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Practice HESI BSN265
week 3
| Term | Definition |
|---|---|
| An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? | confusion and tachycardia |
| The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? | Willingness of the client to learn the injection sites. |
| In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) | Monitor hemoglobin and hematocrit levels. Set the infusion pump to infuse the albumin within four hours. Assess for increased bleeding after administration. |
| A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? | Evaluate his blood pressure, pulse, and respiratory status. |
| What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? | Bronchodilators and steroids. |
| A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? | Lower left quadrant pain and a low-grade fever. |
| The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? | Cyanosis of the fingertips. |
| A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's | temperature. |
| The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? | She sustained an insect bite to her left arm yesterday. |
| A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? | Adequate cellular nourishment |
| A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response? | Discuss perimenopause and related comfort measures. |
| Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? | Encourage the client to perform Kegel exercises 10 times daily. |
| The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? | Potassium 6.0 mEq. |
| The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? | Increase intake of soluble fiber to 10 to 25 grams per day. |
| The nurse formulates the nursing diagnosis of, "Urinary retention related to sensorimotor deficit" for a client with multiple sclerosis. Which nursing intervention should the nurse implement? | Teach the client techniques of intermittent self-catheterization. |
| A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? | Estrogen deficiency causes the vaginal tissues to become dry and thinner. |
| Which postmenopausal client's complaint should the nurse refer to the healthcare provider? | Episodes of vaginal bleeding. |
| Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? | medium yellow |
| A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client? | Restrict salt and fluid intake. |
| An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns? | Regenerative function of the skin is absent because the dermal layer has been destroyed. |
| When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching? | Tell the client to carry a medic alert card stating that he is a total neck breather. |
| A pt who was in a mvc was admitted and the R knee was placed in skeletal traction. RN documented this nursing dx in the pt EMR "Potential for impairment of skin integrity r/t immobility from traction." Which nursing intervention is indicated for this dx? | Provide back and skin care while maintaining the traction. |
| A middle-aged male client with DM continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? | He visits his diabetic brother who just had surgery to amputate an infected foot. |
| A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? | A potassium supplement will be prescribed. |
| A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? | Schedule extra rest periods. |
| A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? | The immunization is administered once to older adults or persons with a history of chronic illness. |
| During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? | Reposition the head to validate that the head is in the proper position to open the airway. |
| The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include? | Maintain a fluid intake of 3 to 4 L per day. |
| A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? | Lung tissue biopsy. |
| The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? | Check for tube placement and residual volume q4 hours. |
| A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? | "At what time do you take your medication?" |
| In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? | potassium |
| A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? | Start an IV nitroglycerin infusion. |
| During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? | An individual may select healthcare providers from outside of the PPO network. |
| A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? | Serum creatinine. |
| A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? | Purulent sputum. |
| A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? | Raising the head of the bed on blocks. |
| A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? | Calcium loss from bones can be slowed by increasing calcium intake and exercise. |
| The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? | Two weeks before menstruation. |
| A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? | Inability to get pregnant. |
| A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's MAR. Which medication is most likely the cause of the bradycardia? | Propanolol (Inderal). |
| A female pt is brought in by her daughter for a flu shot. She has lost significant wt, poor personal hygiene and inadequate clothing for the weather. Pt.states that she lives alone and denies problems or concerns. What action should the nurse implement? | Collect further data to determine whether self-neglect is occurring. |
| Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? | Headache, diaphoresis, and palpitations. |
| Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? | Place a large tourniquet at the client's bedside. |
| The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? | Sweating, trembling, tachycardia. |
| A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? | "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." |
| A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? | Osteoporosis resulting from hormonal changes. |
| While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? | Four to six weeks after the exposure. |
| Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? | 3+ bacteria in urine. |
| A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit? | Elevated CK-MB. |
| Which milestone indicates to the nurse successful achievement of young adulthood? | Completes education and becomes self-supporting. |
| The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement? | Question the healthcare provider's prescription. |
| A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client? | Impaired communication related to paralysis of skeletal muscles. |
| The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? | The usual activity patterns of each member of the group. |
| The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? | "Have you ever been 'frozen' in one spot, unable to move?" |
| The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? | Allow the client to sit with the bed in a high Fowler's position. |
| Which assessment finding by the nurse during a client's clinical breast examination requires follow-up? | Newly retracted nipple. |
| The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? | If the client's wound is infected. |
| After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? | 5 minutes before and 30 minutes after the next dose. |
