HESI Extra Credit Module 10 | LATEST UPDATE 2022

HESI Extra Credit Module 10 1. Questions 1. 1.ID: 2 A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema Correct D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 1 A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output Correct C. Increased blood pressure D. Increased respiratory rate Correct E. Decreased respiratory depth Awarded 2.0 points out of 2.0 possible points. 3. 3.ID: 4 A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr Correct D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 6 A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb (1.8 kg) in 24 hours Correct Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 6 A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) Correct B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L) Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 5 A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution Correct Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9 A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease Correct D. Heart failure being treated with loop diuretics Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 4 A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness Correct D. Hyperactive bowel sounds Correct E. Hyperactive deep tendon reflexes Awarded 2.0 points out of 2.0 possible points. 9. 9.ID: 4 A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness Correct C. Increased urine output Correct D. Chvostek sign E. Hyperactive deep tendon reflexes Awarded 2.0 points out of 2.0 possible points. 10. 10.ID: 0 A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention Correct C. Trousseau sign Correct D. Skeletal muscle weakness E. Decreased deep tendon reflexes Awarded 2.0 points out of 2.0 possible points. 11. 11.ID: 7 A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions Correct B. Checking the client’s pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client’s carotid pulse for 15 seconds Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 7 A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: A. 1 inch B. 1½ inches (3.8 cm) C. 2 inches (5 cm) Correct D. 4 inches (10 cm) Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9 The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2 Correct Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 7 A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100 Correct Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 0 A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm Correct Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 0 A nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min Correct Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 4 A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED Correct B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 0 A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia Correct Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 1 The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. “I need to keep the sun off the radiation site.” B. “I can use over-the-counter cortisone cream on the radiation site if it gets red.” Correct C. “I need to be careful not to wash off the marks that the radiologist made on my skin.” D. “I need to wash the skin at the radiation site with a mild soap and water and pat it dry.” Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 6 A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. Correct B. Visitors must remain at least 2 feet (61 cm) from the client C. A dosimeter badge must be placed on the client’s bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode. Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: 7 A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request? A. “Short walks are OK.” B. “You need to stay in your room for now.” Correct C. “Yes, it’s fine to take a walk around the nursing unit.” D. “Do you think that a walk around the unit will tire you out?” Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 0 A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client’s vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container Correct Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 2 A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items: A. Within the client’s reach on the left side B. Within the client’s reach on the right side Correct C. Just out of the client’s reach on the left side D. Just out of the client’s reach on the right side Rationale: Unilateral neglect is unawareness of one side of the body. The client behaves as if that part is not there. The client does not look at the paralyzed limb when moving about. Unilateral neglect results in increased risk for injury. It is possible for the client to relearn to look for and to move the affected limb(s). Therefore in this condition the client’s personal care items are placed within the client’s reach on the right side. Hemiparesis is a weakness of the face, arm, and leg on one side. The client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. This reduces client frustration and aids in ensuring client safety because the client does not have to strain and reach for needed items. The nurse adapts the client’s environment to the deficit by focusing on the client’s unaffected side and by placing the client’s personal care items on the affected side within reach. Placing items out of the client’s reach presents a risk of injury. Test-Taking Strategy: Use the process of elimination. Eliminate the options first that are potentially hazardous to the client. To select from the remaining options, focus on the subject, unilateral neglect. With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of the environment. Review care of the client with unilateral neglect if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1403). