HESI EXIT EXAM PN 2019 TEST BANK

HESI EXIT EXAM PN 2019 TEST BANK • a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Determine the amount of water and exact time it was taken • A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication? Monitor the client for nausea or vomiting following the treatment • The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence • The pn determines that a client with cirrhosis is experiencing peripheral....take? Protect the clients feet from injury • A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? Maintain system integrity and to promote lung reexpansion • photo of chest and locating apical HR just below the left nipple • At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next? note the most recent white blood count • Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? implement complementary pain relief methods • A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement? Measure appropriate vital signs • The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? initiate the urine stream? • An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN? weights are touching the foot of the bed • The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made • The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded • -which food types are included when measuring fluid take • -what container to use for the most accurate measurement • ... request return visit for examination after her period when hormones are lowest • A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? -The 6-year old son hits his younger sister during the interview • -the 10-year old daughter has circular burns on her trunk and legs • -the 3-year old has multiple bruises on the chest and both legs • A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy? 1700 • the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? gastric residual volumes • A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants mouth. • Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? deltoid • Before inserting medication into a clients vagina, what instructions should the pn... urinate until bladder is empty • An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? A history of untreated gonnorhea can lead to PID • A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times • A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-actualiztion • A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? Explain risks associated with using herbs instead of the prescribed antihypertensives. • A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? Act as the clients advocate when discussing the issue with the HCP • The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? watch the client for abnormal bleeding • ... "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin " • A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? neuro-vital signs related to bleeding and intracranial pressure • The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. • While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... screening for tardive dyskinesia • A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? position client in left lateral position to inspect perianal area for fissures or sacs • the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of improvement • The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? observe the appearance of the urine in the drainage tubing • A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... urinary output of 20 mL/hr • The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? report the findings to the charge nurse • The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. -Toileting assistance for a client receiving therapy after a total hip replacement • -daily skin care for a client with a descending double barrel colostomy • -morning care for a client with a staph wound infection • A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? Obtain prescribed calcium gluconate for tetany • A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use • An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... Consecutive evening serum glucose readings of 260 mg/dl • The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments -A client who is admitted with a suspected ruptured appendix • -A client who is post-lumbar puncture is reporting a severe headache • -An older male adult with Alzheimers who wanders out of his room • -A postoperative client who needs reinforcement of discharge instruction • Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream • An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds • The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? interventions to decrease emotional stress • An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? reinforce the need for extra rest periods and plenty of sleep • The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing • when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?` An older client with a stroke who is febrile and confused • which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any food injury or sore that does not readily heal • during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding? increase intake of dried peaches and apricots • A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsals pedis pulse • When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse • Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? give the medication and document the heart rate • A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply -remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application • -place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dre