HESI FINAL EXAM VERSION 3

HESI FINAL EXAM VERSION 3 A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Allow the client to use a bedpan. B. Explain the fetal head is descending. C. Perform a sterile vaginal exam. < D. Assist the client to the bathroom. 2. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? A. Dyspnea, cough and fatigue. < B. Hepatomegaly and distended neck veins. C. Pain over the pericardium and friction rub. D. Narrowing pulse pressure and distant heart sounds. 3. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? A. Teach the client to problem-solve for herself and establish her own priorities. B. Schedule a home visit in the afternoon to assess the son and client’s role as caregiver. C. Provide feedback to the client about her atonement for guilt about her son’s impairment. D. Acknowledge the client’s stress and suggest that she consider respite care. < 4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client’s telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take? A. Administer the Toprol immediately and monitor the client carefully until the heart rate increases. B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client’s BP q30 minutes. C. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern. < D. Give the Toprol as scheduled if the client’s systolic blood pressure reading is greater than 180. 5. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? A. Anxiety. B. Insomnia. C. Muscle cramping. < D. Increased appetite. 6. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? A. High urinary pH. B. Fever. C. Abdominal ascites. D. Orthopnea. < 7. The nurse is reviewing a client’s electrocardiogram and determines that the PR interval (PRI) is prolonged. What does this finding indicate? A. Inability of the SA node to initiate an impulse at the normal rate. B. Initiation of the impulse from a location outside the SA node. C. Increased conduction time from the SA node to the AV junction. < D. Interference with the conduction through one or both ventricles. 8. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical area of his abdomen. What instruction should the nurse provide? A. Stroke the inner thigh below the perineum to initiate urinary flow. B. Pour warm water over the external sphincter at the distal glans. C. Apply downward manual pressure at the suprapubic region. < D. Contract, hold, and then relax the pubococcygeal muscle. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse’s accurate understanding of the expected outcome for the client following this surgery? A. Supplemental hormonal therapy will probably be unnecessary. < B. The thyroid will regenerate to a normal size within a few years. C. The client will be restricted from eating seafood. D. The remainder of the thyroid will be removed at a later date. 9. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? A. Lower the head of the bed and apply suprapubic pressure. B. Encourage the client to move to a hands-and-knees position. C. Prepare the client for an emergency cesarean birth. D. Assist the client to sharply flex her thighs up against the abdomen.