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision Making/Clinical Judgment,Safety Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 3 A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids Correct C. Giving foods that are primarily liquid D. Placing food in the affected side of the client’s mouth Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 1 A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to: A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field Correct D. Keep all objects in the impaired field of vision Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 2 A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to: A. Sit in soft, deep chairs B. Rock back and forth to start movement Correct C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 8 A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and immediately: A. Documents the event B. Notifies the healthcare provider C. Checks the client’s bladder for distention Correct D. Checks to see whether the client has a prescription for an antihypertensive Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 7 A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately: A. Suctions the client B. Obtains a pulse oximeter C. Contacts the health care provider Correct D. Increases the rate of the client’s intravenous (IV) solution Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 2 An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen Correct Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 2 A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough Correct Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 3 A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client’s headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin) Correct Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 7 A client is found to have AIDS. What is the nurse’s highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client Correct D. Identifying risk factors related to contracting AIDS with the client Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 3 A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves: A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material Correct Rationale: To apply a cast, the skin is washed and dried well, but it is not soaked in a warm-water bath. Padding is applied and a stockinette is placed smoothly and evenly over the area to be casted. The plaster is then rolled onto the padding and the edges are trimmed or smoothed as needed. Local anesthesia of the fractured extremity is not necessary, although an analgesic may be administered to alleviate pain. A local anesthetic will block nerve sensation, and it is important for the client to be able to report any changes in sensations after the cast is applied. If the client has open wounds on the fractured extremity, a window will be cut in the cast to allow visualization and treatment of the wound. A wound would not be covered with cast material. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the words “2 hours.” Next eliminate the option that involves administration of a local anesthetic, recalling that a local anesthetic will block nerve sensation. Recognizing that covering an open wound with a cast material would not permit assessment of the wound will allow you to eliminate this option. Review client instructions regarding the application of a plaster cast if you had difficulty with this question. Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 251-253). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Giddens Concepts: Mobility, Client Education HESI Concepts: Mobility, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 7 A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? A. “I may feel cool while the cast is drying.” B. “I shouldn’t use anything to scratch underneath the cast.” C. “If I smell any odor from the cast, I should call the doctor.” D. “I can dry the cast faster if I use a hairdryer on the hot setting.” Correct Awarded 1.0 points out of 1.0 possible points. 35. 35.ID: 1 A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys. Correct Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 0 Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours Correct Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 7 A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A. “I should wear a sock over my stump.” B. “I can wash my leg with a mild soap.” C. “I need to check my leg for irritation every day.” D. “I’ll put lotion on my leg a few times a day.” Correct Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 5 A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A. “I should always maintain good posture.” B. “I should stop my exercises if I get tired.” C. “I should avoid all exercise when my joints are inflamed.” Correct D. “Doing range-of-motion exercises every day will ease the pain.” Awarded 1.0 points out of 1.0 possible points. 39. 