia the client symptoms of flushing and itching are characteristics of red man syndrome - a known side effect of vancomycin that can occur if infused to quickly Prior to administering a dose of propranolol hydrochloride (Inderal)10 mg by mouth the nurse assesses the client BP as being 88/50 mmHg what should the nurse do at this time - Correct answer Hold the medication and notify the doctor with the BP reading Rationale: Propanolol hydrochloride (Inderal) is a medication to lower systolic blood pressure if this is not like pressure is below 90 mmHg the medication should not be provided and the doctor should be notified A client is prescribed nitroglycerin ointment 1/2 inch every 6 hours and has a PRN prescription for nitroglycerin tablets 0.3 mg sublingual as needed for chest pain what should the nurse instruct the client about the use of these medication in the event of an acute angina attack - Correct answer Take one nitroglycerin tablet sublingual every five minutes for up to three doses in 15 minutes for chest pain The nurse is evaluating the need for clients on a cardiac step down unit to continue to have central venous access device in place what is the primary reason for removing these devices if they are no longer needed - Correct answer Reduce the risk of hospital acquired infections Rationale: Centrally located venous access devices are a source for a hospital acquired infections the need for these devices should be evaluated and remove a soon as the clients health status once the removal
Diverticulitis - Correct answer Fecal impaction and obstruction of the lumen of a diverticulum (pouch) inflammation of the diverticulum A client who has been prescribed codeine for pain is experiencing nausea and vomiting what should the nurse do to assist his client
- Correct answer Notify the physician Rationale: Nausea vomiting should be reported to the doctor because a change to another analgesic may be necessary The nurse is teaching a group of students on fetal growth and development which statement regarding fetal circulation is correct
- Correct answer - The umbilical vein transport nutrients and oxygen rich blood to the fetal body
- the foreman oval shunts blood from the right atrium directly to the left atrium bypassing the lungs
- the umbilical cord contains 1 umbilical vein and 2 umbilical arteries An elderly client admitted for pneumonia score 17 on the Braden scale recession scale which intervention should the nurse include in the clients plan of care - Correct answer Implement a two hour turning schedule with a UAP Rationale: The skin is the largest organ on the human body and serves as a barrier to a variety of harmful environmental conditions on a mission the nurse should use a skin risk assessment tool to assess the clients risk for skin breakdown and implement appropriate interventions based on the clients risk I am planning care for a client with cervical spinal injury following MVa which nursing problem has the highest priority - Correct answer Ineffective airway clearance
Rationale: nursing care should be provided according to the principle ABC The nurse is designing a study to evaluate the effectiveness of grief counseling and caregivers who recently lost a spouse after a long-term illness when determining what previous research studies have a dress effectiveness of grief counseling what should the nurse do first - Correct answer Collect research abstracts of studies that focus on the effectiveness of grief counseling Rationale: An astroid provides a quick overview of the study and question address as the research question and gives the reader a very short description of the research method study results and conclusion it's function is to help determine if the research report is relevant to the reader or not 18-year-old child is admitted for treatment of osteosarcoma the nurse notes a stiff body posture elevated heart rate and lack of interaction with the parents which nursing intervention should the nurse implement - Correct answer Administer prescribed pain medication Rationale: Fayetteville acute pain in school age children include activation of the sympathetic nervous system elevated heart rate blood pressure and sweating social withdrawal grimacing crying or decrease interest in normal activities school age children have an awareness of bodily harm and will often fear the administration of medication more than the pain itself they may verbally denies pain to avoid a pain management technique A client who has been taking sildenafil citrate (Viagra) as needed is prescribe sublingual nitro glycerin 0.3 mg as needed for chest pain what should the nurse discuss with the client about taking
Rationale: celiac disease is a hereditary lifelong autoimmune disorder where the ingestion of gluten causes injury to the intestinal lining. Clients should have a gluten free diet Which test diagnose celiac disease - Correct answer Blood test and endoscopy with intestinal biopsy Signs and symptoms of celiac disease - Correct answer Weight loss diarrhea abdominal cramping loss of appetite Hint: Think stomach cramp gives you diarrhea with diarrhea you dont wanna eat and if you dont eat you lose weight A client recovering from an ileostomy feels like it we can dizzy the clients vital signs are blood pressure 95/60 weak and rapid pulse, temperature 99.3 and respiratory rate 20 what nursing diagnosis is a priority at this time - Correct answer Deficient fluid volume Rationale: Lightheadedness dizziness (orthostatic hypotension) low BP, tachycardia and mild increased respiratory rate are all signs of hypovolemia the nursing diagnosis is deficient fluid volume has highest priority at this time clients with ileostomies are particularly at risk for developing hypovolemia due to impaired water absorption A client with irritable bowel syndrome is recovering from surgery to create an ileostomy what foods should the nurse instruct the client to avoid to reduce the risk of food blockage - Correct answer Dried fruits & nuts
Rationale: dried fruits and nuts can cause a blockage in the small intestine the client should be instructed to avoid these food items with an ileostomy A client with malnutrition is assessed for osteomalacia what data show the nurse review to determine their clients risk for this health problem - Correct answer Vitamin D levels Rationale: Malnutrition has widespread affects on various organ systems osteomalacia is defective mineralization of newly formed bones secondary to chronic deficiency of vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide the nurse with the most accurate information regarding this health problem The nurse has determine an adolescent client needs reinforcement education about prevention of a sickle cell crisis which instruction should the nurse include select all that apply - Correct answer Wear warm clothes outside in cold weather take your hydroxyurea (Droxia) daily as prescribed Drink at least eight 12 ounces glasses of water a day Get regular exercise but do not exercise so much that you become tired Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle cell disease. it occurs when the micro circulation is obstructed by sickling of the red blood cells resulting in local tissue ischemia and severe pain. the three most common identify triggers for the development of a vaso-occlusive crisis are hypoxemia, dehydration, and body temperature changes The nurse is caring for a client with schizophrenia who has refused they are risperidone for the last week the client has been suspicious of nursing staff and periodically aggressive for the past
