Hesi Fundamentals 2 Practice Questions and answers correct and verified A+

Hesi Fundamentals 2 Practice Questions and answers correct and verified A+Hesi Fundamentals 2 Practice Questions and answers correct and verified A+ The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? a. observe the appearance of the skin under the ice pack b. instruct the client regarding the need for the covering c. reapply the covering after filling with fresh ice d. ask the client how long the ice was applied to the skin - correct answer-Answer: a. observe the appearance of the skin under the ice pack Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the other actions b,c,d as needed. The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60gtt/mL how many drops per minute should the client receive? a. 31 gtt/min b. 62 gtt/min c. 93 gtt/min d. 124 gtt/min - correct answer-Answer: d. 124 gtt/min Rationale: d is the correct calculation: 182/2.2 = 82.73 kg 5mcg x 82.73 = 413.65 mcg/min. 250/50,000mcg = 200 mcg/ml 413.65/200 = 2.07 mL 60 x 2.07 = 124.28 gtt/min The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by caesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse plans to set the flow rate at how many gtt/min? a. 42 gtt/min b. 83 gtt/min c. 125 gtt/min d. 250 gtt/min - correct answer-Answer: b. 83 gtt/min Rationale: 1000ml / 4 hours = 250 ml/hour 250ml/60 min = 4.1667ml/min 4.1667ml/min x 20 gtt/ml = 83.33 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? a. aspirating gastric contents to assure a pH value of 4 or less b. hearing air pass in the stomach after injecting air into the tubing c. examining a chest x-ray obtained after the tubing was inserted d. checking the remaining length of tubing to ensure that the correct length was inserted - correct answer-Answer: c. examining a chest x-ray obtained after tubing was inserted Rationale: both a and b are methods used to determine proper placement of NG tubing. However, the best indicator is c. D is not an indicator of proper placement Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? a. reassure the client that he will become accustomed to the stoma appearance in time b. instruct the client that the stoma will become smaller when the initial swelling diminishes c. offer to contact a member of the local ostomy support group to help him with his concerns d. encourage the client to handle the stoma equipment to gain confidence with the procedure - correct answer-Answer: b. instruct the client that the stoma will become smaller when the initial swelling diminishes Rationale: postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (b). This will help reduce the client's anxiety and promote acceptance of the colostomy. (a) does not provide helpful teaching or support. (c) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (d). A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the NG tube the last 2 hours. What action should the nurse take first? a. irrigate the nasogastric tube with sterile normal saline b. reposition the client on her side c. advance the nasogastric tube an additional five centimeters d. administer an intravenous antiemetic prescribed for PRN use - correct answer-Answer: b. reposition the client on her side Rationale: the immediate priority is to determine if the tube is functioning properly, which could then relieve the client's nausea. The least invasive intervention (b) should be attempted first, followed by (a and c) unless either of these interventions is contraindicated. IF these measures were successful, the client may require an antiemetic (d). A hospitalized male patient is receiving nasogastric feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but now feels fine. What action is the best for the nurse to take? a. record the coughing incident. No further action is required at this time b. stop the feeding, explain to the family why it is being stopped, and notify HCP c. after clearing the tube with 30mL of air, check the pH of fluid withdrawn from the tube d. inject 30 mL of air into the tube while auscultating the epigastrium for gurgling - correct answer-Answer: c. stop the feeding, explain to the family why it is being stopped, and notify HCP Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any further action (c). (a) and (b) are not indicated. The auscultating method (d) has been found to be unreliable for small-bore feeding tubes. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? a. demonstrate loss of remote memory b. exhibits expressive dysphagia c. has a diminished attention span d. is disoriented to place and time - correct answer-Answer: d. is disoriented to place and time Rationale: The client is exhibiting disorientation (d). (a) refers to memory of the distant past. The client is able to express himself without difficulty (b) and does not demonstrate a diminished attention span (c). A client with chronic kidney disease selects a scrambled egg for his breakfast. What action should the nurse take? a. commend the client for selecting a high biologic value protein b. remind the client that protein in the diet should be avoided c. suggest that the client also select orange juice, to promote absorption d. encourage the client to attend classes on dietary management of CKD - correct answer-Answer: a. commend the client for selecting a high biologic value