39.ID: 8 A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states: A. “It’s important for me to drink a lot of fluids.” B. “A fad diet or starvation diet can cause an acute attack.” C. “I don’t need medication unless I’m having a severe attack.” Correct D. “Physical and emotional stress can cause an attack.” Rationale: Treatment of gout includes both nutrition and medication therapy. The client should be encouraged to limit the use of alcohol and reduce the consumption of foods high in purines. Such foods include sardines, herring, mussels, liver, kidney, goose, venison, and sweetbreads. Medication therapy is a primary component of management for clients with gout, and the health care provider normally prescribes a medication that will promote uric acid excretion or reduce its production. Fluid intake is important in preventing the development of uric acid stones. Fad or starvation diets can precipitate an acute attack because of the rapid breakdown of cells they induce. Excessive physical and emotional stress can exacerbate the disease. Test-Taking Strategy: Use the process of elimination and your knowledge of the treatment for gout. Also note the strategic words “needs additional instruction,” which indicate a negative event query and the need to select the incorrect client statement. Recall that in this disorder the client experiences an increased uric acid level and that medications are needed to promote the acid’s excretion. Review the management of gout if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1577). St. Louis: Mosby. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Musculoskeletal Giddens Concepts: Mobility, Client Education HESI Concepts: Mobility, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 9 A nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to: A. Raise his voice when talking to the client B. Talk directly into the client’s impaired ear C. Be cordial and smile when talking to the client D. Face the client when talking, keeping the hands away from the mouth Correct Awarded 1.0 points out of 1.0 possible points. 41. 41.ID: 9 A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client? A. Expect excessive ear drainage for about 2 weeks. B. Avoid rapidly moving the head and bending over for at least 3 weeks. Correct C. Rinse the ear canal at least twice a day to clear out any excess drainage. D. It is all right to shower as long as the ear dressing is changed immediately after the shower. Awarded 1.0 points out of 1.0 possible points. 42. 42.ID: 6 A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to: A. Limit sodium in the diet Correct B. Increase fluid intake to at least 3000 mL/day C. Lie down when vertigo occurs and keep a light on in the room D. Move the head from the right to the left when vertigo occurs to determine the extent of its effects Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 0 A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? A. Supine B. Semi-Fowler Correct C. On the side that has undergone surgery D. Prone on the side that has undergone surgery Awarded 1.0 points out of 1.0 possible points. 44. 44.ID: 2 A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will: A. Limit activity for 24 hours B. Take acetaminophen for discomfort C. Leave the eye patch in place until he has been seen by the health care provider D. Expect to experience pain, nausea, and vomiting after the procedure Correct Awarded 1.0 points out of 1.0 possible points. 45. 45.ID: 8 During a client’s yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client: A. That he has glaucoma in the left eye B. That he has glaucoma in the right eye C. That the intraocular pressure in both eyes is normal Correct D. That he needs to increase his fluid intake, because the pressure in the right eye is low Awarded 1.0 points out of 1.0 possible points. 46. 46.ID: 4 A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client: A. To maintain strict bedrest for 48 hours B. To expect bloody drainage on the eye dressing C. That vision will be perfectly clear immediately after surgery D. That redness and swelling of the eyelids and conjunctiva are expected Correct Rationale: The scleral buckling procedure is performed to treat retinal detachment. In the preoperative period the nurse places an eye patch over the client’s affected eye to reduce eye movement. Some clients may require bilateral patching. Redness and swelling of the eyelids and conjunctiva, the result of surgical manipulation, are expected. Blood loss in retinal detachment surgery is minimal, and only serous drainage is expected on the postoperative dressing. The client should not expect immediate return of vision. Postoperative inflammation and eye drops interfere with vision. Because healing takes place over weeks to months, vision will improve gradually. Strict bedrest for 48 hours is not required; however, depending on the location and size of the retinal break, activity restrictions may be needed to prevent further tearing or detachment and to promote drainage of any subretinal fluid. Test-Taking Strategy: Use the process of elimination. Eliminate first the options containing the words “strict” and “perfectly clear.” To select from the remaining options, recall that redness and swelling of the eye occur as a result of surgical manipulation. Review client instructions after scleral buckling if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 397). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Eye Giddens Concepts: Client Education, Sensory Perception HESI Concepts: Sensory/Perception, Teaching and Learning/Patient Education Awarded 1.0 points out of 1.0 possible points. 47. 47.ID: 6 A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor’s house and notes that the child has sustained a contusion of the eye. The nurse advises the child’s mother to immediately: A. Call an ambulance B. Call an optometrist C. Apply ice to the affected eye Correct D. Irrigate the eye with cool water Awarded 1.0 points out of 1.0 possible points. 48. 48.ID: 0 A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? A. Assessing the client’s vision Correct B. Placing ice on the eye C. Removing the sand particles D. Irrigating the eye with sterile saline solution Awarded 1.0 points out of 1.0 possible points. 49. 