HESI-RN Fundamentals Comprehensive Solutions, Exams of Nursing

Download HESI-RN Fundamentals Comprehensive Solutions and more Exams Nursing in PDF only on Docsity! HESI-RN Fundamentals Comprehensive Solutions for Every Question Global Insights A+ Graded Exams from Renowned Sources Handpicked from Elite Universities For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply.) A. Bacon, egg, and cheese biscuit B. Chinese chicken and vegetables, with rice and soy sauce C. Strawberry, spinach salad with yogurt-based blue cheese dressing D. Chicken salad stuffed fresh tomato with a side of celery sticks E. Grilled tilapia with a fresh green side salad F. Grilled hot dog on a bun with ketchup and mustard - -correct ans- -A, B, F Rationale: The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in sodium. A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.) A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. C. Limit total fluid intake to no more than 1000 mL/day. D. Have the client sit on the side of the bed instead of getting up and walking. E. Ask the client to take deep breaths and cough five times every hour while awake. - -correct ans- -A, B, E Rationale:As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting at the side of the bed is not a replacement for ambulating. Having the client sit up helps expand the lungs. Taking deep breaths, through coughing or incentive spirometry, helps expand the lungs and decrease atelectasis. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult." - -correct ans- -A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement. A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury - -correct ans- -A Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home." - -correct ans- -C Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse. The nurse is preparing to change the bed of a client who is non-responsive, and receiving continuous enteral tube feedings. What step must the nurse take prior to changing the bed? A. Stop the feeding for 15 minutes prior to changing the bed. B. Obtain extra linens to absorb any feeding that leaks out of the mouth. C. Ask another nurse to help with changing the bed. D. Ask the client's spouse to leave the room during the bed change. - -correct ans- -A Rationale: This client is at risk for aspiration during the bed change as the head of the bed must be lowered. Stopping the feeding will help decompress the stomach and decrease the risk. The client should not be leaking fluid out of the mouth. Check the feeding for residual. If the feeding is not moving out of the stomach, notify the healthcare provider. Assistance with changing a bed is nice for the nurse, but is not imperative for the client's safety. The spouse does not need to leave the room. The nurse is at a teen event. Which teen's statement would cause the nurse to input some safety tips? (Select all that apply.) A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." B. "I hang around with my friends after the games, like football and baseball." C. "I work until 10:00 pm at a local fast-food restaurant." D. "I never use my seatbelt while I am driving. I hate the way it feels." E. "We often go and play beach volleyball when it is nice out." - -correct ans- -A, D Rationale: Sexual exploration is not uncommon as a teen. However, pregnancy can occur with ejaculation on the perineal area. Accidents are the leading cause of death in the teen years and seatbelt use must be encouraged at all times. The remaining statements demonstrate normal growth and development for the teen years. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit - -correct ans- -A Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry. The health care provider diagnoses metastatic cancer and recommends a gastrostomy for an elderly client in stable condition. The client's adult child is concerned and states to the A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea. - -correct ans- -D Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. - -correct ans- -C Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium - -correct ans- -D Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning. The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am B. 9:00 am C. 12:00 noon D. 2:00 pm - -correct ans- -A Rationale: The aPTT test should be drawn 1 hour before the scheduled dose. The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.) A. Call the health care provider. B. Elevate the head of the bed. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage. - -correct ans- -A, C, D, E Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency. The head of bed may need to be lowered or placed in Trendelenburg position to increase circulation to the brain. The remaining selections are correct. The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which findings support the evaluation? (Select all that apply.) A. The area around the insertion site is swollen. Place a cotton ball into the inner canal. E. Pull the auricle down and back. - -correct ans- -A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E). The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.) A. Footboard at the end of the bed B. Heals without redness bilaterally C. Skin intact on the back D. Sheepskin booties in place E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely. - -correct ans- -B, C, E, F Rationale: The footboard helps prevent foot drop, but does not measure the effectiveness of the treatment. The sheepskin booties are in place to protect the heal, but they do not demonstrate the effectiveness. The remaining are assessments that demonstrate the interventions are effective. The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months - -correct ans- -B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B. The nurse is performing an intake interview for a newly admitted client to the rehabilitation unit. Which questions will the nurse include in the interview? (Select all that apply.) A. "When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?" E. "Do you urinate every hour, on the hour, when you are awake?" - -correct ans- -A, B, C, D Rationale: The goal of the intake interview is to understand the client's daily routines so those routines can be observed and upheld while residing on the rehabilitation unit. Asking about how long the client will be on the rehabilitation unit helps the nurse to understand the client's expectations of the duration of the stay. Urinary and bowel patterns are important to understand, but the issue with this assessment is the frequency of urination. The better question is, "How often do you urinate when you are awake?" The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30 to 45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision. - -correct ans- -A, C Rationale: The client must stay on her back or on the unaffected side, not on the operative side. Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm will help lymph drainage. The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home"