HESI NC2 CUSTOM PRACTICE QUESTIONS

HESI NC2 CUSTOM PRACTICE QUESTIONS A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? a. Assess the client’s vital signs. b. Observe the client’s pupils for dilation. c. Document the client’s drug tolerance. d. Administer the analgesic as requested An older female client has normal saline infusion at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take? a. Determine what IV medications have recently been administered. b. Explain that without redness or edema, there is no need to re-start the IV. c. Consult with the health care provider about the best location to start a new IV. d. Convert the IV to a saline lock and continue to monitor the site. The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which client is at the highest risk for complications related to hypertension? a. Older Asian male who eats a diet consisting of smoked, cured, and pickled foods. b. Young adult Hispanic female who has a hemoglobin of 11 g/dL and drinks beer every day. c. Post-menopausal Caucasian female who overeats and is 20% above ideal body weights. d. Middle-aged African-American male who has a serum creatinine level of 2.9 Mg/dL. An 82-year-old female client with Type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. Which should the nurse recommend? a. Soak feet for 10 minutes before cutting nails. b. As a family member to cut her toenails. c. Seek routine nail care with a podiatrist. d. Encourage monthly pedicures at a nail shop. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. I need to take the prescribed amount of the drug to get rid of my gout. b. The pain and swelling can be controlled by taking this drug every day. c. I should take this drug when I have gout attacks to reduce symptoms. d. I need to take this drug every day to keep from having any flare-ups. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? a. Has everyone at home already had varicella? b. Do you have any dry patches on your feet and hands? c. Do your family members share combs and brushes? d. Have the antifungal creams been effective? A community hit by a hurricane has suffered mass destruction and flooding. Sewage facilities are non- functioning, and the area is contaminated with human excreta. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority? a. Isolate all infectious diarrhea victims. b. Provide fluid and electrolyte replacement. c. Administer prophylactic antibiotics as prescribed. d. Administer cholera vaccine. The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? a. Liver b. Oranges c. Kidney beans d. Leafy green vegetables A male client with AIDS and Pneumocystis jirovenci pneumonia has a CD4 T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client’s question? a. Exposure to multiple environmental infectious agents overburdens the immune system until it fails. b. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. c. The humoral immune response lacks B cells that form antibodies and opportunistic infections result. d. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. Methotrexate is prescribed for a client with rheumatoid arthritis who is also taking aspirin. What is the best explanation for the nurse to provide as to why a second medication has been added? a. Methotrexate slows the disease progression while aspirin controls the symptoms. b. Methotrexate enhances the effectiveness of the aspirin. c. Methotrexate helps to reduce the side effects of the aspirin therapy. d. Methotrexate has less harmful side effects than aspirin. A government office worker is seen in the emergency room after opening and envelope containing a powder like substance which is being tested for anthrax. Which discharge instruction should the nurse provide the client concerning inhalation anthrax? a. Cleanse all surfaces touched with pre-moistened anti-bacterial wipes. b. Return to the emergency room if flu-like symptoms develop within 42 days. c. Isolation from friends and family members is recommended for 3 weeks. d. Notify co-workers to get the anthrax vaccine at the public health department. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse’s assessment of the test after 62 hours indicates 5 mm of erythema without induration. Which is the best initial nursing action? a. Document negative results in the client’s medical record. b. Review client’s history for possible exposure to TB. c. Refer client to a healthcare provider for isoniazid therapy. d. Instruct the client to return for a repeat test in 1 week. A 55 year old client with osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse? a. Limit your exercise to just your daily activities. b. Jogging or running are excellent aerobic exercises. c. Swimming is an excellent exercise for you. d. Tennis or racquetball will increase your muscle strength. The nurse is triaging clients who have been injured during a tornado. Which client requires immediate action? a. An adult male with type 1 diabetes who is ambulatory with capillary refill of 2 seconds and respirations at 22 breaths/minute. b. A middle aged female with a broken humerus who is unable to follow commands and is crying. c. A middle aged male with acute anxiety, a laceration on his left cheek, and respirations of 24 breaths/minute. d. An older female with degenerative disk disease who is hard of hearing