49.ID: 0 A client with chronic kidney disease is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? A. Fever and tachycardia B. Headache and confusion Correct C. Bradycardia and hypothermia D. Irritability and generalized weakness Awarded 1.0 points out of 1.0 possible points. 50. 50.ID: 4 A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective? A. Weight and BUN B. Blood pressure and weight Correct C. Potassium and creatinine levels D. Blood urea nitrogen (BUN) and creatinine levels Awarded 1.0 points out of 1.0 possible points. 51. 51.ID: 2 A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? A. Irrigate the catheter B. Reposition the client C. Check the system for kinks Correct D. Hang the second exchange and continue to monitor the outflow Awarded 1.0 points out of 1.0 possible points. 52. 52.ID: 1 A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? A. Irrigate the fistula with 3 mL of normal saline solution B. Infuse 50 mL of normal saline once per 24 hours C. Palpate for a vibrating sensation at the fistula site Correct D. Flush the fistula with 1 mL of heparin solution once per shift Awarded 1.0 points out of 1.0 possible points. 53. 53.ID: 7 A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular tachycardia Correct Awarded 1.0 points out of 1.0 possible points. 54. 54.ID: 0 A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client’s blood pressure has dropped. Which action by the nurse is appropriate? A. Contacting the health care provider Correct B. Continuing to monitor the client C. Increasing the flow rate of the intravenous (IV) solution D. Placing pressure on the bladder to aid expulsion of any additional clots Awarded 1.0 points out of 1.0 possible points. 55. 55.ID: 6 A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client? A. Cough B. Hemoptysis C. Diaphoresis D. Pleuritic chest pain Correct Awarded 1.0 points out of 1.0 possible points. 56. 56.ID: 3 A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? A. Monitoring urine output B. Monitoring bowel sounds C. Checking pedal pulses distal to the graft site D. Limiting elevation of the head of the bed to 45 degrees Correct Awarded 1.0 points out of 1.0 possible points. 57. 57.ID: 2 A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? A. Peaked T waves B. ST-segment depression Correct C. Widened QRS complex D. An isolated premature ventricular contraction (PVC) Awarded 1.0 points out of 1.0 possible points. 58. 58.ID: 8 The wife of a client with angina pectoris calls the health care provider’s office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client’s wife to: A. Have her husband rest and, if no relief is obtained, call back B. Discuss the situation with the doctor, who will call her as soon as he gets into the office C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED Incorrect Rationale: Chest pain that is unrelieved by rest and nitroglycerin may be not typical anginal pain but instead a sign of myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the 24 hours after MI, it is imperative that the client receive emergency cardiac care. If the client needs to go to the ED, the nurse must instruct the client’s wife to call an ambulance to transport her husband. The client’s wife must not drive the client, because the client should not exert energy and place an increased workload on the heart and the client’s wife would not be able to provide care if an emergency arose during transport to the hospital. Telling the wife that she will have to discuss the situation with the health care provider, who will call her as soon as he gets to his office, delays necessary interventions. Having her husband rest delays necessary interventions; also, the usual procedure is to have the client take one nitroglycerin tablet and seek medical attention if the pain is unrelieved. Test-Taking Strategy: Use the process of elimination. Eliminate first the options that would delay necessary intervention. To select from the remaining options, recall that in such an emergency an ambulance is called for transport to the hospital. Review the interventions when an MI is suspected if you had difficulty with this question. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 743, 745). St. Louis: Mosby. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision Making/Clinical Judgment, Perfusion Awarded 0.0 points out of 1.0 possible points. 59. 59.ID: 8 A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately: A. Calls a code B. Assesses the client Correct C. Checks the cardiac leads and wires D. Obtains a rhythm strip from the monitor device Awarded 1.0 points out of 1.0 possible points. 60. 60.ID: 8 The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. A. Dyspnea Correct B. Dependent edema C. Neck vein distention D. Abdominal distention E. Crackles on auscultation of the lungs Correct Awarded 2.0 points out of 2.0 possible points. 61. 61.ID: 8 A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? A. “I should sit up in my recliner.” B. “I should lie on my right side in bed.” Correct C. “I should sit on the side of my bed and lean on the overbed table.” D. “I should stand with my back and hips against the wall and my shoulders bent slightly forward.” Awarded 1.0 points out of 1.0 possible points. 62. 62.ID: 2 A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client’s record? A. Night sweats and a low-grade fever B. Positive result on an acid-fast bacillus smear Correct C. Cough and expectoration of mucopurulent sputum D. A tuberculin skin test result that indicates 5 mm of redness Awarded 1.0 points out of 1.0 possible points. 63. 