protein Rationale: Foods such as milk and eggs (a) are high biologic proteins which are allowed because they are complete proteins and supply essential amino acids that are necessary for growth and cell repair. Although a low-potassium diet is followed (b) some protein is essential. Orange juice is rich in potassium and should not be encouraged (c). The client has made a good diet choice so d is not necessary. When assessing an 82 year old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the: a. arms b. upper torso c. head d. feet - correct answer-Answer: b. upper torso Rationale: The center of gravity for adults is the hips (b). However, as the person grows older, a stooped posture is common because of changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (b) becoming the center of gravity for older persons. Although (a) is a part, or an extension of the upper torso, this is not the best and most complete answer. In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly: a. is often to be expected, and progresses with age b. often follows relocation to new surroundings c. is a result of irreversible brain pathology d. can be prevented with adequate sleep - correct answer-Answer: b. often follows relocation to new surroundings Rationale: relocation (b) often results in confusion among elderly clients, moving is stressful for anyone. (a) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (c) is wrong. Adequate sleep is not a prevention for confusion (d). A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client: a. asks relevant questions regarding the dressing change b. states he will be able to complete the wound care regimen c. demonstrates the wound care procedure correctly d. has all the necessary supplies for wound care - correct answer-Answer: c. demonstrates the wound care procedure correctly Rationale: a return demonstration for a procedure (c) provides an objective assessment of the client's ability to perform a task, while (a and b) are subjective measures. (d) is important but is less of a priority to discharge than the nurse's assessment of the client's ability to complete the wound care A client who is 5'5 and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? a. what is your daily calorie consumption? b. what vitamin and mineral supplements do you take? c. do you feel that you are overweight? d. will a clear liquid diet be okay after surgery? - correct answer-Answer: b. what vitamin and mineral supplements do you take? Rationale: Vitamin and mineral supplements (b) may impact medications used during the operative period. (a and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (d) rather than the client's preference. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? a. provide additional coffee on the client's breakfast tray b. exchange the client's grape juice for cranberry c. bring the client additional fruit at mid-morning d. encourage additional oral intake of juices and water - correct answer-Answer: d. encourage additional oral intake of juices and water Rationale: dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (d). Caffeine is a diuretic (a) and may worsen the fluid volume deficit. Any type of juice will be beneficial (b) since the client is not dysuric a sign of UTI. The client needs to restore fluid volume more than solid foods (c). Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? a. apply a condom catheter b. apply a skin protectant c. encourage increased fluid intake d. assess for bladder distention - correct answer-Answer: d. assess for bladder distention Rationale: urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (d). (a and b) are useful actions to protect the skin of a client with urinary incontinence, (c) may worsen bladder distention A client with acute hemorrhagic anemia is to receive four units of packed RBC's as rapidly as possible. Which intervention is most important for the nurse to implement? a. obtain the pre-transfusion hemoglobin level b. prime the tubing and prepare a blood pump set-up c. monitor vital signs q15 minutes for the first hour d. ensure the accuracy of the blood type match - correct answer-Answer: d. ensure the accuracy of the blood match type Rationale: all interventions should be implemented when administering blood, but (d) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take 3 doses of the medication each day. Since at the time of discharge, time-released capsules are not available, which dosing schedule should the nurse advise the client to follow? a. 9 am, 1 pm, 5pm b. 8 am, 4pm, midnight c. before breakfast, before lunch, before dinner d. with breakfast, with lunch, with dinner - correct answer-Answer: b. 8am, 4pm, midnight Rationale: theophylline should be administered on a regular ATC schedule (b) to provide the best bronchodilating effect and reduce the potential for adverse effects. (a,c,d) do not provide ATC dosing. (d) food may alter absorption of the med A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the intravenous infusion pump? a. 13 ml/hr b. 63 ml/hr c. 80 ml/hr d. 125 ml/hr - correct answer-Answer: b. 63 ml/hr Rationale: 250/4 = 63 When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? a. establish a new nursing diagnosis b. note which actions were not implemented c. add additional nursing orders to the plan d. collaborate with