NR 340 FINAL EXAM

NR 340 HESI FINAL EXAM (160 Questions and Answers)

• While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client’s legs. What additional assessment provides further data to support this finding?
• The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant receive?
• In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should the nurse implement?
• A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective?
• An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client’s comment, what previous lab values should the nurse compare with today’s lab report?
• Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
• Which signs or symptoms are characteristic of an adult client diagnosed with Cushing’s syndrome?
• A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client
• An outcome for treatment of peripheral vascular disease is, “The client will have decreased venous congestion.” What client behavior would indicate to the nurse that this outcome has been met?
• The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?
• The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?
• The nurse formulates a nursing diagnosis of, “High risk for ineffective airway clearance” for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
• Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds and firm, distended abdomen. Which prescription for the client should the nurse question?
• A client’s telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate?
• In assessing a 70-year-old female client with Alzheimer’s disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client’s plan of care?
• A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?
• An 85-year-old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
• The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide?
• In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?
•  A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?
• The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm3. What intervention should the nurse implement?
• A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has “little reason to live.” She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client’s confidentiality and to help ensure her safety, which action is best for the nurse to implement?
• It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?
• A nurse is completing the health history for a 25-year-old male client who reports that he is allergic to penicillin. Which question should the nurse ask after receiving this information?
• A 10-year-old child with meningitis is suspected of having diabetes insipidus. In evaluating the child’s laboratory values, which finding is indicative of diabetes insipidus?
• A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
• A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are, BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are, PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority?
• A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What action should the nurse take first?
• A client in labor states, “I think my water just broke!” The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
• The nurse is planning care for a non-potty-trained child with nephrotic syndrome. Which intervention provides the best means of determining fluid retention?
• The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend’s child the following day. What response should the nurse provide this mother?
• The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, “The pills don’t seem to be working. They are not helping the pain at all.” Which factor should influence the nurse’s response?
• A nurse is interested in studying the incidence of infant death in a particular city and wants to Question: A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per minute. Which drug is the transport team most likely to administer to this infant?
• Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?
• A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
• A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement?
• A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, “I don’t know how I will go on.” What is the most likely reason for the nurse’s behavior?
• An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client’s blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6º F. The client’s fundus is firm and one fingerbreadth above the umbilicus. What action should the charge nurse implement first?
• In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize that which intervention is essential?
• Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions?
• A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?
• A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client’s respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. What is the legal status of the nurse?
• A client with which problem requires the most immediate intervention by the nurse?
• The charge nurse should intervene when what behavior is observed?
• Which assessment finding indicates a client’s readiness to leave the nursing unit for a bronchoscopy?
• The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
• administer the first application of the topical antimicrobial agent mafenide acetate (Sulfamylon) to the burned area. Which intervention should the nurse implement first?
• A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond?
• A client diagnosed with Type 1 diabetes is NPO for a diagnostic test. The nurse is preparing to administer 24 units of 70/30 insulin. Which intervention should the nurse implement first?
• The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid?
• A 36-year-old client is admitted to the ICU following a six-hour surgery to repair a fractured pelvis, and the estimated intraoperative blood loss (EBL) was 3,000 ml. Current client data include: BP 85/70, heart rate 140 beats/minute, urine output 10 ml/hr, PAWP 2, RAP -3, Hct 20%, Hgb 7 g/dl. What action should the nurse take at this time?
• The nurse administers nalbuphine (Nubain) to a postoperative client. What etiology, secondary to the medication’s effects, places the client at risk for injury?
• A client who has end-stage renal disease (ESRD) continues to be despondent after receiving the biologic response modifier (BRM) epoetin alfa (Epogen, Procrit) for 3 weeks. Which parameters should the nurse assess when evaluating the effectiveness of this BRM?
• A 25-year-old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. What is the most important information for the nurse to include in the teaching plan?
• A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement?
• A young adult male is brought to the emergency room with multiple gunshot wounds in the chest, abdomen, and head. After collecting the client’s blood-saturated clothing as forensic evidence for the medical examiner, which action should the nurse implement?
• A male client asks the nurse how long his hospital stay will be following his scheduled surgery. Which resource provides the best guide for the nurse in responding to the client?
• A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?
• The nurse-preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?
• Prior to obtaining an axillary temperature, the nurse should perform which action?
• When is the best time for the nurse to assess a client for residual urine?
• Which finding should raise the greatest concern for a nurse who is performing an ENT examination?
• During a home visit, the nurse should evaluate the adequacy of a client’s treatment for COPD by assessing for which primary symptom?
• The community health nurse is working in a multi-ethnic health center. In what situation should the nurse intervene?
• A 62-year old male client with a history of coronary artery disease complains that his heart is “racing” and he often feels dizzy. His blood pressure is 110/60, and he uses portable oxygen at 2 liters per nasal cannula. Based on the rhythm shown, the nurse should administer which prescription?
• The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
• A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe?
• A client with late stage rheumatoid arthritis frequently drops the silverware while eating. Which resource would be of greatest value to this client?
• The mother of a one-month-old calls the clinic to report that the back of her infant’s head is flat. How should the nurse respond?
• A 10-year-old boy is admitted to Neuro Intensive Care following a supratentorial craniotomy. What postoperative intervention should the nurse plan to implement?
• …….. finding in an elderly female client who was started on digoxin (Lanoxin) 0.25 mg indicates that the medication is producing a therapeutic effect?
• The nursing diagnosis, “High risk for infection” is most relevant for a client with which hematologic problem?
• …….. alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85%. What action should the nurse take first?
• A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test?
• Following a traumatic delivery, an infant receives an initial Apgar of 3. What intervention is most important for the nurse to implement?
• A client weighing 176 pounds is started on a weight-based heparin protocol. The pharmacy provides 500 ml D5W with 25,000 units of heparin. The sliding scale prescription reads: “Begin the infusion for the client weighing 74-80 kg to infuse at 1000 units/hr; more than 80 kg infuse at 1,200 units/hr; less than 74 kg infuse at 800 ml/hr.” The nurse should regulate the infusion pump at how many ml/hour? (Enter numerical value only.)
• The nurse plans to administer two preoperative medications to a client in a single syringe. The prescription is for meperidine (Demerol) 75 mg and promethazine (Phenergan) 25 mg. The Demerol is contained in a vial labeled 100 mg/ml, and the Phenergan is in a vial labeled, “25 mg/ml.” How many total ml will the syringe contain that the nurse administers to this client? (Enter numerical value only. If rounding is required, round to the nearest hundredth.)
• A 16-year-old male is admitted after a motor vehicle collision with 50% burns over his body. One liter of normal saline is prescribed to infuse over 4 hours. The drop factor is 60 drops per ml. The nurse should regulate the infusion to administer how many drops per minute? (Enter numerical value only.)