hesi inet version 5
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1. After placing a 36-week-gesation newborn in an isolette and drying the
infant with several blankets, what Should the nurse implement next?
a. Administer the vitamin K injection.
b. Remove the wet blankets and linens from the isolette.
c. Place erythromycin opthalmic ointment in both eyes.
d. Open the door to assess the infant's vital signs.: b. Remove the wet blankets
and linens from the isolette.
Wet blankets can contribute to heat loss in the newborn. Removing them and
replacing them with dry linens helps maintain the infant's body temperature, which
is crucial, especially for preterm or near-term infants like a 36-week-gestation
newborn.
2. A client in the third trimester of pregnancy com- plains of frequent nasal
stiffness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm
is elevated and she has an increased costal angle. Which intervention should
the nurse implement?: d. Record the respiratory findings in the clients record as
normal
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
a. Ask family to remain nearby, but in another room.
b. Encourage family to speak often with the client.
c. Teach family how to assist the client to a wheelchair.
d. Instruct family to offer client only soft, bland foods: b. encourage family to
speak often with the client
Even if the client has decreased awareness, hearing familiar voices can be comfort-
ing. Family members can share memories, express love, or simply be present with
the client, which can be emotionally supportive for everyone involved.
4. A woman was admitted yesterday afternoon with severe abdominal pain.
Her pregnancy test and ultrasound were negative, so an exploratory laparoto-
my was completed during the night. When coffee ground material is observed
in the drainage from the nasogastric tube (NGT), which
Intervention should the nurse implement?
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a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage.
c. Listen for evidence of diminished bowel sounds.
d. Irrigate the nasogastric tube with water until clear.: b. perform gastroccult test
on the nasogastric drainage
A gastroccult test is used to detect the presence of blood in gastric contents.
Performing this test on the nasogastric drainage will help confirm whether the coffee
ground material is indeed blood, which is a crucial step in assessing the patient's
condition.
5. The nurse Is reviewing the laboratory values for a client with acute pan-
creatitis who reports of the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
client's clinical recovery?
a. Lipase.
b. Creatinine.
c. Bilirubin.
d. Glucose.: a. Lipase.
Lipase is an enzyme produced by the pancreas. Elevated levels of lipase in the blood
are indicative of pancreatic inflammation and are commonly used to diagnose and
monitor acute pancreatitis. A decreasing trend in lipase levels can indicate clinical
improvement and resolution of pancreatitis symptoms.
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 ml of dark red fluids has drained from the nasogastric tube
In the last hour. Which action should the nurse take first?
a. Determine the clients vital signs
b. Monitor urinary output hourly.
c. Notify the surgeon immediately.
d. Assess the client's level of pain.: a. Determine the clients vital signs
Assessing the client's vital signs, especially blood pressure and heart rate, is the
most immediate and essential action in this situation to determine if the client is
experiencing hypovolemia (a significant decrease in blood volume). The dark red
drainage may indicate bleeding, and vital signs can help assess the client's overall
hemodynamic status.
, hesi inet version 5
Study online at https://quizlet.com/_fdd7zf
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at
all times.
b. Use nasal or cough tissues followed by hand washing at all times.
c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.
d. Avoid large crowded areas during the colder months of the year: c. get annual
flu and pneumococcal vaccine polyvalent (PPSV23) vaccines
These vaccines help protect against influenza and pneumococcal disease, both of
which can cause serious complications in people with respiratory conditions. The
flu can exacerbate these conditions, and pneumococcal pneumonia is a serious
bacterial infection that can be particularly harmful.
8. The mother of a one-month-old infant calls the clinic to report that the back
of her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active.
b. Turn the infant on the left side braced against the crib when sleeping.
c. Prop the infant in a sitting position with a cushion when not sleeping.
d. Place a small pillow under the infant's head while lying on the back.: a.
Position the infant on the stomach occasionally when awake and active.
This recommendation aligns with safe sleep guidelines for infants. While the infant
should be placed on their back to sleep to reduce the risk of sudden infant death
syndrome (SIDS), supervised tummy time when the infant is awake and active can
help prevent the development of a flat head (positional plagiocephaly) by allowing
them to strengthen neck muscles and change head positions.
