NSG 353 HESI PRACTICE EXAM 2

  1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain? • Serum cholesterol level (not related to the acute attack gout) • Capillary glucose level (not related to the acute attack gout) • Daily caloric intake (Starvation diet can cause an acute attack of gout) • Daily calcium intake (not related to the acute attack gout) 2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night he reports a severe, pounding headache, and has observable goose bumps. The nurse should assess for which trigger? • Loud hallway noise (Not manifestation of autonomic hyperreflexia) • Fever (Not manifestation of autonomic hyperreflexia) • Full bladder • Frequent cough (Not manifestation of autonomic hyperreflexia) * A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high-level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. 3. After learning that she as terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this”? Based on this response, the nurse deicides to include Which nursing problem in the client’s plan of care? • Acute pain (physical pain less than 6 month) • Spiritual distress (indicates anger toward God for her disease) • Ineffective coping (not reflect) • Complicated grieving (not reflect) 4. A nurse working on an Endocrine Unit should see which client first? • An Adolescent male with type 1 diabetes who is arguing about his insulin dose (dealt with at a later time) • A older client with Addison’s disease whose current blood sugar level is 62 mg/dl (blood sugar level is low (normal 60 -110 mg/dl, but is not critical) • An adult with a blood sugar of 384 mg/dl and a urine output of 350 ml in the last hour (exhibiting sign of diabetes insipidus, which include hyperglycemia & urine output, but this patient can be seen after corticosteroid pt) • A client taking corticosteroids who has become disoriented in the last two hours (safety) * Rationale: safety is a priority intervention. Mania & psychosis can occur during corticosteroid therapy, which places the client at risk for injury, so this should be first seen. 5. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? • Report the incident to the local Child Protective Service (further assessment is needed before implementing) • Find a home health agency that specializes in brain injuries (further assessment is needed before implementing) • Determine the mother’s basic skill level in providing care (client is manifesting disease syndrome complications, and the mother’s skill in providing basic care should be determined) • Consult the ethics committee to determine how to proceed (further assessment is needed before implementing) 6. A male client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? • Determine if the sensation feels uncomfortable (Electronic stimulators, such as a transelectrial nerve stimulator (TENS) unit, effective in reducing low back pain by “closing the gate” to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching) • Decrease the strength of the electrical signals (indicated if the sensation is too strong) • Remove electrodes and observe for skin redness (not necessary because the tingling sensation is expected) • Check the amount of gel coating on the electrodes (not necessary because the tingling sensation is expected) 7. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action in the treatment plan should the nurse implement? • Tell client to drive over the bridge until fear is manageable • Teach client to listen to music or audio books while driving • Encourage client to have spouse drive in stressful places • Recommend that the client avoid driving over the bridge 8. The nurse preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which action the nurse include? • Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection A short, small gauge needle should be to inject into the small muscle mass of an infant rather than which is used for an adult) • Administer into the deltoid muscle while the parent holds the infant securely (deltoid muscle site in the arm should not be used in infants whose muscle mass is underdeveloped) • Divide the medication into two injections with volumes under 1 ml • Use a quick dart-like motion to inject into the dorsogluteal site (dorsoglutel site is not recommended due to the proximity to nerves and blood vessels) * IM injection for children under 3 year of age should not exceed 1 ml, so the prescribed dose should be divided into smaller volumes for injection in two different sites. 9. Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse? • Diarrhea and flatulence (are also side effect of lovastatin that require intervention, but are of loss priority) • Abdominal cramps (are also side effect of lovastatin that require intervention, but are of loss priority) • Muscle pain (Lovastatin main priority of side effect) • Altered taste (are also side effect of lovastatin that require intervention, but are of loss priority) * Statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the health care provider 10. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? • Check the client’s temperature, blood sugar, and urine output • Transport the client for laboratory tests and electrocardiogram (EKG) • Delegate care of the crying client to an unlicensed assistant • Send the client to the shelter’s nutrient center to obtain water and food 11. The nurse is collecting a sterile sample for culture and sensitivity form a disposable three chamber-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? • Tubing located on the top of the suction chamber (do not provide access to chest drainage) • Plastic tubing located at the chest insertion site (should not be disconnected or accessed to collect a sample) • Stopper port located above the water-seal level (do not provide access to chest drainage) • Rubberized port at the bottom of collection chamber (with one-way value) 12. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Selection of which food items indicates to the nurse that the client understands the prescribed diet? • Roasted turkey, canned vegetables (low-fiber diet) • Baked potato with skin, raw carrots (not low-fiber diet) • Pancakes, whole-grain cereals (not low-fiber diet) • Roast pork, fresh strawberries (not low-fiber diet) 13. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? • Conversion of the client’s PPD test from negative to positive (indication for prophylactic treatment) • Length of time of the exposure to tuberculosis (do not provide data indicating the need to question or hold the prescribed treatment) • Current diagnosis of hepatitis B (contraindicated for a person with liver disease because it may cause liver damage. The nurse should hold the prescribed dose and contact healthcare provider) • History of intravenous drug abuse (do not provide data indicating the need to question or hold the prescribed treatment) 14. After placing a client at 26-weeks’ gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement? • Place the client in the Trendelenburg position (not alleviate pressure on the vena cava and aorta) • Instruct the client to take deep breathe (not alleviate pressure on the vena cava and aorta) • Place a wedge under the client’s hip • Remove the client’s legs from the stirrups (not alleviate pressure on the vena cava and aorta) * the client is likely to be experiencing supine hypotensive syndrome due to pressure of enlarging uterus on the vena cava and aorta. Placing a wedge under either hip tilts the uterus off these large vessels and relieves symptoms. 15. A gravida 2 para 1, at 38-weeks’ gestation, scheduled for a repeat cesarean section in one week, is bought to the labor and delivery unit complaining of contraction every 10 minutes. While assessing the client, the client’s mother enters the labor suite and says in a loud voice, “I’ve had children and I know she is in labor. I want her to have her cesarean section right now!” What action should the nurse take? • Request the mother to leave the room (The nurse should ask the family member to leave the room because the behavior is disruptive to the nurse and to the client. After the assessment is completed, the nurse should then address the family member’s concerns) • Tell the mother to stop speaking for the client (is confrontational and could escalate the situation) • Request security to remove her from the room (are not indicated at this time unless the situation with the family member escalates) • Notify the charge nurse of the situation (are not indicated at this time unless the situation with the family member escalates) 16. A client with a chronic health problem has difficulty ambulating short distances due to generalized weakness but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? • A quad cane (used to when there is partial or complete leg paralysis or some hemiplegia • Crutches with 2-point gait (requires at least partial weight bearing on each foot, but does not provide the stability) • Crutches with 3-point gait (useful when the client must bear all of the weight on one foot, and this is not the problem experienced by this client) • Crutches with 4-point gait (provide stability and require weight bearing on both legs, which this client should be able to provide) 17. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with impaired nurse’s request, what action is best for the charge nurse to take? • Since treatment is completed, assign the nurse to routine RN responsibilities • Ask to meet with impaired nurse’s therapist before allowing her back on the unit • Allow the impaired nurse to return to work and monitor medication administration (provides essential monitoring and helps ensure nurse compliance and promote client safety) • Meet with staff to assess their feeling about the impaired nurse’s return to the unit 18. A client had subtotal parathyroidectomy two days ago and is now preparing for discharge. Which assessment finding is most important for the nurse to provide to the healthcare provider? • No bowel movement since surgery (are signs of discomfort, but are not as important as a positive Chvostek’s sign) • Afebrile with normal pulse (is an expected finding) • No Appetite for breakfast (are signs of discomfort, but are not as important as a positive Chvostek’s sign) • A positive Chvostek’s sign * A positive Chvostek’s sign is spasm of the cheek muscle when the facial nerve is tapped indication a decreased serum calcium caused by lack of parathyroid hormone. This critical information should be relayed to the healthcare provider. 