Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
BSN266 Week7/8 Hesi
Practice HESI BSN266 #2
| Question | Answer |
|---|---|
| The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? | An image that describes metastatic sites of cancer. |
| The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? | Auscultation |
| Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? | Slow capillary refill in the digits with absent distal pulse points. |
| A nurse is preparing a teaching plan for a client who is post-menopausal. Which measure is most important for the nurse to include to prevent osteoporosis? | Perform weight resistance exercises. |
| A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? | Fingerstick glucose of 300 mg/dl. |
| The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? | Administer medications for pain relief, shortness of breath, and nausea. |
| A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? | Assess for signs of bleeding and hypovolemia. |
| The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? | Compress the flank and upper buttocks. |
| The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? | Risk for infection. |
| Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine | |
| but that his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? | Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. |
| A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. | |
| The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? | An electrical stimulus is discharged when no ventricular response is sensed. |
| The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? | Prevent the formation of effusion fluid. |
| The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? | Determine the time the client last voided. |
| A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication? | Gastrointestinal disturbance. |
| What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? | Use a bag-valve-mask resuscitator while removing the client from the area. |
| The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client? | Return to pre-illness weight. |
| A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? | Chest x-ray indicating a mediastinal shift. |
| A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis? | Inflammation is reduced by inhibiting prostaglandin synthesis. |
| The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? | Pulse change from 85 to160 beats/minute lasting more than 10 minutes. |
| A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? | "Get involved with a support group. I will give you some names." |
| Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? | Cherry red color to the mucous membranes. |
| A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? | "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." |
| A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. | |
| The client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? | Assist the client to ambulate in the hall. |
| A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? | Leave the cream on the skin for 1 to 2 hours before the procedure. |
| A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? | Evaluate the effectiveness of narcotic analgesics. |
| A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? | Bluish periumbilical skin discoloration. |
| A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? | Provide cheese and bread to eat. |
| A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify? | Flushed skin and headache. |
| Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? | Use an end-tital CO2 detector. |
| The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? | Have intercourse or masturbate at least twice a week. |
| The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? | Extend the arm, dorsiflex the wrist, and extend the fingers. |
| A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information? | Low impact exercise, walking, swimming and water aerobics. |
| A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? | Heart palpitations. |
| In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? | Left lateral, supine, brief periods on the right side, and prone. |
| A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? | Achieve a sense of control. |
| During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? | Promotion of comfort. |
| The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis? | "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." |
| A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? | Turn off the television and darken the room. |
| A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which conclusion regarding this lab data is accurate? | Low risk for prostate cancer. |
| The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? | Avoid allergy medications that contain pseudoephedrine or phenylephrine. |
| The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) | Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head |
| The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? | Assist the client in coping with hot flashes. |
| The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement? | Give IV fluids with electrolytes. |
| The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. | |
| The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? | It is slow to leave the stomach. |
| Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? | Human papillomavirus. |
| A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. | |
| What action should the nurse implement? | Notify the healthcare provider. |
| The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) | Hearing aid. Contact lenses. Partial dentures. |
| The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? | Nothing by mouth is allowed for 6 to 8 hours before the study. |
| A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? | Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. |
| The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? | Check stools for occult blood. |
| The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? | Yellowish discoloration of the sclerae. |
| A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client’s adjustment to HIV infection? | Discuss retesting to verify the results, which will ensure continuing contact. |
| The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? | Maintains correct spinal alignment to protect the surgical area. |
| What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? | Catheterize every 3 to 4 hours. |
| Which client should the nurse assess first? | A 55-year-old newly admitted client complaining of jaw pain and indigestion. |
| Which client is at highest risk for compromised psychological adjustment after a hysterectomy? | A 29-year-old woman whose uterus ruptured after giving birth to her first child. |
| The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). | |
| Which explanation best describes how they are different? | Method of insertion. |
| The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? | Increased abdominal pain with rebound tenderness. |
| A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, | |
| the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? | Exposure to cold environmental temperatures. |
| Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? | Metastatic cancer. |
| What is the primary nursing problem for a client with asymptomatic primary syphilis? | Deficient knowledge. |
| The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? | Pathologic fracture of two ribs on the right chest. |
| A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). | |
| The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? | Document the finding as the only action. |
| A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? | Notify the client's healthcare provider. |
| When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.) | Keeping the head of the bed elevated 30 degrees. Changing the enteral-feeding bag every 24 hours. Checking the placement of the tube by means of gastric aspiration. |
| During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client’s stoma is dry and dark red in color. What action should the nurse implement? | Notify the surgeon. |
| A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? | Evaluate the client's ability to adjust the voltage to control pain. |
| The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? | There is a radical change in appearance as a result of this surgery. |
| Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? | Anticoagulation therapy. |
| The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? | Increase in abdominal fat deposits. |
| A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? | Instill the first dose of nystatin (Mycostatin) vaginally per applicator. |
| The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? | Apply the blood pressure cuff to the arm on the non-operative side. |
| A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? | The registered nurse (RN) case-manager for the unit with 1 year's experience. |
| The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? | Upper chest subcutaneous emphysema. |
| The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement? | Gloves should be worn during direct contact with the client's skin. |
| A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? | Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. |
| An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? | Measure the blood pressure. |
| A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? | Give a sublingual nitroglycerin tablet. |
| The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client’s urinary catheter is not draining. What should the nurse implement? | Irrigate the catheter. |
| An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? | Impaired comfort |
| When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? | Dry, itchy skin changes may occur. |
| The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? | Teach measures to avoid the Valsalva maneuver. |
| A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? | Allow the client nothing by mouth until the gag reflex returns. |
| A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands? | The client should not be catheterized through the stent for at least three months. |
| When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? | Acute pain related to movement of the stone. |
| A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) | Obtain consent for the procedure. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. |
| A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? | "I know I will miss having sexual intercourse with my husband." |
| Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) | pH 6. Specific gravity 1.015. |
| The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? | Wash hands after caring for the client. |
| The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? | Observe the client for coughing colored sputum after drinking a small amount of colored water. |
| A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? | Serosanguineous nasal drainage. |
| The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) | Vagal stimulation. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. |
| A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? | The cell count of the tumor reduces by half with each dose. |
| The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the nurse implement? | Document the temperature reading on the vital sign graphic sheet. |
| A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings? | Myocardial damage that occurred several days earlier is best validated by serum troponin levels. |
| A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) | Smoking can decrease the quantity and quality of sperm. Cessation of smoking improves general health and fertility. |
| The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately? | Severe muscle pain. |
| Which method elicits the most accurate information during a physical assessment of an older client? | Use reliable assessment tools for older adults. |
| What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? | Wheezing becomes louder. |
| Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? | Obtain a prescription for an adjusted dose of insulin. |
Created by:
Janelleu4771
Popular Nursing sets