and continues to ask questions. The nurse working in a disaster area assesses an adult male who has partial-thickness burns on his lower legs, on approximately 10 % of his lower body. Which color of triage tag should the nurse place on this client? a. Black b. Red c. Yellow d. Green An adult client who received partial thickness and full thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the acute phase of the client’s burn recovery? a. 5% dextrose in water. b. 5% dextrose in 0.25 normal saline. c. Total parenteral nutrition. d. Lactate Ringer’s A unlicensed assistive personnel reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8 F, blood pressure of 90/70, pulse of 124/minute, and respirations of 28/minute. When the nurse assesses the client, findings include mottled skin appearance and confusion. Which action should the nurse take first? a. Transfer the client to ICU. b. Initiate an infusion of IV fluids. c. Obtain a wound specimen for culture. d. Assess the client’s core temperature. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? a. Deficient knowledge related to a new medication regimen. b. Risk for injury related to effects of thrombolysis. c. Activity intolerance related to ischemia. d. Ineffective breathing pattern related to adverse drug effects. A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department? a. Obtain supplies to redress the burn area. b. Perform active range of motion exercises. c. Verify the client’s signed consent form. d. Give a prescribed narcotic analgesic agent. Based on this strip, what is the interpretation of this rhythm? a. First degree AV heart block. b. Junctional escape rhythm. c. Sinus bradycardia. d. Normal sinus rhythm. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to a hemothorax? a. Keep the arm and shoulder of the affected side immobile at all times. b. Ensure that there is no fluctuation in the water seal chamber. c. Encourage the client to breath deeply and cough at frequent intervals. d. Maintain the Pleuravac slightly above the chest level. The settings of a client’s synchronized intermittent mandatory ventilation (SIMV) are respiratory rate 12 breath/minute, tidal volume at 600 mL, FiO2 35%, and PEEP 5 cm H2O. Which assessment finding necessitates immediate intervention by the nurse? a. Respiratory rate of 18 breaths/minute. b. Low pressure indicator alarms. c. Bilateral crackles in lung bases. d. Oxygen saturation of 91%. Based on this strip, what is the correct interpretation of this rhythm? a. A Wenckebach, Mobitz type I AV block b. Premature atrial contractions. c. Accelerated junctional rhythm. d. Atrial fibrillation. Based on the interpretation of this strip, what action should be implemented next? a. Open the airway. b. Deliver artificial ventilation. c. Begin chest compressions. d. Call a code. A young adult client, admitted to the ED following a motor vehicle collision, is transfused with 4 units of PRBCs. The client’s pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all of the PRBCs have been transfused? a. 9% b. 19% c. 29% d. 39% A client who experienced partial thickness burns with over 50% BSA 2 weeks ago has several open wounds and develops watery diarrhea. The client’s blood pressure is 82/40 mmHg and temperature 96 F. Which action is most important for the nurse to take? a. Continue to monitor vital signs. b. Increase the room temperature. c. Assess the oxygen saturation. d. Notify the rapid response team Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? a. Monitor daily urine output volume. b. Review food labels for sodium content. c. Use salt tablets after strenuous exercise. d. Drink plenty of water whenever thirsty. The health care provider prescribes ampicillin 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers the drug in a 150 mL IV bag. How many mL/hour should the nurse program the infusion pump? Enter a whole number only A client is currently receiving an infusion labeled 5% Dextrose Injection 500 mL with heparin sodium 25,000 units at 14 mL/hour. A prescription is received to change the rate of the infusion to heparin 1,000 units/hour. How many mL/hour should the nurse program the infusion pump? A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump? Round to the nearest whole number. 33 ml/hr Which nursing intervention promotes achievement of the goal “optimal mobility” for a client who had a total hip replacement 8 hours ago? a. Instruct the client to flex knees and hips, grab the side rail and turn. b. Maintain supine position for the first twelve hours postoperatively. c. Use a turn sheet to log roll the client from back to side d. Assist the client to turn while an abductor pillow is between the legs. An older adult with chronic obstructive pulmonary disease was recently admitted to the hospital with heart failure. Which actions should the nurse take in providing care? SATA a. Monitor electrolytes values b. Maintain pulse oximeter c. Offer low re3sidue snacks d. Provide assistance with mobility e. Encourage increased fluid intake The healthcare provider prescribes the NSAID naproxen 500 mg by mouth twice a day for a client with OA. During a follow up visit one month later, the client tells the nurse “the pills don’t seem to be working. They are not helping the pain at all.” Which factor should influence the nurse