HCP to make changes - correct answer-Answer: b. note which actions were not implemented Rationale: first the nurse should review which actions in the original plan were not implemented (b) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising expected outcome, or identifying a new nursing diagnosis (a). (c) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (d) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutrition? a. chocolate pudding b. graham crackers c. sugar free gelatin d. apple slices - correct answer-Answer: a. chocolate pudding Rationale: the client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid like pudding (a) are easy to swallow and require minimal chewing effort, and provide calories and protein. (c) does not provide any nutritional value. (b ad d) require energy to chew and are more difficult to swallow than pudding. The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective? a. If I exercise at least 2 times weekly for one hour, I will lower my cholesterol. b. I need to avoid eating proteins, including red meat. c. I will limit my intake of beef to 4 ounces per week. d. My blood level of low density lipoproteins needs to increase. - correct answer-Answer: c. I will limit my intake of beef to 4 ounces per week. Rationale: Limiting saturated fat from animal sources to no more than 4 ounces per week (c) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day or at least 4 to 6 times per week (a). Red meat and all proteins do not need to be eliminated (b) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2 oz servings). The low density lipoproteins (d) need to decrease rather than increase. An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? a. be sure to have a complete physical assessment before beginning your planned exercise program b. be careful that the exercise program doesn't simply add to your stress level, making you want to eat more c. increased exercise helps to reduce stress, so you may not need to spend money on a stress management class d. make sure to monitor your weight loss regularly to provide a sense of accomplishment and motviation - correct answer-Answer: a. be sure to have a complete physical examination before beginning your planned exercise program Rationale: the most important teaching is (a) so that the client will not begin a dangerous level of exercise he is not sufficiently fit for. This might result in chest pain, heart attack, or a stroke. (b,c,d) are important instructions but less priority than (a). The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered mediation to demonstrate correct use of the inhaler? a. immediately after exhalation b. during the inhalation c. at the end of three inhalations d. immediately after inhalation - correct answer-Answer: b. during an inhalation Rationale: the client should be instructed to deliver the medication during the last part of the inhalation (b). After the medication is delivered, the client should remove mouthpiece keeping lips closed and breath held for several seconds to allow for distribution of the medication. the client should not deliver the dose as stated in (a, d) and should allow no more than 2 inhalations at a time (c) An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W infusing at a rate of 30 mcg/min is prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? a. 30 b. 60 c. 120 d. 180 - correct answer-Answer: d. 180 Rationale: 500ml 1 mg 30mcg 60 min ______________ X ____________ X _____________ X _________ = 180 5 mg 1000 mcg 1 min 1 hour The healthcare provider prescribes the diuretic meolazone (Zaroxolyn) 7.5 mg PO. Only available in 5 mg tablets. How much should the nurse plan to administer? a. 1/2 tablet b. 1 tablet c. 1 1/2 tablets d. 2 tablets - correct answer-Answer: c. 1 1/2 tablets Rationale: 7.5 / 5 = 1.5 The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20mg/2ml. How many ml should the nurse administer? a. 1 ml b. 1.5ml c. 1.75ml d. 2ml - correct answer-Answer: b. 1.5mL Rationale: 20mg / 2ml = 10mg/1ml 1.5 x 10 = 15 Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5.5 hours. How much heparin has the client received? a. 11,000 units b. 13,000 units c. 15,000 units d. 17,000 units - correct answer-Answer: a. 11,000 units Rationale: 50 x 5.5 = 275 ml 20,000 units / 500 ml = 40 units / ml 275 x 40 = 11,000 The nurse is caring for a client who is receiving 24 hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? a. infuse normal saline at a keep vein open rate b. discontinue the IV and flush the port with heparin c. infuse 10% dextrose and water at 54 ml/hr d. obtain a stat blood glucose level and notify the HCP - correct answer-Answer: c. infuse 10% dextrose and water at 54 ml/hr Rationale: TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (c) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (a) is not maintained or if the TPN is discontinued abruptly (b). There is no reason to obtain a stat blood glucose level (d) and the HCP cannot do anything about this situation. Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding? a. multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm b. localized red rash comprised of flat areas, pinpoint to 0.5cm in diameter c. several areas of red, papular lesions from pinpoint to 0.5 cm in size d. localized petechial areas, ranging in size from pinp