63.ID: 9 A ventilator’s low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client’s room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first: A. Call a code B. Suction the client C. Call the anesthesiologist D. Manually ventilate the client, using a resuscitation bag Correct Awarded 1.0 points out of 1.0 possible points. 64. 64.ID: 5 A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then: A. Prepares for reintubation Correct B. Restrains the client’s wrists C. Calls the rapid response team (RRT) D. Administers an antianxiety medication to the client Awarded 1.0 points out of 1.0 possible points. 65. 65.ID: 0 The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states: A. “I should take an antacid at bedtime.” B. “I should sleep flat on my right side.” Correct C. “The histamine antagonist will help me.” D. “I should avoid eating in the 3 hours before bedtime.” Awarded 1.0 points out of 1.0 possible points. 66. 66.ID: 2 A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to: A. Maintain strict bed rest B. Limit the intake of alcohol C. Take acetaminophen for discomfort D. Eat small frequent meals that are low in fat and protein and high in carbohydrates Correct Awarded 1.0 points out of 1.0 possible points. 67. 67.ID: 9 An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? A. Prone B. Supine with the legs straight C. With the knees drawn up to the chest Correct D. Side-lying with the head of the bed flat Awarded 1.0 points out of 1.0 possible points. 68. 68.ID: 5 A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan? A. Keeping the room warm B. Placing extra blankets on the client C. Providing a high-calorie, high-protein diet Correct D. Encouraging frequent ambulation and activities Awarded 1.0 points out of 1.0 possible points. 69. 69.ID: 6 A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to: A. Contact the health care provider if a fever over 102° F (38.9°C) occurs B. Refrain from eating or drinking during periods of vomiting C. Take the prescribed insulin dose even if he is unable to eat Correct D. Contact the health care provider when the premeal blood glucose value is greater than 350 mg/dL (19.4 mmol/L) Awarded 1.0 points out of 1.0 possible points. 70. 70.ID: 4 A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately: A. Contacts the client’s health care provider Correct B. Tells the client to avoid lying flat C. Instructs the client to eat a small portion of food every 2 to 3 hours D. Administers an antacid to the client and tell her to take a dose every 6 hours Awarded 1.0 points out of 1.0 possible points. 71. 71.ID: 6 A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client’s condition? A. Complaint of headache B. Trace protein in the urine Correct C. Blood pressure 148/94 mm Hg D. Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L) Awarded 1.0 points out of 1.0 possible points. 72. 72.ID: 4 A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? A. Fetal hypoxia B. Discomfort with each contraction C. Increased frequency and longer duration of contractions D. Contractions that can be indented easily with fingertip pressure at their peak Correct Awarded 1.0 points out of 1.0 possible points. 73. 73.ID: 1 A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately: A. Pushes the cord gently back into the vagina B. Prepares the client for cesarean delivery C. Places the client in the knee-chest position Correct D. Prepares to administer a tocolytic medication Awarded 1.0 points out of 1.0 possible points. 74. 74.ID: 9 A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though “something ripped.” For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. A. Bradypnea B. Severe chest pain Correct C. Absence of fetal heart tones Correct D. Increased blood pressure E. Increased frequency of uterine contractions Awarded 2.0 points out of 2.0 possible points. 75. 75.ID: 4 A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? A. An ultrasound examination Correct B. Internal fetal monitoring C. Administration of oxytocin (Pitocin) D. A manual (digital) pelvic examination Awarded 1.0 points out of 1.0 possible points. 76. 76.ID: 6 A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? A. Uterine tenderness Correct B. Lack of uterine activity C. Painless vaginal bleeding D. Constipation Awarded 1.0 points out of 1.0 possible points. 77. 77.ID: 6 A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately: A. Records the findings Correct B. Massages the fundus C. Contacts the health care provider D. Helps the mother void Awarded 1.0 points out of 1.0 possible points. 78. 78.ID: 9 Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that: A. Wearing a bra will increase the discomfort B. Antibiotics are not usually used to treat this disorder C. Breastfeeding must be discontinued until the condition resolves D. Moist heat will increase circulation and may be used before the breasts are emptied Correct Awarded 1.0 points out of 1.0 possible points. 79. 79.ID: 4 A mother calls the clinic and tells the nurse that her newborn’s umbilical cord site looks red and swollen. The nurse should tell the mother: A. That this is a normal occurrence B. To bring the newborn to the clinic Correct C. To increase the number of cord site cleanings each day D. To place an ice pack on the cord for 10 minutes three times a day Awarded 1.0 points out of 1.0 possible points. 80. 80.ID: 7 A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will: A. Bottle feed only B. Breastfeed the newborn every 2 to 3 hours Correct C. Provide water feedings between breast feedings D. Feed her newborn less frequently until the bilirubin level drops Awarded 1.0 points out of 1.0 possible points. 81. 81.ID: 3 A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonate most closely? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome Correct Awarded 1.0 points out of 1.0 possible points. 