Hesi for NUR 112 Questions and Answers with Rationales Updated 2024 |A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should: a. Give the vaccine b. Administer aspirin with the vaccine c. Hold the vaccine and notify the health care provider d. Reschedule administration of the vaccine for the next month ANSWER: - D! The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary. A daughter of a Chinese speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism ANSWER: - C! Assimilation involves incorporating the behaviors of the dominant culture. Maintaining eye contact is characteristic of the American culture and not Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others. A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included? a. "Increase your intake of fat with each meal." b. "Lie down after eating to help your digestion." c. "Reduce your caloric intake to foster weight reduction." d. "Drink several glasses of fluid during each of your meals." ANSWER: - C! Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals. During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements? a. Increased pulse rate b. Slowing of the heart c. Dilation of the bronchioles d. Coronary Artery Vasodilation ANSWER: - B! Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the principal nerve of the parasympathetic portion of the autonomic nervous system, and its axon terminals release acetylcholine. The response of the viscera to acetylcholine varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of the sympathetic nervous system (accelerator nerve) caused by the release of norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the coronary blood vessels; sympathetic impulses dilate these vessels. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? a. Give aspirin for pain; if swelling at the injection site develops, call the health care provider. b. Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. c. Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures. d. Apply ice to the injection site if soreness develops; call the health care provider if the child comes down with a fever ANSWER: - C! Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the health care provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the health care provider. A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag? a. Auscultating for breath sounds b. Removing the tube, then reinserting it c. Administering the tube feeding slowly d. Observing the infant for circumoral cyanosis ANSWER: - B! The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.