HESI Exit Rn V5 160 Questions and Answers

HESI Exit Rn V5 160 Questions and Answers 128. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia 129. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins 130. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces 131. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin 132. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact 133. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) ”The treatment requires reapplication in 8 to 10 days." B) ”Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. 134. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A) Administer a daily dose of lisinopril as scheduled. B) Assess the client for postural hypotension. C) Notify the healthcare provider immediately D) Provide a PRN dose of acetaminophen for headache E) Withhold the next scheduled daily dose of warfarin 135. An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bed side commode next to bed C) Suction oral cavity every 4 hours. D) Encourage family participate in the client's care E) Play classical music in room while client is awake 136. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light D) A medication is used to induce sleep during the procedure E) These medications assist in obstructing client´s vision during the surgery 137. The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply) A) Expresses suicidal thoughts B) Avoid eyes contact C) Reports feeling sad D) Has a disheveled appearance E) Interacts with felt effect 138. A client who is hospitalized and recently diagnosed with Addison’s disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate of intravenous fluid infusion D) Withhold next dose of corticosteroid E) Initiate fall risk precautions 139. 61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client’s plan of care? (Select all that apply) A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding C) Maintain sequential compression devices while in bed D) Administer low molecular weight heparin as prescribed E) Assess pain level and medicate PRN as prescribed 140. An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bedside commode next to the bed C) Suction oral cavity every 4 hours D) Encourage family to participate in the client’s care E) Play classical music in room while client is awake 141. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply). A) Practice relaxation exercises B) Limit fluids to avoid bladder distention C) Space activities to allow for rest periods D) Avoid persons with infections E) Take warm baths before starting exercise 142. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply). A) Provide supplemental oxygen B) Auscultate bilateral lung fields C) Administer a nebulizer treatment D) Reinforce occlusive CT dressing E) Give PRN dose of pain medication 143. After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness 144. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen 145. The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activated charcoal used? What does it do?” What is the nurse's best response? A) ”Activated charcoal decreases the systemic absorption of the poison from the stomach." B) ”The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) ”This substance helps to get the poison out of the body by the gastrointestinal system." D) ”The action may bind or inactivate the toxins or irritants that are ingested by children or adults." 146. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) ”Please state your name?" Upon entering the room the nurse should ask: B) ”What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) “Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" 147. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis 148. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) A) Take out dentures and place in a labeled cup B) Apply a body shroud C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eyes 149. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy. 150. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields 151. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room 152. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages 153. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) A) Take an additional dose for signs of hyperglycemia C) Report persist polyuria to the healthcare provider D) Use sliding scale insulin for finger stick glucose elevation E) Take Glucophage with the morning and evening meal. B) Recognize signs and symptoms of hypoglycemia 154. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying A) ”He has a lot of problems. You need to have patience with him." B) ”I will talk with him and try to figure out what to do." C) ”He is scared and taking it out on you. Let's talk to figure out what to do." D) ”Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day." 155. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client’s health care providers. B) “I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client’s written consent before I release any information to you. 156. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects 157. A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) A) Protect medication from exposure to light B) Monitor for changes in level of consciousness C) Observe for onset of generalized bruising or bleeding D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes 158. A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) A) Give the client 4 ounces of orange juice B) Obtain blood pressure and pulse rate C) Provide the client with ½ cup diet carbonated soda D) Administer a PRN dose of regular insulin E) Check the client’s current finger stick blood glucose 159. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply) A. Interacts with a flat affect B. Avoids eye contact C. Has a disheveled appearance D. Report feeling sad E. Expresses suicidal thoughts 160. A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate of intravenous fluid infusion D) Withhold next dose of corticosteroid E) Initiate fall risk precautions