HESI 366 v1 || 100% Valid Solutions.
.assessment findings for a client following a colectomy for familial polyposis include an
ileostomy bag that contains large amount of fecal liquid and an IV infusion of dextrose 5% in
lactated ringer's infusing at a rate of 100ml/hour. Which assessment is most important for the
nurse monitor? Serum electrolytes.
a. urinary output
b. serum electrolytes
c. peristomal skin integrity
d. skin turgor correct answers b. serum electrolytes
. An older client is being admitted to a rehabilitation unit from a medical-surgical unit following
a left hip replacement. When reviewing the client's prescribed medications, which intervention
should the nurse implement FIRST?
a. reconcile prescribed medication dosages with published recommended dosage ranges
b. compare admission prescriptions with the list of medications previously taken by the client
c. determine which medications may be given in generic form rather than brand name only
d. provide client teaching regarding the desired effects of the client's admission prescriptions
correct answers b. compare admission prescriptions with the list of medications previously taken
by the client
A new nurse preparing to irrigate an intravenous cath is attaching a 24-gauge action should the
charge nurse implement
A. Suggest the nurse use a 20-gauge
B. Direct the nurse to change IV tubing
C. Instruct the nurse to remove the needle
D. Prompt the nurse to apply pressure to the site correct answers C-Instruct the nurse to remove
the needle
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub
while leaving a client's room after taking vital signs. What action should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients correct answers C.
Remind the UAP to continue rubbing the hands together until they are dry
A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is
distended, blood pressure is elevated, and 6500 mL were infused while 5,500 mL were drained.
In response to this finding, what action should the nurse take?
A. Instruct the client to cough
B. turn the client from side to side
C. irrigate the drainage tube with normal Saline
D.lower the head of the bed correct answers B.turn the client from side to side
,The nurse is developing the plan of care for a client with pneumonia and includes the nursing
problem of Ineffective airway clearance related to thick pulmonary secretions. Which
intervention is most important for the nurse to include in the client's plan of care?
A. Provide frequent rest periods.
B. Administer at minute per nasal cannula.
C. Increase fluid intake to 3,000 mL/ daily.
D. Maintain the client in a semi-Fowler's position. correct answers C. Increase fluid intake to
3,000 mL/ daily.
10. The adult child of an older adult client who has Parkinson's disease, calls the clinic and
reports that the client has been confused for the past week. Which action Should the nurse take?
Select all that apply.
A.
Determine if the mother has recently experienced a fall.
B.
Review the client's current food and medication allergies.
C.
Encourage increased intake of high-protein foods.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination. correct answers A.
Determine if the mother has recently experienced a fall.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
A.
16 year old client diagnosed with major depression who refuses to participate in group
B.
a 17 year old client diagnosed with bipolar disorder who is pacing around the lobby
C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
D.
a 14 year old client with anorexia nervosa who is refusing to eat the evening snack. correct
answers C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
A client is admitted for medical management of a bowel obstruction. The drainage volume from
the nasogastric tube over the last 12 hours is 300milliliters. Which assessment finding provides
the earliest indication that the client is experiencing gastrointestinal motility?
A. normalized electrolytes
B. decreased nausea
, C. passing of flatus
D. return appetite correct answers C. passing of flatus
A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin and
IV heparin in the emergency department. Which finding indicates the client is having a
satisfactory response?
A) Activated partial thromboplastin time (aPTT) is 2 times the control value.
B) S3 heart sounds are present with auscultation.
C) Guaiac test of the stools is positive.
D) Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. correct answers
A) Activated partial thromboplastin time (aPTT) is 2 times the control value.
The nurse assesses a client who had bilateral total knee replacement four hours ago. The nurse
notes that the dressing on the client's right knee is saturated with serosanguineous drainage. What
action should the nurse implement?
a.Monitor the client's current WBC
b.Withhold next scheduled dose of low molecular weight heparin
c.Confirm that the continuous passive motion device is intact
d.Determine if the wound drainage device is functioning correctly correct answers d.Determine if
the wound drainage device is functioning correctly
15. A client who weighs 65kg receives a prescription for lorazepam 44mcg/kg IV to be
administered 20 minutes before scheduled procedure. The medication is available as " lorazepam
2mg/ml vial". How many ml should the nurse administer. ( enter numerical value only. If
rounding is required, round to the nearest tenth). correct answers 1.4ml
The nurse identifies several problems for an older adult client experiencing diarrhea and fecal
incontinence who is confused to bed and being cared for by a primary caregiver. In the planning
care, the nurse should determine which nurse problem is the highest priority?
A. fluid volume deficit
B. Bowel incontinence
C. caregiver role strain
D. Impaired bed motility correct answers A. fluid volume deficit
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of
25,000/mm3. Which intervention is most important for the nurse to include in this patient's plan
of care
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain clients temperature q4 hours correct answers Assess urine and stool for occult blood.