response? a. Noncompliance is probably impacting optimum medication effectiveness. b. Drug dosage is inadequate and needs to be increased to four times a day. c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream d. NSAIDs response is variable and another NSAID may be more effective. A client who had a radical neck dissection returns to the surgical unit with two Jackson Pratt drains in the right side of the incision. One JP bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP? a. Place the client in a right lateral side lying position and elevate the head of the bead b. Irrigate the JP with 1 mL then close the opening with its tab c. Reinforce the incisional dressings and assess behind the neck for drainage d. Compress the bulb with the tab open and then reinsert the tab into its opening While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healtcare provider, the nurse should note which of the client’s laboratory values? a. Hematocrit b. Blood pH level c. Neutrophil count d. Serum potassium level Which nursing problem has the highest priority when planning care for a client with Meniere’s disease? a. Alteration in body temperature related to decreased hypothalamic functioning b. Alteration in comfort related to pain in the ear c. Potential for injury related to vertigo d. Impaired skin integrity related to immobility When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing problem of “visual sensory/perceptual alterations.” This problem is based on which etiology? a. Photosensitivity b. Limited eye movement c. Decreased peripheral vision d. Blurred distance vision A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea. The examining healthcare provider believes that the client is experienced and acute myocardial infarction. Which client history findings contraindicate the use of tPA? a. Current age is 65, father died of MI at 55 b. Had a cerebrovascular hemorrhage 2 months ago c. Reports being intolerant to medication containing aspirin d. Treats type 2 diabetes with an oral hypoglycemic agent. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect? a. Sensorineural b. Conductive c. Presbycusis d. Mixed sensorineural-conductive An adult client is admitted with AIDS and oral candidiasis with painful mouth ulcers. The nurse delegates oral care to the UAP and discusses how to assist the client. Which instruction should the nurse provide the UAP? a. Provide a soft bristled toothbrush for the client to use during oral care b. Wear sterile gloves when cleansing any areas of infected mucosa c. Offer the client mouthwash for thorough cleansing after brushing teeth d. Assist with personal care, but leave oral care for the nurse to complete A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement? a. Compare the client’s pain scale rating with the prescribed dosing b. Ask the client to choose which medication is needed for the pain c. Determine which prescription will have the quickest onset of action d. Document the client’s report of pain in the medical record An older client is receiving an IV of 0.45% NaCl at 75 mL/h. Which assessment finding indicates to the nurse that the client is developing a complication of this therapy? a. Average daily urinary output of 1,200 mL b. Pulse rate 110 per minute and dyspnea upon exertion c. Episodes of vertigo and loss of balance d. Capillary refill at 3 seconds During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question? a. Stand above the client and speak loudly b. Raise the pitch of your voice and speak slower c. Restate question articulating consonants carefully d. Sit with the light of the window behind you as you speak. An older male client with obesity and diabetes develops intermittent claudication. Which additional information, obtained by the nurse during the assessment, is most significant? a. Participates in 2 rounds of golf a week b. Has a familial history of hypertension c. Drinks alcohol socially on weekends d. Smokes 1.5 packs of cigarettes daily The nurse is caring for a hospitalized older client with a left hip fracture as a result of a fall at home. Which assessment finding warrants immediate intervention by the nurse? a. Unable to stand at beside without assistance b. Left extremity capillary refill greater than 5 seconds c. Family hesitant to explain how the injury occurred d. Multiple extremity bruises at various healing stages While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish colored lesions on the client’s hands, arms and face. On palpation, they are slightly rough to the touch. Based on this assessment findings, which action should the nurse implement? a. Ask about recent international travel b. Refer the client for a skin lesion biopsy c. Apply lubricating lotion to the areas d. Record the presence of senile lentigines To assess the quality of an adult client’s pain, what approach should the nurse use? a. Provide a numeric pain scale b. Ask the client to describe the pain c. Observe body language and movement d. Identify effective pain relief measures When performing postural drainage on a client with COPD which approach should the nurse use? a. Perform the drainage immediately after meals b. Instruct the client to breath shallow and fast c. Obtain arterial blood gases prior to the procedure d. Explain that the client may be place in five positions