HESI PN Fundamentals Exam V2

HESI PN Fundamentals Exam
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of
aqueous humor for a client with glaucoma?

Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide
(Naturetin)
Demecarium bromide
(Humorsol)

A client receiving steroid therapy states, "I have difficulty controlling my temper which is sound
like me,and I don't know why this is happening." What is the nurse's best response?

Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct theclient to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.

A client receiving steroid therapy states, "I have difficulty controlling my temper which is
sounlike me,and I don't know why this is happening." What is the nurse's best response?

Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the
problem.Instruct theclient to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies
a cooling blanket and administers an antipyretic medication. The nurse explains that the
rationale forthese interventions is to:

Promote equalization of osmotic
pressures.
Prevent hypoxia associated with
diaphoresis.
Promote integrity of intracerebral
neurons.
Reduce brain metabolism and limit hypoxia.

A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12
hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water
will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added
to the 50 mL IVPB bag? Record your answer using one decimal place. mL
1.5

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved
byrepositioning. What nursing diagnosis should be included on the client's plan of care?

Risk for pressure ulcer

,Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning
Impairedskin integrity, related to the effects of pressure and shearing
force


1
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down
tothe underlying fascia. The nurse should document the assessment finding as which stage of
pressureulcer?
Stage I Stage
II Stage III
Unstageable

A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the
wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no
break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss
involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion,
blister, or shallow crater. A stage III pressureulcer involves full thickness tissue loss with visible
subcutaneous fat. Bone, tendon, and muscle are not exposed.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure
thata medication reconciliation is completed? Select all that apply.

After reporting severe pain
Onadmission to the hospital
Upon entering the operating room
Beforetransfer to a rehabilitation facility
At time of scheduling for the surgical procedure

Medication reconciliation involves the creation of a list of all medications the client is taking and
comparing it to the health care provider's prescriptions on admission or when there is a transfer to
a different setting or service, or discharge. A change in status does not require medication
reconciliation. A medication reconciliation should be completed long before entering the operating
room. Total hip replacement is electivesurgery, and scheduling takes place before admission;
medication reconciliation takes place when the client is admitted.


A client is taking lithium sodium (Lithium). The nurse should notify the health care provider
forwhich ofthe following laboratory values?

White blood cell (WBC) count of 15,000
mm3
Negative protein in the urine
Blood urea nitrogen (BUN) of 20
mg/dL
Prothrombin of 12.0 seconds

,White cell counts can increase with this drug. The expected range of the WBC count is 5000 to
10,000 mm3for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are
normal values.

Often when a family member is dying, the client and the family are at different stages of
grieving. During which stage of a client's grieving is the family likely to require more
emotional nursing carethan the client?

Anger
Denial
Depression
Acceptance


In the stage of acceptance, the client frequently detaches from the environment and may become
indifferent to family members. In addition, the family may take longer to accept the inevitable
death than does the client.Although the family may not understand the anger, dealing with the
resultant behavior may serve as a diversion. Denial often is exhibited by the client and family
members at the same time. During depression, thefamily often is able to offer emotional support,
which meets their needs.

The client asks the nurse to recommend foods that might be included in a diet for
diverticulardisease.Which foods would be appropriate to include in the teaching plan? Select all that
apply.

Whole grains
Cooked fruit and
vegetables
Nuts and seeds
Lean red meats
Milk and eggs

With diverticular disease the patient should avoid foods that may obstruct the diverticuli.
Therefore the fibershould be digestible, such as whole grains, and cooked fruits and vegetables.
Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular
disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and
infection, which is known as diverticulitis. The client should also decrease intake of fats and red
meats.


A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe
knee.What should the nurse include in the pain assessment? Select all that apply.



Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside
table
Painpattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate

, The client's family statement about increases in pain with ambulation

Accurate pain assessment includes pain history with the client's identification of pain location,
intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of
pain includes time of onset,duration, and recurrence of pain and its assessment helps the nurse
anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse
prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as a reflexive
jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are
most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore
the nurse has to ask theclient directly instead of accepting statement of the family members.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the
nurse take?
Immediately stop the infusion.
Lowerthe height of the enema
bag.
Advance the enema tubing 2 to 3 inches.
Clamp the tube for 2 minutes, then restart the infusion.


Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema
solution.Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to
the distention without causing excessive discomfort. Stopping the infusion is not necessary.
Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting
the infusion may be attempted if slowing the infusion does not relieve the cramps.

During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces thedressing on the pressure ulcer. Legally, were the nurse's actions adequate?

The nurse also should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was applied
Treatment shouldnot have been instituted until the health care provider's prescriptions were
received.

According to the Nurse Practice Act, a nurse may independently treat human responses to actual or
potential health problems. An activity level is prescribed by a health care provider; this is a
dependent function of the nurse. There is not enough information to come to the conclusion that
debridement should have been done before the dressing was applied. Application of an emollient
and reinforcing a dressing are independent nursingfunctions.

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight
andthat the client is now lying unconscious on the floor. What is the most important action the
nurse needs to take?

Ask the client if he is
okay. Call security from
the room.