.assessment findings for a client following a colectomy for familial polyposis include an
ileostomy bag that contains large amount of fecal liquid and an IV infusion of dextrose 5% in
lactated ringer's infusing at a rate of 100ml/hour. Which assessment is most important for the
nurse monitor? Serum electrolytes.
a. urinary output
b. serum electrolytes
c. peristomal skin integrity
d. skin turgor correct answers b. serum electrolytes
. An older client is being admitted to a rehabilitation unit from a medical-surgical unit following
a left hip replacement. When reviewing the client's prescribed medications, which intervention
should the nurse implement FIRST?
a. reconcile prescribed medication dosages with published recommended dosage ranges
b. compare admission prescriptions with the list of medications previously taken by the client
c. determine which medications may be given in generic form rather than brand name only
d. provide client teaching regarding the desired effects of the client's admission prescriptions
correct answers b. compare admission prescriptions with the list of medications previously taken
by the client
A new nurse preparing to irrigate an intravenous cath is attaching a 24-gauge action should the
charge nurse implement
A. Suggest the nurse use a 20-gauge
B. Direct the nurse to change IV tubing
C. Instruct the nurse to remove the needle
D. Prompt the nurse to apply pressure to the site correct answers C-Instruct the nurse to remove
the needle
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub
while leaving a client's room after taking vital signs. What action should the nurse take?
A. Instruct the UAP to return to the client's room to perform handwashing
B. Supervise the UAP in the next client's room to evaluate hand hygiene
C. Remind the UAP to continue rubbing the hands together until they are dry
D. Advice the UAP to wear gloves when obtaining vital signs for all clients correct answers C.
Remind the UAP to continue rubbing the hands together until they are dry
A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is
distended, blood pressure is elevated, and 6500 mL were infused while 5,500 mL were drained.
In response to this finding, what action should the nurse take?
A. Instruct the client to cough
B. turn the client from side to side
C. irrigate the drainage tube with normal Saline
D.lower the head of the bed correct answers B.turn the client from side to side
,The nurse is developing the plan of care for a client with pneumonia and includes the nursing
problem of Ineffective airway clearance related to thick pulmonary secretions. Which
intervention is most important for the nurse to include in the client's plan of care?
A. Provide frequent rest periods.
B. Administer at minute per nasal cannula.
C. Increase fluid intake to 3,000 mL/ daily.
D. Maintain the client in a semi-Fowler's position. correct answers C. Increase fluid intake to
3,000 mL/ daily.
10. The adult child of an older adult client who has Parkinson's disease, calls the clinic and
reports that the client has been confused for the past week. Which action Should the nurse take?
Select all that apply.
A.
Determine if the mother has recently experienced a fall.
B.
Review the client's current food and medication allergies.
C.
Encourage increased intake of high-protein foods.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination. correct answers A.
Determine if the mother has recently experienced a fall.
D.
Instruct the daughter to check her mother's temperature.
E.
Ask if the mother is experiencing any pain with urination.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's
immediate attention?
A.
16 year old client diagnosed with major depression who refuses to participate in group
B.
a 17 year old client diagnosed with bipolar disorder who is pacing around the lobby
C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
D.
a 14 year old client with anorexia nervosa who is refusing to eat the evening snack. correct
answers C.
an 18 year old client with antisocial behaviour who is being yelled at by the other clients
A client is admitted for medical management of a bowel obstruction. The drainage volume from
the nasogastric tube over the last 12 hours is 300milliliters. Which assessment finding provides
the earliest indication that the client is experiencing gastrointestinal motility?
A. normalized electrolytes
B. decreased nausea
, C. passing of flatus
D. return appetite correct answers C. passing of flatus
A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin and
IV heparin in the emergency department. Which finding indicates the client is having a
satisfactory response?
A) Activated partial thromboplastin time (aPTT) is 2 times the control value.
B) S3 heart sounds are present with auscultation.
C) Guaiac test of the stools is positive.
D) Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. correct answers
A) Activated partial thromboplastin time (aPTT) is 2 times the control value.
The nurse assesses a client who had bilateral total knee replacement four hours ago. The nurse
notes that the dressing on the client's right knee is saturated with serosanguineous drainage. What
action should the nurse implement?
a.Monitor the client's current WBC
b.Withhold next scheduled dose of low molecular weight heparin
c.Confirm that the continuous passive motion device is intact
d.Determine if the wound drainage device is functioning correctly correct answers d.Determine if
the wound drainage device is functioning correctly
15. A client who weighs 65kg receives a prescription for lorazepam 44mcg/kg IV to be
administered 20 minutes before scheduled procedure. The medication is available as " lorazepam
2mg/ml vial". How many ml should the nurse administer. ( enter numerical value only. If
rounding is required, round to the nearest tenth). correct answers 1.4ml
The nurse identifies several problems for an older adult client experiencing diarrhea and fecal
incontinence who is confused to bed and being cared for by a primary caregiver. In the planning
care, the nurse should determine which nurse problem is the highest priority?
A. fluid volume deficit
B. Bowel incontinence
C. caregiver role strain
D. Impaired bed motility correct answers A. fluid volume deficit
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of
25,000/mm3. Which intervention is most important for the nurse to include in this patient's plan
of care
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain clients temperature q4 hours correct answers Assess urine and stool for occult blood.