82. 82.ID: 2 A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? A. Greater-than-average length B. Higher-than-normal birth weight C. Short palpebral fissures and a flat midface Correct D. Greater-than-average head circumference Awarded 1.0 points out of 1.0 possible points. 83. 83.ID: 8 A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include? A. Call the health care provider if the infant is lethargic. Correct B. Expect increased urine output with the shunt. C. Call the health care provider if the anterior fontanel bulges when the infant cries. D. Position the infant on the side of the shunt for sleep. Awarded 1.0 points out of 1.0 possible points. 84. 84.ID: 4 A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn’s bedside? A. Flashlight B. Sterile dressing Correct C. Cardiac monitor D. Blood pressure cuff Awarded 1.0 points out of 1.0 possible points. 85. 85.ID: 9 A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child’s condition: A. Indicates improved neurological status B. Indicates decreased intracranial pressure C. Indicates deterioration in neurological function Correct D. Is unchanged from the previous neurological assessment Awarded 1.0 points out of 1.0 possible points. 86. 86.ID: 5 An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will: A. Avoid giving citrus juices to her child B. Have her child use a straw to make drinking easier Correct C. Give acetaminophen (Tylenol) to her child for discomfort D. Give her child extra fluids to relieve a foul odor from the mouth Awarded 1.0 points out of 1.0 possible points. 87. 87.ID: 1 A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? A. “I should put a steam vaporizer in her room.” Correct B. “I’ll take her out into the cool, humid night air.” C. “I can open the freezer door and encourage her to breathe in the cool air.” D. “I can run the hot water in my bathroom and cuddle her in the steamy room.” Awarded 1.0 points out of 1.0 possible points. 88. 88.ID: 7 A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for: A. Bleeding B. A high fever C. Failure to thrive D. Signs of congestive heart failure (CHF) Correct Awarded 1.0 points out of 1.0 possible points. 89. 89.ID: 3 A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately: A. Calls a code B. Holds the infant in an upright position C. Places the infant in the knee-chest position Correct D. Contacts the respiratory therapy department Awarded 1.0 points out of 1.0 possible points. 90. 90.ID: 2 A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? A. “Has he had any loss of appetite?” B. “Has he complained of a backache recently?” C. “Has he been excessively tired or lethargic?” D. “Has he had a sore throat in the last few months?” Correct Awarded 1.0 points out of 1.0 possible points. 91. 91.ID: 3 A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report? A. Scleral jaundice B. Projectile vomiting C. Hard, pale stools D. Bloody mucus stools and diarrhea Correct Awarded 1.0 points out of 1.0 possible points. 92. 92.ID: 5 A nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child’s diet? A. Rice Correct B. Wheat cereal C. Rye crackers D. Oatmeal biscuits Awarded 1.0 points out of 1.0 possible points. 93. 93.ID: 8 A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first: A. Weighs the child B. Takes the child’s temperature C. Attaches the child to a pulse oximeter Correct D. Administers the prescribed antibiotic Awarded 1.0 points out of 1.0 possible points. 94. 94.ID: 7 A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? A. Lethargy Correct B. Bradycardia C. Hyperactivity D. Reddened cheeks Awarded 1.0 points out of 1.0 possible points. 95. 95.ID: 0 A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child: A. A sugar cube B. A teaspoon of sugar C. ½ cup (118 ml) of diet cola D. ½ cup (118 ml) of fruit juice. Correct Awarded 1.0 points out of 1.0 possible points. 96. 96.ID: 1 A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? A. Hypertension Correct B. Low serum potassium C. Increased creatinine level D. Cloudy yellow urine Awarded 1.0 points out of 1.0 possible points. 97. 97.ID: 6 A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply. A. “I will be so glad when my baby outgrows all of this bleeding.” Correct B. “I need to cancel all of the dental appointments that I’ve made for him.” Correct C. “If he gets a cut, I should hold pressure on it until the bleeding stops.” D. “I should check the house for any household items that could fall over easily.” E. “I should move furniture with sharp corners out of the way and pad the corners of the furniture.” Awarded 2.0 points out of 2.0 possible points. 98. 98.ID: 1 A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse tells the client: A. To plan to drain the reservoir every 2 to 3 hours initially Correct B. That if mucus drains from the reservoir the health care provider should be contacted C. That sometimes force is needed to insert the catheter into the reservoir D. To obtain 26F catheters from the medical supply store for the irrigations Awarded 1.0 points out of 1.0 possible points. 99. 99.ID: 1 A nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beats does the nurse recognize? A. Sinus bradycardia B. Ventricular fibrillation C. Ventricular tachycardia D. Premature ventricular contractions (PVCs) Correct Awarded 1.0 points out of 1.0 possible points. 100. 100.ID: 1 The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately: A. Checks for a radial pulse B. Assesses the client's neurological status C. Increases the flow rate of the client's intravenous infusion D. Begins cardiopulmonary resuscitation (CPR) Correct Awarded 1.0 points out of 1.0 possible points.