HESI 101-200 Flashcards
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
A client presents in the emergency room with right-sided facial asymmetry. The
nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke?
Inability to close the affected eye, raise brow, or smile
The nurse is teaching a client how to perform colostomy irrigations. When
observing the client’s return demonstration, which action indicated that the client understood the teaching?
Keeps the irrigating container less than 18 inches above the stoma
The nurse should teach the client to observe which precaution while taking dronedarone?
Avoid grapefruits and its juice
A client who sustained a head injury following an automobile collision is
admitted to the hospital. The nurse include the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?
Confusion and papilledema
The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?
Confirm the necessity for continued use of the CVC.
During an annual physical examination, an older woman’s fasting blood sugar
(FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
A new mother tells the nurse that she is unsure if she will be able to transition into
parenthood. What action should the nurse take?
Determine if she can ask for support from family, friend, or the baby’s father.
A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?
Stop the normal saline infusion.
An elderly female is admitted because of a change in her level of sensorium.
During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care?
Ensure proper alignment of the leg in traction.
An Unna boot is applied to a client with a venous stasis ulcer. One week later,
when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?
Document the ongoing wound healing.
At the end of a preoperative teaching session on pain management techniques, a
client starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing diagnosis for this client?
Anxiety
The nurse note a visible prolapse of the umbilical cord after a client experiences
spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?
Elevate the presenting part off the cord.
A client who had a right hip replacement 3 day ago is pale has diminished breath
sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider?
Reassess readiness for SNF transfer.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)
Recognize signs and symptoms of hypoglycemia.
Report persist polyuria to the healthcare provider.
Take Glucophage with the morning and evening meal.
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply
Contains a list with definitions of unfamiliar terms
Uses common words with few syllables
Uses pictures to help illustrate complex ideas
During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI)
This is a picture. Please reference the document
An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)
Notify the healthcare provider of the client’s change in mental status.
Include q2 hour’s reorientation in the client’s plan of care.
An older male comes to the clinic with a family member. When the nurse
attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse implement first?
Assess the surroundings for noise and distractions
The nurse caring for a client with acute renal fluid (ARF) has noted that the client
has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?
Large amounts of fluid and electrolyte replacement.
Which intervention should the nurse include in the plan of care for a child with tetanus?
Minimize the amount of stimuli in the room
Suicide precautions are initiated for a child admitted to the mental health unit
following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client’s room
A family member of a frail elderly adult asks the nurse about eligibility
requirements for hospice care. What information should the nurse provide? (Select all that apply.)
A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.
A client with atrial fibrillation receives a new prescription for dabigatran. What
instruction should the nurse include in this client’s teaching plan?
Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
A nurse with 10 years experience working in the emergency room is reassigned to
the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
A mother with an infected episiotomy
An infant who is admitted for surgical repair of a ventricular septal defect (VSD)
is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?
Digoxin.
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
Supervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
Ask the client what he is thinking about at his time.
After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
Administer PRN nebulizer treatment.
Obtain 12 lead electrocardiogram.
Monitor continuous oxygen saturation.
The nurse caring for a 3 mont old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
Administer a prescribes analgesia for pain
A 4 year old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that included methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?
Use sunblock or protective clothing when outdoors
Two days after admissions male client remembers that he is allergic to eggs, and informs the nurse of the allergy. What actions should the nurse implement (Select all that apply)
Notify the food services department of the allergy
Enter the allergy information in the clients record
Add egg allergy to the clients allergy arm band
The rapid response teams detect return of spontaneous circulation (ROSC) after 2 mins of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?
Reform bilateral chest auscultation
After administering an antipyretic medication. Which intervention should the nurse implement?
Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?
Describe radioactive iodine as a tasteless, odorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the Post-anesthesia Care Unit (PACU). Which intervention should the nurse implement first?
Determine client’s pulse, blood pressure and respirations
The nurse is caring for a groups of clients with the help of licensed practical nurse (LPN) and an unexperienced unlicensed assistive personal (UAP). Which procedures can the nurse delegate to the UAP? ( select all that apply)
Take postoperative vital signs for a client who has an epidural following knew arthroplasty
Collect a sputum specimen for a client with a fever of unknown origin
Ambulate a client who has a femoral-popliteal bypass graft yesterday
A male client with cirrhosis has ascites and reports feeling short of breath. The clients is in semi Fowler position with his arms at his side. What action should the nurse implement.
Raise the bed to a Fowler’s position and support his arms with a pillow
A client with a history of chronic pain requests a non-opiod analgesic. The client is alert but has difficult describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?
Administer the analgesic as requested
A client with chronic health problem has difficult ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?
Crutches with a 4 point gait
The nurse uses parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement ) to calculate the 24-hours IV fluid replacement for a client with 40 % burns who weights 76 kg. How many ml should the client receive ?
12160 (4ml x 67 kg x 40 (bsa) = 12, 160 ml)
A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
Observe aspiration site
An 18 year old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual papnicolaou (pap) smears
A client admitted to the psychiatric unit diagnosed with major depression want to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
Establish a structured routine for the client to follow
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrant immediate intervention by the nurse?
Ventricular arrhythmias
The mother of a 7 month old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child’s diaper more often
A resident of a long-term care facility, who has moderate dementia, is having difficulty in the dinning room. The client becomes frustrated when dropping utensils on the floor and then refused to eat. What action should the nurse implement?
Encourage the client to eat finger foods
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to assess the effectiveness of the medication?
Bowel patterns
While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor
A 16 year old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump?
83
While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. What action should the nurse implement first?
Submit a referral for an evaluation by a physical therapist
A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement?
Palpate at the radial pulse site with the pads of two or three fingers
A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assertive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?