9. A woman is brought to the labor and delivery unit after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
a. Inspect the perineum for lacerations.
b. Collect specimen for hemoglobin and hematocrit.
c. Massage the fundus and give an oxytocin agent
d. Place the infant to breast for bonding: c. Massage the fundus and give an
oxytocin agent
, hesi inet version 5
Study online at https://quizlet.com/_fdd7zf
The immediate concern after precipitous delivery is to manage postpartum hemor-
rhage (PPH), which can occur due to uterine atony. Massaging the fundus helps
to stimulate uterine contractions, and administering an oxytocin agent (such as
oxytocin or methylergonovine) can further help control bleeding by causing the
uterus to contract.
10. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Elevated white blood cell count.
b. Presence of gram positive bacteria in the sputum.
c. Decreased creatinine clearance
d. Elevated cholesterol and lipoproteins.: c. Decreased creatinine clearance
Before administering a high dose of piperacillin/tazobactam, it is important to assess
the client's renal function, as this medication is primarily eliminated through the
kidneys. A decreased creatinine clearance suggests impaired renal function, which
can lead to drug accumulation and potential toxicity. The healthcare provider should
be informed so that they can adjust the dose or consider alternative medications if
necessary.
11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrat-
ing Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24
mmol/L). Which assessment finding warrants Immediate intervention by the
nurse?
a. Muscle stiffness.
b. Abdominal pain.
c. Mental stupor.
d. Fruity breath.: c. mental stupor
DKA can lead to altered mental status due to severe metabolic acidosis and elec-
trolyte imbalances. A mental stupor can indicate a worsening of the client's condition
and may precede more serious complications like diabetic coma. The ABG results
show a pH of 7.50, which is alkalotic, PaCO2 of 30 mmHg (indicating respiratory
compensation), and HCO3- of 24 mEq/L, which is normal. These results, combined
with the clinical picture of DKA, suggest a mixed acid-base disorder, likely with a
Study online at https://quizlet.com/_fdd7zf
1. After placing a 36-week-gesation newborn in an isolette and drying the
infant with several blankets, what Should the nurse implement next?
a. Administer the vitamin K injection.
b. Remove the wet blankets and linens from the isolette.
c. Place erythromycin opthalmic ointment in both eyes.
d. Open the door to assess the infant's vital signs.: b. Remove the wet blankets
and linens from the isolette.
Wet blankets can contribute to heat loss in the newborn. Removing them and
replacing them with dry linens helps maintain the infant's body temperature, which
is crucial, especially for preterm or near-term infants like a 36-week-gestation
newborn.
2. A client in the third trimester of pregnancy com- plains of frequent nasal
stiffness and occasional nosebleeds. Her chest circumference has increased
by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm
is elevated and she has an increased costal angle. Which intervention should
the nurse implement?: d. Record the respiratory findings in the clients record as
normal
3. A terminally ill male hospice client who is at home is showing decreased
awareness of his surroundings. His appetite is poor and he often refuses oral
intake of solids and liquids. For the past several days he has been unable to
get out of bed. Which action should the hospice nurse implement?
a. Ask family to remain nearby, but in another room.
b. Encourage family to speak often with the client.
c. Teach family how to assist the client to a wheelchair.
d. Instruct family to offer client only soft, bland foods: b. encourage family to
speak often with the client
Even if the client has decreased awareness, hearing familiar voices can be comfort-
ing. Family members can share memories, express love, or simply be present with
the client, which can be emotionally supportive for everyone involved.
4. A woman was admitted yesterday afternoon with severe abdominal pain.
Her pregnancy test and ultrasound were negative, so an exploratory laparoto-
my was completed during the night. When coffee ground material is observed
in the drainage from the nasogastric tube (NGT), which
Intervention should the nurse implement?
, hesi inet version 5
Study online at https://quizlet.com/_fdd7zf
a. Verify correct placement of the nasogastric tube
b. Perform gastroccult test on the nasogastric drainage.
c. Listen for evidence of diminished bowel sounds.
d. Irrigate the nasogastric tube with water until clear.: b. perform gastroccult test
on the nasogastric drainage
A gastroccult test is used to detect the presence of blood in gastric contents.
