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BSN 246 Week 7/8
Health Assessment Practice HESI
| Question | Answer |
|---|---|
| Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? | Maintain eye contact with the client while listening to the translation. |
| A male pt is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? | A fracture that bends or splinters part of the bone. |
| A pt in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse identify in the client's history? | Heart Failure |
| The registered nurse (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? | pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. |
| The RN is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? | Paid resolution of wheezing Improved pulse oximetry values |
| The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during the initial dose? | Dystonia |
| A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? | Face the client so the client can see the RN's mouth. Reduce environmental noise surrounding the client. |
| The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). | Gastric pain on an empty stomach. Intolerance of spicy foods. |
| While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? | Monitor infusing IV fluids and any replacement blood products. |
| After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? | Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. |
| The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? | Fever related to infection. |
| Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? | Lethargy |
| The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? | The development of resistant strains of TB are decreased with a combination of drugs |
| A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? | Request a male nurse or healthcare provider to perform the exam. |
| The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? | The client is treating the nurse with respect. |
| The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? | Dyspnea |
| The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? | Amylase |
| A female client calls the clinic and talks with the (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? | Consult with healthcare provider about another treatment for this effect. |
| The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? | The client will remain free from injury. |
| A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? | Withhold medication and report symptoms and vital signs to healthcare provider. |
| The RN notifies the S/O of a pt admitted to hospice w/ shallow respirations, of a change in the pt's condition. The pt's respiratory pattern has changed to Cheyne Stokes. After receiving this information, the pt's spouse begins vacuuming. | Which stage of grief is the spouse displaying? Denial |
| The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) | Diminished hair on legs Skin cool to touch |
| The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? | Sphygmomanometer. |
| A F pt is recently diagnosed w/ Sarcoidosis. The pt tells the RN that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs in which ethnic group of women? | African American women. |
| The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) | Diminished hair on legs Skin cool to touch |
Created by:
Janelleu4771
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