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HESI OJO ULTIMO – Miami Dade College 155 -When assessing a client,the nurse should establish which findings as objective? (Select all that apply.) A Hypertension. B Nausea. C Diaphoresis. D Anxiety. E Edema. F Urticaria. Ans:A,C,,E,F 154-This item can have multiple correct answers. Refer to question instructions for answering information. A Review the staff nurse job description to ensure that it is clear, accurate, and current. B Assign eachstaff nurse a turn as the unit charge nurse on a regular, rotating basis. C Analyze the amount of overtime needed by the nursing staff to complete assignments. D Confirm that all of the staff nurses are being assigned to equal numbers of clients.Ans:A 153 -A client s right to give informed consent is based on which ethical principle? Multiple-Choice Single-Answer A Nonmaleficence. B Practice of beneficence C Respect for autonomy. D Commitment to fidelity. Ans:C 152 -The nurse observes an un licensed assistive personnel (UAP) using an alcoholbased cleanser after delivering a client's breakfast tray to the room. The UAP rubs both hands thoroughly for 2 minutes while standing at the door to the client's room. What action should the nurse take? A Inform the UAP that hand washing helps to promote better asepsis. B Explain that the hand rub can be completed in less than 2 minutes. C Encourage the UAP to remain in the client's room until completed. D Determine why the UAP was not wearing gloves in the client's room. Ans: A151 -Which interventions most important to include in the nursing care plan of a client receiving furosemide (Lasix)? A Frequently assess the client's blood pressure. B Assess urinary output every shift. C Assess the client for abnormal bleeding. D Do not administer medication if the client is hypokalemic. Ans: D 150 -The nurse notices that the catheter of a client who had a transurethral resection of the prostate (TURP) 2 days ago is not draining and his bladder is distended. What action should the nurse take initially? A Milk the catheter tubing. B Discontinue the catheter. C Irrigate the catheter. D Change the catheter. Ans: C 149 -Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow's hierarchy of needs,what priority need should be addressed first?A Physiological needs. B Safety and security. C Self-actualizat on. D Love and belonging. Ans:A 148 -A male client with diabetes mellitus Type 2, who is taking pioglitazone (Actos) PO day reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellow sh cast to his skin. What instruction should the nurse provide? "A urine specimen will be needed to determine what kind of infection you have developed." B "Use insulin per sliding scale until the nausea resolves,and then resume your oral medication." C "You have become dehydrated from the nausea. You will need to rest and increase fluid intake." D "You need to seek immediate medical assistance to evaluate the cause of these symptoms." Ans :D 14 7 -The nurses planning care for a child who is complaining of persistent itching due to scabies. Which measure should the nurse implement to minimize this chi d's risk for complications?A Keep the child's nails short and encourage use of hand mittens. B Monitor for desquamation and normal flora overgrowth. C Shave the body hair before applying the scabicide lotion. D Wash skin between applications of topical antiphrastic doses. Ans: A 146 -The healthcare provider prescribes digoxin (Lanoxin) 0.275 mg V STAT. The available vile contains 2 ml of digoxin (Lanoxin) labeled1 "500 mcg/2 ml " How many ml should the nurse administer? (Enter numeric value only. If rounding is required1 round to the nearest tenth.) 1.1 ML 144 -A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A Apply adult diapers after each attempt to void. B Check residual urine volume using an indwelling urinary catheter. C Assist the client to a bedside commode every two hours. D In struct the client to use the call button when a bedpan is needed. Ans:C143 -The nurse is preparing to administer 1000 ml of dextrose 25% total parenteral nutrition (TPN) to a client with ulcerative colitis. Which intervention is most important for the nurse to implement? A Review the client's intake and output. B Assess vital signs prior to administration. C Administer the TPN through a central line D Evaluate the client's nutritional history. Ans: C 142 -The nurse would expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms? A Dull , left lower cramping pain and low grade fever. B Change in bowel habits blood in stool, and unexplained anemia. C Rigid board-like abdomen and elevated white blood cell count. D Diarrhea , abdominal pain, and weight loss. Ans:D 141 -What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm? A Assess IV site frequently for signs of extravasation. B Monitor capillary refill distal to the infusion site.C Explain that temporary burning at the IV site may occur. D Apply a topical anesthet c at the infusion site for burning. Ans:A 140 -When planning care for a group of clients on a medical unit, which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A Use a mechanical lift to transfer a client to the chair. B Prepare a schedule for positioning a bedfast client. C Complete a Braden Scale to predict pressure ulcer risk. D Determine if a client has learned how to use a walker. Ans :A 139 -A 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings action should the nurse take first? A Determine what triggers precipitated this attack. B Encourage the child to cough and deep breathe. C Report findings to the healthcare provider. D Administer a prescribed bronchodilator.Ans :D 138 -The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which interventions most important for the nurse to include in the client's plan of care? A Maintain the client in a semi-Fowler's position. B Provide frequent rest periods. C Increase fluid intake to 3,000 ml/daily. D Administer 02 at 5 I /minute per nasal cannula. Ans: C 137 -The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%;Client B with a postoperative hemoglobin of 8.7 mg/ di ;Client C, newly admitted with a potassium level of 3.8 mEq/ L;and Client D, scheduled for an appendectomy who has a white blood cell count of 15.000 mm3. What intervention should the nurse implement? A Increase the oxygen flow rate to 4 liters/minute per face mask for Client A. B Determine the availability of two units of packed cells in the blood bank for Client B. C Inform Client D that surgery is likely to be delayed until the infection responds to antibiotics. D Remove any foods , such as banana or orange juice ,for the breakfast tray for Client C.Ans :B 136 -The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) A Rhonchi. B High pitched or fine crackles. C Stridor. D High pitched wheeze. Ans:D 135 -On the third post-burn day, a client's average hourly urine output is 25 ml. Which intervention should the nurse plan to implement? A Change the type of intravenous fluid infusing. B Replace the indwelling urinary catheter. C Increase the rate of the intravenous infusion. D Decrease the rate of the intravenous infusion. Ans : C 134 -A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?