19. A client with cirrhosis is receiving a low protein diet. The nurse should explain to the family that this diet restriction is implemented to reduce the risk of which complication of cirrhosis? • Delirium tremors (decreased protein intake does not prevent) • Abdominal ascites (decreased protein intake does not prevent) • Hepatic encephalopathy • Esophageal varices (decreased protein intake does not prevent) * Protein end-products (amino acids) are converted (deaminated) by the liver to a fuel source by the removal of ammonia (NH3), which accumulates in the blood in those with cirrhosis and contributes to the potentially fatal complication of hepatic encephalopathy. 20. While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client’s chest pain? • Tell me about the activities that cause your pain? • When did you first notice the pain your chest? • Does your pain occur when walking short distances? (yes or no question) • How do you feel when the pain becomes noticeable? 21. A 59-year-old male client comes to the clinic and reports his concern over a lump that, “just popped up on my neck a week ago.” In performing and examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? • Lymphangitis • Malignancy • Bacterial infection • Viral infection * - Rapid enlargement of a lymph node, particularly the subclavian node with no tenderness or inflammation is suggestive of malignancy. - Lymphangitis: is characterized by pain and inflammation - In infectious processes (Bacterial and Viral infection), the involved nodes become warm and tender to touch 22. An older client with atrial fibrillation receives a new prescription for dabigatran to reduce risk of blood clot formation. What information should the nurse include in this client’s medication teaching plan? (select all that apply) • Medication injections are self-administered daily • Plan to monitor and record the pulse rate daily • Contact the healthcare provider if bruising occurs • Report bleeding in the urine or stool right away • Inform dentist of medication usage before procedures * Dabigatran is an oral anticoagulant used to decrease clot formation in atrial fibrillation, thus reducing the risk for stoke. As an anticoagulant, excessive bleeding may occur and bruising and bleeding should be reported to the healthcare provider promptly, as well as all practitioners, such as dentist, who should be aware of the increased risk for bleeding prior to any scheduled procedures. 23. A morbidly obese woman is scheduled for gastric bypass surgery. She completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? • Discuss small, low fat, low sugar meal preparation techniques • Encourage the client to keep a daily dietary for two weeks • Suggest that the client’s husband do the family grocery shopping • Advise the client to arrange for dietary counseling after discharged 24. After reviewing the Braden Scale finding of residents at a long-term facility, the charge nurse should to tell unlicensed assistive personal (UAP) to prioritize skin care for which client? • An older adult who is unable to communicate elimination needs • A older man whose sheets are damp each time he is turned (risk for skin breakdown) • A woman with osteoporosis who is unable to bear weight • A poorly nourished client who requires liquid supplements 25. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer’s disease. What action should the nurse take? • Explain the memory loss and confusion is common with Vitamin B12 deficiency • Ask if the client experiencing any change in bowl habits • Determine if the client is taking iron and folic acid supplements • Encourage the husband to bring the client to the clinic for a complete blood count * Pernicious anemia is related to the absence of the intrinsic factor in gastric secretion, leading to malabsorption of vitamin B12, and commonly causes memory loss, confusion, cognitive problem, and GI manifestations. 26. A male client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicated to the nurse that ICP has increased. • Increased Glasgow coma scale score (improvement in neurologic status) • Nuchal rigidity and dystonia (do not necessarily reflect increased ICP) • Confusion and papilledema (Papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP • Periorbital ecchymosis (do not necessarily reflect increased ICP) * Papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP 27. At 0715, after receiving report on four medical clients, the nurse is preparing a prioritized “to do” list. Which action should the nurse plan to do first? (click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client’s medical records) • Administer metformin to client D • Insert the IV in a new location for client C • Complete a focused assessment for client A (The client with heart failure is exhibiting signs for worsening failure evidenced by his HR, RR, and scattered infiltrates on the chest x-ray, so a focused assessment is the highest priority) • Validate the blood pressure for client D 28. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? • Drank a glass of water in the past 2 hours • Experiences facial swelling after eating crab (allergy to shellfish, is critical to the prevention of a life-threatening complication, anaphylactic shock, induced by iodine- based dyes used to visualize the coronary arteries during the cardiac catherization. While NPO precaution are routinely taken prior to the procedure.) • Reports left chest wall pain prior to admission • Verbalizes a fear of being in confined space