A client with an stage renal failure has requested no further treatment be provided when the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have ended in demands that treatment be continue what should the nurse do it this time - Correct answer Explained that the client has requested that all treatments be stop Rationale: The nurse is responsible for the following clients wishes for treatment the daughter does not need to leave because there's no evidence that the client is upset resuming Dallas treatment is not what the client wants and should not be done the nurse can explain the change in treatments with a daughter and does not need to ask a physician to have this conversation The education department of a healthcare organization has design client education sheet that explains the process of being admitted to the hospital in English Spanish and French since these are the three major language is spoken by the hospitals client population what does the client education sheet reflects - Correct answer Sensitivity to the diverse Client population Rationale: By creating a client education sheet that can be read by the hospitals major client population the education department is demonstrating sensitivity to the diverse client population the education sheet does not reflect racial profiling stereotyping or inappropriate categorizing of the clients population The nurse is emptying the urinary collection bag for a client with history of HIV in which sequence sure the nurse perform the following actions after the urinary collection bag has been drained
- Correct answer Ensure urinary collection bag is placed below the clients bladder empty that your receptacle remove PPE
Wash hands with soap & water Document amount of urine collected Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne illnesses in cases of hematuria healthcare professionals including nurses need to completely situational risk assessment prior to each client interaction to determine risk and choose the appropriate infection control strategy to minimize risk to themselves and their client population according to the CDC A GRANDSon is concern about the older clients happiness and so much time is spent talking about the past what should the nurse respond to the grandson - Correct answer Reminiscing is a common activity in older adults that helps them to stay connected Rationale: The nurse should explain that reminiscing is normal and common activity in older adults talking about the past helps older adult clients stay connected to other people by providing a topic of conversation even if they don't experience much during the day Family of an elderly Japanese woman is upset because the client has not received any pain medication the nurse explains that the client never complain about pain and did not write the pain and severe when assess what should the nurse manager do - Correct answer Explain that in the Japanese culture people often show a stoic response to pain so that it is important to look for PHYSICAL clues Rationale: individuals of Japanese descent will not complain about pain as they do not want to dishonor themselves or their families some will either refuse pain medication when offered therefore it is important to look for physical clothes like (rocking, sweat on brows, elevated blood pressure) and input from the family when assessing for pain
phlebitis - Correct answer Inflammation of the rain caused by irritation solutions medication or the angiocatheter being in place for days superficial thrombophlebitis - Correct answer Inflammation of a vein just below the surface of the skin caused by formation of a thrombus this may cause pain, tenderness or hardening of the vein these often resolved without intervention elevating the extremity and applying warm compress can relieve symptoms The case manager on an oncology unit is determining which clients might be appropriate to consider for hospice which client will most likely benefit the most from this level of care
- recovering from radioactive iodine for thyroid cancer
- metastatic liver cancer receiving IV morphine for pain
- recovering from lumpectomy for breast cancer with no nodal involvement
- chemotherapy for chronic leukemia w/ low WBC - Correct answer ANS: Client with metastatic liver cancer receiving IV morphine for pain. Rationale: The client with my tastic cancer of the liver being treated with IV morphine has the direct prognosis and would most probably benefit from hospice care although the other clients are diagnosed with cancer the health conditions are stabilized with treatment hospice would not be indicated for them at this time The nurse has inserted in indwelling urinary catheter into email client after the flow Of urine has started and the nurse has inserted additional length of tubing through the clients made us what should the nurse do - Correct answer Inflate the balloon with 10 mL of sterile water A client recovering from a CABG (coronary artery bypass surgery) asked the nurse why he has bandages on his legs which of the
following should the nurse do to assist this client - Correct answer Remind the client that the veins from the surgery were harvest for the leg region Rationale: preoperative teaching Would have included the veins to be use for the surgery the nurse to remind the client of this teaching to explain the presence of the bandages at this time A client with community acquired pneumonia is admitted and started on IV vancomycin upon assessment the client reports itching in the nurse observes skin changes. After stopping the infusion which action should the nurse implement first - Correct answer Obtain a blood pressure Rationale: Community acquired pneumonia is a lung infection most often caused by streptococcus pneumonia. vancomycin is a powerful antibiotic commonly used to treat community acquired pneumonia the client symptoms of flushing and itching are characteristics of red man syndrome - a known side effect of vancomycin that can occur if infused to quickly Prior to administering a dose of propranolol hydrochloride (Inderal)10 mg by mouth the nurse assesses the client BP as being 88/50 mmHg what should the nurse do at this time - Correct answer Hold the medication and notify the doctor with the BP reading Rationale: Propanolol hydrochloride (Inderal) is a medication to lower systolic blood pressure if this is not like pressure is below 90 mmHg the medication should not be provided and the doctor should be notified
