NUR 2520 HESI ALL EXAM QUESTIONS AND ANSWERS NEW UPDATE 2024/2025 TOP RANKED A+ BEST EXAM SOLUTION FOR NURSING WITH RATIONALES

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? Call respiratory therapy. Begin manual ventilation immediately. Monitor oxygen saturation levels every 5 minutes. Silence the alarm and call the technician. That's right! Rationale: Ventilators provide mechanical respirations. A constant alarm and low oxygen saturation indicates a malfunction or problem with the respirations being provided. The first action that must be taken is to begin manual ventilation until the problem has been resolved. 15s 1 / 1 points The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A peanut butter sandwich with soda and cookies. A tuna fish sandwich with chips and ice cream. A salad with three kinds of lettuce and fruit. Vegetable soup, crackers, and milk. That's right! Rationale: In a high protein diet, a lunch with fish and dairy contains the highest amount of protein. For instance, four ounces of tuna contains 11 grams of protein, and ice cream 5 grams of protein per cup. 2m 2s 1 / 1 points The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours. For the next 24 hours, notify nurse when the bladder is full, and the nurse So close! will collect catheterized specimens. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours. Rationale: Voiding, discarding the sample, and beginning the collection are the correct steps for collecting a 24-hour urine specimen. Discarding even one voided specimen during the collection invalidates the test. 23s 0 / 1 points An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? Incorrectly administered too much insulin. Skipped eating lunch. Ate an extra peanut butter sandwich before gym class. Had a cold and ear infection for the past two days. So close! Rationale: Acute infections increase the body's need for insulin to control hyperglycemia and put the client at risk for diabetic ketoacidosis (DKA). 50s 0 / 1 points At 40-weeks gestation, a client who is in active labor is lying in a supine position and tells the nurse that she has finally found a comfortable position. What action should the nurse take? Encourage the client to turn on her left side. Place pillows under the client's head and knees. Explain to the client that her position is not safe. Place a wedge under the client's right hip. That's right! Rationale: So close! Hypotension from pressure on the vena cava due to the weight of the fetus is a risk for the full-term client. Placing a wedge under the right hip will displace the fetus and relieve pressure on the vena cava. 26s 1 / 1 points The nurse is assessing a client with a closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest level of neurologic functioning? Withdrawal from painful stimuli. Decerebrate posturing during position changes. Localization of a tactile stimulus. Decorticate posturing during tracheal suctioning. Rationale: The lowest level of neurological functioning is characterized by decerebrate posturing (abnormal extension). Posturing (decorticate or decerebrate) is not considered a purposeful response to pain. As neurological functioning deteriorates, the client will progress from localization of a tactile stimulus to withdrawal from painful stimuli, followed by decorticate posturing in response to the stimuli, before finally exhibiting file:///Users/balrajsivia/Downloads/R decerebrate posturing. 51s 0 / 1 points A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? "There is no one who will hurt you." "You are in a safe place. No one can get to you here." "You seem quite frightened right now." "What would you like to see me do to protect you?" That's right! Rationale: A client with delusions firmly holds false beliefs to be true, and it is best to acknowledge feelings related to the delusion. Reassuring statements such as, "You will be alright" are not effective for such clients. 21s 1 / 1 points So close! The wife of a newly-diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide? Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism. Encourage the wife to ventilate her feelings about having a husband with Parkinson's disease. Compile a list of alternative medications that are effective in curing Parkinson's disease. Rationle: The client's wife should be given truthful information that there is no known cure for Parkinson's disease available today. 1m 26s 0 / 1 points The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? Identifies 2 treatments for constipation due to immobility. Names 3 home safety hazards to be resolved immediately. States 4 risk factors for the development of osteoporosis. Lists 5 calcium-rich foods to be added to her daily diet. That's right! Rationale: A major goal for an older client with osteoporosis is maintenance of safety to prevent falls. The outcome is stated with the client actions that are specific and time oriented, such as the client names 3 home safety hazards to be resolved immediately. 23s 1 / 1 points An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints? So close! Responsiveness to painful stimuli. Pupils equal, round and reactive. Range-of-motion and circulation. Speech patterns and processes. Rationale: While a client is in restraints, the nurse should assess and record findings related to range-of-motion and circulation, and these assessments should be performed at regular intervals.