| Which information about mammograms is most important to provide a post-menopausal female client? | Yearly mammograms should be done regardless of previous normal x-rays. |
| What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? | Perform a breast self-exam (BSE) procedure monthly. |
| A 72-year-old male client tells the nurse that he is experiencing SOB. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? | Productive cough with grayish-white sputum. |
| A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because | gram-negative organisms are more resistant to antibiotic therapy. |
| A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? | The tumor's estrogen receptor guides treatment options. |
| A client who is sexual active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? | Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). |
| The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? | An allergy to sulfa drugs. |
| Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. | Wear gloves when coming in contact with the blood or body fluids of any client. |
| A client’s susceptibility to ulcerative colitis is most likely due to which aspect in the client’s history? | Jewish European ancestry. |
| The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit? | Shuffling gait, masklike facial expression, and tremors of the head. |
| The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? | Shock the client with 200 joules per hospital policy. |
| Which client should the nurse recognize as most likely to experience sleep apnea? | Obese older male client with a short, thick neck. |
| A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? | Prevention of deformities. |
| Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? | Sudden, stabbing, severe pain over the lip and chin. |
| During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? | Attempt to reinsert the tracheostomy tube. |
| A pt w/ a 16-year history of diabetes mellitus is having renal function tests d/t of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? | Nocturia |
| During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? | muscle weakness |
| During lung assessment, the nurse instructs the pt to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? | May indicate pneumonia |
| When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? | Place a small book or magazine on the abdomen and make it rise while inhaling deeply. |
| How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? | Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. |
| A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? | Check the client's gag and swallow reflexes. |
| The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's | serum potassium level is 3. |
| In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? | Smoking cessation program. |
| Elderly M pt comes to the geriatric clinic c/o pain in his L calf. The nurse notices a reddened area on the calf of his R leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? | Pain in the calf upon exertion which is relieved by rest and elevating the extremity. |
| A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What initial medication should the nurse anticipate administering to the client? | Digoxin |
| A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? | "Most lumps are benign, but it is always best to come in for an examination." |
| The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? | Initiate a weight-reduction diet to achieve a healthy body weight. |
| A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant | - |
| and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) | Alcohol consumption can cause erectile dysfunction. Low testosterone levels affect sperm production. Cessation of smoking improves general health and fertility. |
| The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) | The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS. The diaphragm should be replaced every 3 months to maintain integrity. |
| A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? | An accurate menstrual cycle diary for the past 6 to 12 months. |
| The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? | Diabetes Mellitus |
| What discharge instruction is most important for a client after a kidney transplant? | Use daily reminders to take immunosuppressants. |
| The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? | Difficulty in handwriting. |
| A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? | Initiate continuous cardiac monitoring. |
| The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. | - |
| Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? | Call for an ECG to be performed immediately. |
| A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? | Give an antihypertensive medication. |
| The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? | Increased protein in the urine, slightly increased serum glucose levels. |
| An 81-y/o M client has emphysema, lives at home w/ his cat and manages self-care with no difficulty. During a home visit, the nurse notices his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? | Help the client to determine ways to increase his fluid intake. |
| Small bowel obstruction is a condition characterized by which finding?Intermittent lower abdominal cramping. | Severe fluid and electrolyte imbalances. |
| Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to this client? | Advise the client to remain in bed with the leg elevated. |
| The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? | Serum calcium of 5 mg/dl. |
| A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? | k |
| A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? | "AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual." |
| A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. | - |
| Which question is a priority for the nurse to ask this client or her family on admission? "Does the client | take digitalis?" |
| What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? | From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. |
| A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? | Advise the client to notify the healthcare provider for immediate medical attention. |
| The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? | Normal skin coloring. |
| In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? | A 50-year-old whose mother had unilateral breast cancer. |
| A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? | Inflammatory with peau d'orange. |
| A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? | Information about smoking cessation. |
| After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output | - |
| of 54 ml for the last 2 hours. What priority nursing action should be implemented? | Report the findings to the surgeon. |
| A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? | "The test you are having tomorrow requires that you have nothing by mouth tonight." |
| The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. | - |
| The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client? | Disabled family coping related to dissonant coping style of significant person. |
| A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? | Feelings of dizziness. |
| When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? | Elimination of hazards to home safety. |
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