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EVOLVE HESI FUNDAMENTALS PRACTICE
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A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? - CORRECT ANSWES -- After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? - CORRECT ANSWES -- Give the missed dose at 1300 and change the schedule to administer daily at 1300. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? - CORRECT ANSWES -- Give an around-the-clock schedule for administration of analgesics. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? - CORRECT ANSWES -- determine the etiology of the problem What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? - CORRECT ANSWES -- A decreased flow rate could result in the formation of a thrombosis. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? - CORRECT ANSWES -- Continue asking the mother questions about the child. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? - CORRECT ANSWES -- Assess for bladder distention.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? - CORRECT ANSWES -- Blood transfusions are forbidden. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? - CORRECT ANSWES -- Acknowledge that she is supporting the arm correctly. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? - CORRECT ANSWES -- Fowler's. An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? - CORRECT ANSWES -- It is important that you continue your medication while learning to meditate. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? - CORRECT ANSWES -- 150 The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? - CORRECT ANSWES -- Frontal lobe A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? - CORRECT ANSWES -- Initiate an alternate site for the IV infusion of the medication. A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? - CORRECT ANSWES -- Request and document the name of the certified translator. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? - CORRECT ANSWES -- Place a pillow between your knees while lying in bed to prevent hip dislocation. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? - CORRECT ANSWES -- Assist the ambulating client back to the bed. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? - CORRECT ANSWES -- During the inhalation The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? - CORRECT ANSWES -- I will limit my intake of beef to 4 ounces per week. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? - CORRECT ANSWES -- Loosen the right wrist restraint. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? - CORRECT ANSWES -- 8 a.m., 4 p.m., and midnight. An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? - CORRECT ANSWES -- 180 An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? - CORRECT ANSWES -- The nurse who transferred the client to the chair when the fall occurred. The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? - CORRECT ANSWES -- The client voluntarily signed the form. The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? - CORRECT ANSWES -- Flush the tube with water. An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? - CORRECT ANSWES -- Be sure to have a complete physical examination before beginning your planned exercise program.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the - CORRECT ANSWES -- upper torso Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? - CORRECT ANSWES -- upper arm circumference During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? - CORRECT ANSWES -- Degree of flexion and extension of the client's knee joint. A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? - CORRECT ANSWES -- What vitamin and mineral supplements do you take? An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? - CORRECT ANSWES -- Gently lift the client when moving into a desired position. During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? - CORRECT ANSWES -- Acknowledge the client's distress and tell her it is all right to cry. Which action is most important for the nurse to implement when donning sterile gloves?
- CORRECT ANSWES -- Keep gloved hands above the elbows. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? - CORRECT ANSWES -- Skim milk, turkey salad, roll, and vanilla ice cream. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
- CORRECT ANSWES -- Reposition in a Sim's position with the client's weight on the anterior ilium. An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? - CORRECT ANSWES -- Inquire about the source and type of pain A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client - CORRECT ANSWES -- demonstrates the wound care procedure correctly.
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? - CORRECT ANSWES -- Commend the client for selecting a high biologic value protein. When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? - CORRECT ANSWES -- Many complimentary healing practices can be used in conjunction with conventional practices. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is - CORRECT ANSWES -- Fowler's. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? - CORRECT ANSWES -- 11,000 units Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? - CORRECT ANSWES -- Chocolate pudding. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? - CORRECT ANSWES -- Re-oxygenate the client before attempting to suction again. When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? - CORRECT ANSWES -- Note which actions were not implemented. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? - CORRECT ANSWES -- The body's receptors adapt over time as they are exposed to heat. (D) describes thermal adaptation, which occurs 20-30 minutes after heat application. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? - CORRECT ANSWES -- is disoriented to place and time. Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? - CORRECT ANSWES -- 1.5 tablets The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? - CORRECT ANSWES -- 83 gtt/min. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? - CORRECT ANSWES -- Encourage additional oral intake of juices and water The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? - CORRECT ANSWES -- Infuse 10 percent dextrose and water at 54 ml/hr. A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? - CORRECT ANSWES -- 63 ml/hour. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? - CORRECT ANSWES -- Move the chair parallel to the right side of the bed, and stand the client on the right foot. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? - CORRECT ANSWES -- ) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? - CORRECT ANSWES -- Healthcare provider notified of client's refusal to have blood specimens collected for testing. At the beginning of the shift, the nurse assesses a client who is admitted from the post- anesthesia care unit (PACU). When should the nurse document the client's findings? - CORRECT ANSWES -- Immediately after the assessments are completed.
serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? - CORRECT ANSWES -- Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? - CORRECT ANSWES -- Insert a Huber-point needle into the port An implanted infusion port needs to be accessed using a Huber-point needle (B) (non- coring) to be prevent damage to the self-sealing septum of the port. During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? - CORRECT ANSWES -- Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? - CORRECT ANSWES -- Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? - CORRECT ANSWES -- Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems
