Hesi for NUR 112 Questions With Correct 100% Answers Graded A+

Hesi for NUR 112 Questions With Correct 100% Answers Graded A+ 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 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 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." 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 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 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 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. A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome (AIDS). The primary nurse reports to the nursing team that the client cried when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify that this comment most likely is a result of the nursing assistant's: a. Values and beliefs about sexual lifestyles. b. Anger and mistrust of homosexual males in general. c. Discomfort with men who are unable to control their emotions. d. Hostility over having to care for someone with a sexually transmitted infection A! This statement reflects values and beliefs regarding homosexuality as being bad and deserving of punishment. There is not enough evidence presented to justify drawing the conclusion that the nursing assistant has anger and mistrust of homosexual males in general or discomfort with men who are unable to control their emotions. Although there may be hostility over having to care for someone with a sexually transmitted infection, no information is given to suggest that the nursing assistant has been assigned to care for this client. A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. The nurse explains that a PEG tube is preferred for administering a tube feeding because: a. There is less chance of aspiration b. This procedure does not require a pump c. Self-administration of the feeding is possible d. More tube feeding mixture can be given each time A! When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What instruction should the nurse include in the accident-prevention teaching plan? a. Remove small objects from the floor. b. Cover electric outlets with safety plugs. c. Remove toxic substances from accessible areas. d. Test the temperature of water before bathing. D! Excessively high temperatures can damage the delicate skin of an infant. Although infants are capable of putting small things in their mouths, they are not yet able to crawl and probably will not be placed on the floor. At 3 months of age infants are not yet able to explore the environment to the point that electric outlets pose a problem. At 3 months of age infants are still too small and have not yet developed motor capabilities to get into containers of poison. A nurse has provided discharge instructions to a client that received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: a. Picks up the walker and carries it for short distances b. Uses the walker only when someone else is present c. Moves the walker no more than 12 inches in front of the client during use d. States that a walker will be purchased on the way home from the hospital C! Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital. A client with terminal cancer is to receive 2 mg of hydromorphone (Dilaudid) IV every 4 hours as needed for severe breakthrough pain. The vial contains10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ___ mL 0.2 mL The nurse is teaching hygiene practices to a 16-year-old patient who has recently had her first menstrual flow. Under which phase of development does the nurse classify the patient? a. Prepubescence b. Postpubescence c. Late adolescence d. Middle adolescence D! Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20. A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? a. Presence of distention b. Extent of weight gained c. Amount of high-fiber food consumed d. Length of time this problem has existed D! First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time. Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? a. Returning the aspirate and withholding the feeding b. Discarding the aspirate and administering the full feeding c. Returning the aspirate and subtracting the amount of the aspirate from the feeding d. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding C! The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance. Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? a. Acetylsalicylic acid (Aspirin) b. Hydromorphone (Dilaudid) c. Meperidine (Demerol) d. Alprazolam (Xanax) A! Because of its antiinflammatory effect, acetylsalicylic acid is useful in treating arthritis symptoms. Opioids should be avoided because they promote drug dependency and do not affect the inflammatory process. Alprazolam is an antianxiety, not an antiinflammatory, agent. A client with rheumatoid arthritis takes aspirin (ASA) routinely to reduce pain. The client asks whether it is the arthritis, the aspirin, or some other ear problem that causes the bilateral ear buzzing the client is now experiencing. What is an appropriate nursing response? a. "The ringing in your ears is a sign of otitis media." b. "Aspirin may have damaged your eighth cranial nerve, the acoustic nerve." c. "Accumulation of cerumen, or ear wax, causes ringing in the ears." d. "Your symptoms are an expected response to the aging process." B! ASA may damage the eighth cranial (acoustic) nerve, causing ringing in the ears and impaired hearing. Pain, not ringing in the ears, is a sign of otitis media; ASA toxicity affects the eighth cranial nerve, not the middle ear. Diminished hearing, not ringing, occurs because of mechanical obstruction of the outer ear. Aging may cause decreasing acuity in the extremes of pitch, but it does not cause ringing in the ears. If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already? a. Measles, mumps, and rubella vaccine b. Booster dose of inactivated polio vaccine c. Two doses of diphtheria, tetanus, and pertussis vaccine d. First booster dose of diphtheria, tetanus, and pertussis vaccine C! The schedule for active immunization is three doses of diphtheria, tetanus, and pertussis (DTaP) at 2-month intervals beginning at 2 months of age. The measles, mumps, and rubella vaccine is not given until 12 to 15 months because maternal antibodies block the formation of the infant's antibodies. An inactivated polio vaccine booster (fourth dose) is due at 4 to 6 years of age. The first booster dose of DTaP is given at 15 to 18 months, or approximately 1 year after the third dose that is given at 6 months of age. A nurse withholds a prescribed opioid medication from a client with intractable pain because the nurse fears the client will become addicted. In this situation the nurse is adhering to the ethical principle of: a. Veracity b. Autonomy c. Paternalism d. Beneficence D! Beneficence commonly is referred to as "doing of good"; it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety. Unfortunately in this situation the client's priority is relief from pain and the nurse should be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices. A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use? a. Sharing personal experiences with a smoking-cessation program b. Showing pictures of the effects of smoking on the cardiopulmonary system c. Presenting information on how smoking affects appearance and odor of the breath d. Citing statistics about the relationship between smoking and cardiopulmonary diseases C!