HESI-RN

1. A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? Supine with the foot of the bed raised 2. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes? Participants can identify at least three coping strategies to use during labor 3. Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio? A self evaluation that identifies how the nurse has met professional objectives and goals. 4. a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map? Multisicipilinary group 5. An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? Stage 3 6. When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care? Coordinating and educating about multidisciplinary services 7. A low potassium diet is prescribed for a client what foods should the nurse try to avoid? Dried prunes 8. A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? Hypotension, rapid weak pulse, and rapid respiratory rate 9. The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? Use a soft tip rubber suction catheter and avoid deep vigorous suctioning. 10. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? The nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? Spinal cord injury 11. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? 12. The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? Frequent blood pressure checks, including readings taken automated machines are recommended 13. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? Monitor for increased blood pressure and pulse 14. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? Confront the client about the consequences of the behavior. 15. A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 16. A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state. 17.After eye drops are instilled, which instruction should the nurse provide to the client? Close your eyelids 18. The nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? A Buretrol Attachment 19. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours 20. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is C) Manage pain 21. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 22. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? C) "I understand the need to use those new skills." 23. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? C) Gravida 3 para 1 24. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN 25. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube 26. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to D) Restore yin and yang 27. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? B) thrombus formation