Reposition the client with the head of the bed elevated
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to hold, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and intimated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?
Ask the older brother how he felt during the incident
After six days on a mechanical ventilator, a male client is extubated and placed on 40% oxygen via face mask. He is awake and cooperative, but complaint of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
Hold oral intake until swallow evaluation is done
The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (select all that apply)
Interacts with a flat affect
Avoids eye contact
Has a disheveled appearance
A client in the post-anesthesia care unit (PACU) has an either on the Aldrete post anesthesia scoring system. What intervention should the nurse implement?
Transfer the client to the surgical floor
In caring for the body of a client who just died, which tasks can be delegated to the unlicensed assertive personnel (UAP)? (select all that apply)
Place personal religious artifacts on the body
Attach identifying name tags to the body
Follow cultural beliefs in preparing the body
An adult male reports the last time he received penicillin he developed a severe maculopapular rash al over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
Be alert for possible cross-sensitive to cephalosporin agents
A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
The client’s need for pain medication should be determined
A client with cirrhosis of the liver is admitted which complications related to end stage liver disease. Which intervention should the nurse implement? (select all that apply)
Monitor abdominal girth
Report serum albumin and globulin levels
Note the signs of swelling and edema
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Report weight gain of 2 pounds in 24 hours
Which problem, noted in the client’s history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin repute inhibitor (SSRI)?
Aural migraine headaches
When implementing a disaster intervention plan, which intervention should the nurse implement first?
Identify a command center where activities are coordinated
The nurse is evaluating a client’s symptoms, and formulates the nursing diagnosis, “high risk for injury due to possible urinary tract infection.” which symptoms indicate the need for this diagnosis?
Fever and dysuria
A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4 + pitting edema of both lower extremities. When the client complains that the anti embolic stockings are too constricting, which intervention should the nurse implement?
Maintain both lower extremities elevated on pillows
A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activated of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client’s plan of care?
Teach family proper range of motion exercises
The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?
Postmenopausal women needs an intake of at least 1,500 mg of calcium daily
when evaluating a client’s rectal bleeding, which findings should the nurse document?
Color characteristics of each stool
The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document the is sound?
High pitched or fine crackles
An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a CT scan, he requests something for a sever headache. When the nurse offers hims a rep scribed dose of acetaminophen, he asks of something stronger. Which intervention should the nurse implement?
Explain the reason for using only non-narcotics
The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assertive personnel (UAP)? ( Select all that apply)
Weigh the client and report any weight gain
Report any client complaint of pain or discomfort
Note and report the client’s food and liquid intake during meals and snacks
Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client’s plan on care?
Medicate as needed for pain and anxiety
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to not as a result of this increases in glaucoma surgeries?
Decrease prevalence of glaucoma in the population
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
Convey to the client that birth is imminent
To evaluate the effectiveness of male client;s new prescription for ezetimibe, which action should the clinic nurse implement?
Remind the client to keep his appointments to have his cholesterol level checked
Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?
Fall prevention measures
A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm hg, temperature 98.6 F, pulse 124 bpm and respirations 22 breaths/min. Based on these data, the nurse formulates the first portion of nursing diagnosis as “risk of injury”what term best expresses the “related to “portion of nursing diagnosis?
Shock
An older client who as diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaint of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?
New onset of purple skin lesions
In assessing a client twelves hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?
Ensure that no dependent loops are present in the tubing
The healthcare provider prescribes the antibiotics Cefdinir (cephalosporin) 300 mg PO every 12 hours for ancient with post operative wound infections. Which feeds should the nurse encourage this client to eat?
Yogurt and/or buttermilk
The charge nurse is making assignments on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?
A young male with schizophrenia who said voices is telling him to kill his psychiatrist
A client at 30 weeks gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35mg is given subcutaneously. Based on which findings should the nurse withheld the next dose of this drug?
Maternal pulse rate of 162 beats per min
In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client’s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?
Anxiety related to fear of suffocation
A client with a cervical spinal cord injury (SCI) has crutch field tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client’s plan of care?
Provide daily care of tong insertion sited using saline and antibiotic ointment
A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?
Determine the client’s vital signs
A client is admitted to the mergence department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?
No wheezing upon auscultation of the chest
The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?
During acute illness
A 350-bed acute care hospital declares an internal disaster because the mergence generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?
Tell all their assigned clients to stay in their rooms
The nurse is auscultating a clients heart sounds. Which description should the nurse use to document this sounds?
Murmur
The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?
Administer the medication via the oral route as prescribed
A client refuses to ambulate, reporting abdominal discomfort and bloating caused by “too much gas buildup”the client’s abdomen is distended. Which prescribed PRN medication should the nurse administer?
Simethicone (Mylicon)
The public health nurse received funding to initiate primary prevention program int he community. Which program best fits the nurse’s proposal?
Vitamin supplements for high risk pregnant women
When assessing an adult male who presents as the community health clinic with a shivery of hypertension, the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflux disease (GERD) and depression. Which intervention is the most important of the nurse to implement?
Review the client’s use of over the counter (OTC) medications
An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital sings are: temperature 96 F, Heart rate 122 beats/min, respiratory rate 36 breaths/min, mean arterial pressure (MAP) 65 mm Hg and Central venous Pressure (CVP) 7 mm Hg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 60,000 and white blood cell count (WBC) 3,000/mm3. Based enthuse findings this client is at greatest risk for which pathophysiological condition?
Multiple organ dysfunction syndrome (MODS)
A man expresses concern to the nurse about the care his mother is receiving whole hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?
Provide the man and his mother with a copy of the patient’s bill of rights
A client experiencing withdrawal from the benzodiazepines alprazolam (xanax) is demonstrating severe aviation and tremors. What is the best initial nursing action?
Initiate seizure precautions
