NURS 302 Hesi
Questions in this set (58)
The nurse is assessing a client with a chest tube that is A. Emphysema indicates air is leaking beneath the skin
attached to suction and a closed drainage system.
Which finding is most important for the nurse to further
assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the water-seal chamber.
C. Constant air bubbling in the suction-control chamber.
D. Pain rated "8" (0-10) at the insertion site.
Normal urine specific gravity 1.001-1.035
ABX treatment after osteomyelitis Parenteral ABX for 4-8 weeks
Oral ABX for 4-8 weeks
A female client with hyperesthesia on the oncology unit D.
is using a transcutaneous electrical nerve stimulation The oncology nurse has the knowledge and experience with the use of a
(TENS) unit for chronic pain. Which nursing activity transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief,
should the nurse implement instead of delegating to so the nurse should evaluate the client's skill in effectively controlling the pain
a practical nurse (PN)? by adjusting the voltage.
Determine the client's level of discomfort using a pain
rating scale.
Ask the client about her past experience with chronic
pain.
Observe the client's facial expressions for pain and
discomfort.
Evaluate the client's ability to adjust the voltage to
control pain.
, he nurse is providing postoperative instructions for a B, D
female client after a mastectomy. Which information
should the nurse include in the teaching plan? (Select
all that apply.)
Select all that apply
Empty surgical drains once a week using procedure
gloves.
Report inflammation of the incision site or the affected
arm.
Wear clothing with snug sleeves over the arm on the
operative side.
Avoid lifting more than 4.5 kg (10 lb) or reaching
above her head.
In planning care for a client with an acute stroke D.
resulting in right-sided hemiplegia, which positioning After an acute stroke, a positioning and turning schedule that minimizes lying on
should the nurse should use to maintain optimal the affected side, which can impair circulation and cause pain, and includes
functioning? the prone position to help prevent flexion contractures of the hips, prepares
Mid-Fowler's with knees supported. the client for optimal functioning and ambulating.
Supine with trochanter rolls to the hips.
Sim's position alternated with right lateral position q2
hours.
Left lateral, supine, brief periods on the right side,
and prone.
The nurse is assessing a middle-aged male client for D.
risk factors related to chronic illness. Which
finding should the nurse assess further? Development of metabolic syndrome!
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle strength.
Increase in abdominal fat deposits.
What is the priority nursing action while caring for a C.
client on a ventilator when an electrical fire occurs in
the intensive care unit? A client on a ventilator should have respirations maintained with a manual bag-
Tell another staff member to bring valve-mask resuscitator while being moved away from the oxygen wall
extinguishing equipment to the bedside. outlet and fire source.
Close the doors to the client's area when attempting
to extinguish the fire.
Use a bag-valve-mask resuscitator while removing the
client from the area.
Implement an emergency protocol to remove the client
from the ventilator.
The nurse is caring for a client with end stage liver B.
disease who is being assessed for the presence of
asterixis. To assess the client for asterixis, what Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often
position should the nurse ask the client to seen frequently in hepatic encephalopathy. The tremor is induced by
demonstrate? extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic
Extend the left arm laterally with the left palm upward. extension and flexion of the wrist while attempting to hold position.
Extend the arm, dorsiflex the wrist, and extend the fingers.
Extend the arms and hold this position for 30 seconds.
Extend arms with both legs adducted to shoulder width.
Questions in this set (58)
The nurse is assessing a client with a chest tube that is A. Emphysema indicates air is leaking beneath the skin
attached to suction and a closed drainage system.
Which finding is most important for the nurse to further
assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the water-seal chamber.
C. Constant air bubbling in the suction-control chamber.
D. Pain rated "8" (0-10) at the insertion site.
Normal urine specific gravity 1.001-1.035
ABX treatment after osteomyelitis Parenteral ABX for 4-8 weeks
Oral ABX for 4-8 weeks
A female client with hyperesthesia on the oncology unit D.
is using a transcutaneous electrical nerve stimulation The oncology nurse has the knowledge and experience with the use of a
(TENS) unit for chronic pain. Which nursing activity transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief,
should the nurse implement instead of delegating to so the nurse should evaluate the client's skill in effectively controlling the pain
a practical nurse (PN)? by adjusting the voltage.
Determine the client's level of discomfort using a pain
rating scale.
Ask the client about her past experience with chronic
pain.
Observe the client's facial expressions for pain and
discomfort.
Evaluate the client's ability to adjust the voltage to
control pain.
, he nurse is providing postoperative instructions for a B, D
female client after a mastectomy. Which information
should the nurse include in the teaching plan? (Select
all that apply.)
Select all that apply
Empty surgical drains once a week using procedure
gloves.
Report inflammation of the incision site or the affected
arm.
Wear clothing with snug sleeves over the arm on the
operative side.
Avoid lifting more than 4.5 kg (10 lb) or reaching
above her head.
In planning care for a client with an acute stroke D.
resulting in right-sided hemiplegia, which positioning After an acute stroke, a positioning and turning schedule that minimizes lying on
should the nurse should use to maintain optimal the affected side, which can impair circulation and cause pain, and includes
functioning? the prone position to help prevent flexion contractures of the hips, prepares
Mid-Fowler's with knees supported. the client for optimal functioning and ambulating.
Supine with trochanter rolls to the hips.
Sim's position alternated with right lateral position q2
hours.
Left lateral, supine, brief periods on the right side,
and prone.
The nurse is assessing a middle-aged male client for D.
risk factors related to chronic illness. Which
finding should the nurse assess further? Development of metabolic syndrome!
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle strength.
Increase in abdominal fat deposits.
What is the priority nursing action while caring for a C.
client on a ventilator when an electrical fire occurs in
the intensive care unit? A client on a ventilator should have respirations maintained with a manual bag-
Tell another staff member to bring valve-mask resuscitator while being moved away from the oxygen wall
extinguishing equipment to the bedside. outlet and fire source.
Close the doors to the client's area when attempting
to extinguish the fire.
Use a bag-valve-mask resuscitator while removing the
client from the area.
Implement an emergency protocol to remove the client
from the ventilator.
The nurse is caring for a client with end stage liver B.
disease who is being assessed for the presence of
asterixis. To assess the client for asterixis, what Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often
position should the nurse ask the client to seen frequently in hepatic encephalopathy. The tremor is induced by
demonstrate? extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic
Extend the left arm laterally with the left palm upward. extension and flexion of the wrist while attempting to hold position.
Extend the arm, dorsiflex the wrist, and extend the fingers.
Extend the arms and hold this position for 30 seconds.
Extend arms with both legs adducted to shoulder width.
