366 EXIT HESI
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been
sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority
for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway
and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for
rest and sleep, and then definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - 3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
,Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration
(OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks
when caring for a client who is positive for tuberculosis, and required annual updates for healthcare
workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee
rights. Other options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I
am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore."
3. "I have known many clients with depression who have felt better after several weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover." - 3.
"I have known many clients with depression who have felt better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a person to stop
negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative
thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him
how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the
client's feelings and does not provide the same degree of hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate
primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the
nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. - 3. Assess and
document skin condition around the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased nosocomial transmission to
others, so the condition of any invasive lines or breaks in the skin should be assessed and documented
during each shift.
,A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part
of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - 4. Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in
the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is
the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy
is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy
is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually
indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is
breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - 4. Inject air until no air is
auscultated over the larynx during a deep breath.
To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air
into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the
cuff) during inhalation. At the point when sounds of air movement cease, inflation is stopped, indicating
that the cuff is sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10
mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse
implement?
1. Refer for further diagnostic evaluation.
, 2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - 1. Refer for further diagnostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI),
which this client is in a high-risk category for exposure in a homeless environment. Although productive
prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should
not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be
implemented. A dormant form that neither causes disease nor is communicable.
Which contextual factors are considered external environmental influences in the framework for
occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - 1. Economics.
3. Technology.
6. Legislation/regulation.
Economics affects the health of the company and its workforce productivity, in termsof profitability,
growth, and expansion. Technology adds to an industry's capacity to develop and implement new or
improved work processes. Legislation/regulation in the workplace, such as the blood-borne pathogen
standard, affects the workforce in terms of requirements, administration, and control strategies.
Occupational safety programs are built around the workforce to strive for maximum internal
productivity. Interventions are internal environmental influences of an occupational health and safety
program. Socio-economic status is a demographic variable commonly used in epidemiology.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a
disturbance in electrical conduction in the ventricles?
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been
sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority
for the nurse. (Rank in the priority order from highest to lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway
and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for
rest and sleep, and then definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select all that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - 3. Blood-borne pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
,Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration
(OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks
when caring for a client who is positive for tuberculosis, and required annual updates for healthcare
workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee
rights. Other options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I
am never going to get well." What is the most therapeutic response?
1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
2. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore."
3. "I have known many clients with depression who have felt better after several weeks of treatment."
4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover." - 3.
"I have known many clients with depression who have felt better after several weeks of treatment."
Stating the observation that others have recovered can give a client hope. Telling a person to stop
negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative
thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him
how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the
client's feelings and does not provide the same degree of hope.
The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate
primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the
nurse implement?
1. Limit visitors to immediate family to decrease exposure to infection.
2. Maintain "clean" technique in the change of wound dressing and IV site.
3. Assess and document skin condition around the incision and IV site at each shift.
4. Require the use of a face mask by staff when providing care requiring close contact. - 3. Assess and
document skin condition around the incision and IV site at each shift.
Early identification of infection leads to prompt treatment and decreased nosocomial transmission to
others, so the condition of any invasive lines or breaks in the skin should be assessed and documented
during each shift.
,A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part
of preoperative teaching, what information should the nurse provide?
1. The transverse loop ostomy is permanent.
2. Easily removable appliances allow independence in self-care.
3. Daily irrigation is started after the J pouch heals.
4. Stool is eventually expelled through the rectum. - 4. Stool is eventually expelled through the rectum.
An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in
the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is
the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy
is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy
is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually
indicated.
The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is
breathing spontaneously. Which action should the nurse follow?
1. Check the pilot balloon to ensure that it is firm.
2. Verify the healthcare provider's prescription for the required cuff pressure.
3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg.
4. Inject air until no air is auscultated over the larynx during a deep breath. - 4. Inject air until no air is
auscultated over the larynx during a deep breath.
To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air
into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the
cuff) during inhalation. At the point when sounds of air movement cease, inflation is stopped, indicating
that the cuff is sealed against the tracheal wall.
A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10
mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse
implement?
1. Refer for further diagnostic evaluation.
, 2. Determine exposure of others to the tuberculosis.
3. Begin anti-tubercular drug therapy.
4. Quarantine or isolate to control communicability. - 1. Refer for further diagnostic evaluation.
The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI),
which this client is in a high-risk category for exposure in a homeless environment. Although productive
prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should
not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be
implemented. A dormant form that neither causes disease nor is communicable.
Which contextual factors are considered external environmental influences in the framework for
occupational health programs and services? (Select all that apply.)
Select all that apply
1. Economics.
2. Workforce.
3. Technology.
4. Interventions.
5. Socio-economic status.
6. Legislation/regulation. - 1. Economics.
3. Technology.
6. Legislation/regulation.
Economics affects the health of the company and its workforce productivity, in termsof profitability,
growth, and expansion. Technology adds to an industry's capacity to develop and implement new or
improved work processes. Legislation/regulation in the workplace, such as the blood-borne pathogen
standard, affects the workforce in terms of requirements, administration, and control strategies.
Occupational safety programs are built around the workforce to strive for maximum internal
productivity. Interventions are internal environmental influences of an occupational health and safety
program. Socio-economic status is a demographic variable commonly used in epidemiology.
The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a
disturbance in electrical conduction in the ventricles?
