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Hessi EXAM V3-160-2022

Messi
Course

Nursing integration (NUR2480)

112 Documents
Students shared 112 documents in this course
Academic year: 2021/2022
Listed bookSaunders Comprehensive Review for the Nclex-Rn Examination
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Miami Regional University

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HESI EXIT

RN

2022 V

160

Questions

  1. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client’s urinary output. b. Request the client’s reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer’s solution.

  2. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the

    • 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal.

  3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/ mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? a. Elevate the foot of the bed. b. Restrict the client’s fluid. c. Begin supplemental oxygen. d. Prepare the client for hemodialysis.

  4. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings. b. Clients reported having new confidence in making healthy food choices. c. Clients who incurred disease complications promptly received rehabilitation. d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.

  5. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the client is experiencing any anxiety. b. Auscultate the client’s bilateral lung sounds and oxygen saturation. c. Notify the healthcare provider about the client’s distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

  6. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. “When I get out of bed quickly, I feel a little dizzy.” b. “The dressing over my incision feels like it is too tight.” c. “I’m most comfortable when the head of the bed is raised.” d. “This IV infusion makes me urinate more often than usual.”

  7. An older adult male who is in his early 70’s is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client’s living will. Which action should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client’s wishes. c. Place a certified copy of the living will in the client’s record. d. Alert the nursing staff of the client’s don’t resuscitate status.

  8. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a. Determine the client’s level of mobility and need for assistance. b. Instruct the UAP that all clients deserve equal care. c. Advice the client to maintain bedrest so that safety can be ensured. d. Assign another UAP to care for the client.

  9. A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. Provide information on ways to increase activity for the family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggested healthy snack items. d. Determine the parents’ degree of concern about their children’s weight.

  10. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Reports left chest wall pain prior to admission. c. Verbalize a fear of being in a confined space. d. Experience facial swelling after eating crab.

  11. The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Keep the nails trimmed short. b. Apply baby lotion to the skin twice daily. c. Bathe the child daily with bath oil. d. Allow the child to wear only 100% cotton clothing.

  12. A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is empty and the baby is missing. What action should the nurse take first? a. Determine if the newborn is in the nursery. b. Activate the lockdown procedure. c. Ask the mother if any visitors were expected to arrive. d. Match ID bands of all infants and mothers on the unit.

  13. While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? a. “Do you often have feeling of sadness?” b. “Are you having problems concentrating?” c. “Have you though about taking your life?” d. “What problems are you facing right now?”

  14. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “kill, kill.” What question should the nurse ask the client next? a. “When did these voices begin?” b. “Have you taken any hallucinogens?” c. “Are you planning to obey the voices?” d. “Do you believe the voices are real?”

  15. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b. The nurse will encourage the client to walk thirty minutes everyday. c. The client’s blood pressure readings will be less than 160/90 mmHg. d. The client’s skin on the lower legs will be intact at the next clinical visit.

  16. When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a.. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives.

  17. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity for the duration of treatment. d. Normal electroencephalogram after drug administration.

  18. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply)

c. Widens stance while working near the sink. d. Bends from the waist to pick trash off the floor. e. Leans forward to pull a pan from a high shelf.

  1. An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? a. Document neurologic changes. b. Reduce environmental stimuli. c. Administer prescribed neuroleptic. d. Review medications for interactions.

a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter.

  1. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? a. Ask family members to remain with the client in the evening from 1700 to 2100 p. b. Ensure that the client is assigned to a room close to the nurses’ station. c. Postpone administration of nighttime medications until after 2300 p. d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.

  2. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client’s plan of care? a. Ensure adequate IV and oral fluid intake. b. Provide ice packs to major joint areas. c. Space analgesics to prevent addiction to narcotics. d. Re-enforce the importance of nutritional balance.

  3. The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) a. Blurred vision b. Headache. c. Lack of appetite. d. Urinary frequency. e. Chills and fever. f. Swollen hands.

  4. A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing. c. Instruct the nurse to remove the needle. d. Prompt the nurse to apply povidone to the site.

  5. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Initiate seizure precautions. b. Assess neurological status every 8 hours. c. Limit oral water intake. d. Administer a hypertonic IV fluids as prescribed.

  6. The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? a. Confirm that the client has been NPO since midnight. b. Review postoperative instructions with the client. c. Offer to assist the client to the restroom to void. d. Determine when the client last had pain medication.

  7. The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read and drive after dark. c. Gray-white circle around the iris of both eyes. d. Cloudy opacity of the crystalline lens.

  8. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. b. Advise him to take his own food with him when going to fast food restaurants with his friends. c. Encourage him to find activities to do with his friends that do not involve eating. d. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

  9. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued. b. Arrange a meeting with the family, physician, and client. c. Ask the chaplain to discuss death issues with the client. d. Request a consultation with the hospital social worker.

  10. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? a. Bring the emergency crash cart to the bedside. b. Prepare a continuous heparin infusion per protocol. c. Provide supplemental oxygen. d. Notify the healthcare provider.

  11. Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? a. Eat a light diet for the rest of the day b. Rest for the next 24 hours since the preparation and the test is tiring. c. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days d. Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

  12. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is a. Difference in the intake and output b. Changes in the mucous membranes c. Skin turgor d. Weekly weight

  13. A client has been diagnosed with Zollinger-Ellison syndrome information is most important for the nurse to reinforce with the client? a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) b. It is critical to report promptly to your health care provider any findings of peptic ulcers c. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors d. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

  14. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? a. Check the protein level in urine b. Have the client turn to the left side c. Take the temperature d. Monitor the urine output

  15. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a. Diminished bowel sounds b. Loss of appetite c. A cold, pale lower leg d. Tachypnea

  16. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

  17. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

  18. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

  19. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles

  20. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

  21. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses

  22. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) ”I knew this would happen. I've been eating too much red meat lately." B) ”I really enjoyed my fishing trip yesterday. I caught 2 fish." C) ”I have really been working hard practicing with the debate team at school." D)”I went to the health care provider last week for a cold and I have gotten worse."

  23. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

  24. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

  25. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

  26. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

  27. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

  28. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101 degrees Fahrenheit (38 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake

  29. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/

  30. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."

  31. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S

  32. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client’s entire body turns a bright red color C) The client states “I have a feeling of getting warm.” D) The client gags and complains “ I am getting sick.”

  33. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

  34. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10 mg/dl C) Venous blood pH 7. D) Serum potassium 6 mEq/L

  35. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

  36. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

  37. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

  38. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

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Hessi EXAM V3-160-2022

Course: Nursing integration (NUR2480)

112 Documents
Students shared 112 documents in this course

University: Miami Regional University

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HESI EXIT
RN
2022 V3
160
Questions

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