Performing this test on the nasogastric drainage will help confirm whether the coffee
ground material is indeed blood, which is a crucial step in assessing the patient's
condition.
5. The nurse Is reviewing the laboratory values for a client with acute pan-
creatitis who reports of the abdominal pain is not as severe as it was on
admission. Which laboratory test should the nurse review to evaluate the
client's clinical recovery?
a. Lipase.
b. Creatinine.
c. Bilirubin.
d. Glucose.: a. Lipase.
Lipase is an enzyme produced by the pancreas. Elevated levels of lipase in the blood
are indicative of pancreatic inflammation and are commonly used to diagnose and
monitor acute pancreatitis. A decreasing trend in lipase levels can indicate clinical
improvement and resolution of pancreatitis symptoms.
6. While assessing a client who had a laparotomy the previous day, the nurse
notices that 300 ml of dark red fluids has drained from the nasogastric tube
In the last hour. Which action should the nurse take first?
a. Determine the clients vital signs
b. Monitor urinary output hourly.
c. Notify the surgeon immediately.
d. Assess the client's level of pain.: a. Determine the clients vital signs
Assessing the client's vital signs, especially blood pressure and heart rate, is the
most immediate and essential action in this situation to determine if the client is
experiencing hypovolemia (a significant decrease in blood volume). The dark red
drainage may indicate bleeding, and vital signs can help assess the client's overall
hemodynamic status.
, hesi inet version 5
Study online at https://quizlet.com/_fdd7zf
7. The nurse is reviewing the recommended preventative care for clients with
asthma, chronic bronchitis, and emphysema. Which health care measure is
most important for the nurse to recommend to these clients?
a. Ensure supplemental oxygen and respiratory medications are available at
all times.
b. Use nasal or cough tissues followed by hand washing at all times.
c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.
d. Avoid large crowded areas during the colder months of the year: c. get annual
flu and pneumococcal vaccine polyvalent (PPSV23) vaccines
These vaccines help protect against influenza and pneumococcal disease, both of
which can cause serious complications in people with respiratory conditions. The
flu can exacerbate these conditions, and pneumococcal pneumonia is a serious
bacterial infection that can be particularly harmful.
8. The mother of a one-month-old infant calls the clinic to report that the back
of her infant's head is flat. How should the nurse respond?
a. Position the infant on the stomach occasionally when awake and active.
b. Turn the infant on the left side braced against the crib when sleeping.
c. Prop the infant in a sitting position with a cushion when not sleeping.
d. Place a small pillow under the infant's head while lying on the back.: a.
Position the infant on the stomach occasionally when awake and active.
This recommendation aligns with safe sleep guidelines for infants. While the infant
should be placed on their back to sleep to reduce the risk of sudden infant death
syndrome (SIDS), supervised tummy time when the infant is awake and active can
help prevent the development of a flat head (positional plagiocephaly) by allowing
them to strengthen neck muscles and change head positions.
9. A woman is brought to the labor and delivery unit after delivering a term
infant and the placenta in the hospital parking lot 10 minutes ago. Which action
should the nurse perform first?
a. Inspect the perineum for lacerations.
b. Collect specimen for hemoglobin and hematocrit.
c. Massage the fundus and give an oxytocin agent
d. Place the infant to breast for bonding: c. Massage the fundus and give an
oxytocin agent
, hesi inet version 5
Study online at https://quizlet.com/_fdd7zf
The immediate concern after precipitous delivery is to manage postpartum hemor-
rhage (PPH), which can occur due to uterine atony. Massaging the fundus helps
to stimulate uterine contractions, and administering an oxytocin agent (such as
oxytocin or methylergonovine) can further help control bleeding by causing the
uterus to contract.
10. A client has a new prescription for the maximum recommended dosage of
piperacillin/tazobactam for nosocomial pneumonia. The nurse should report
which laboratory finding to the healthcare provider before administering the
prescribed dose?
a. Elevated white blood cell count.
b. Presence of gram positive bacteria in the sputum.
c. Decreased creatinine clearance
d. Elevated cholesterol and lipoproteins.: c. Decreased creatinine clearance
Before administering a high dose of piperacillin/tazobactam, it is important to assess
the client's renal function, as this medication is primarily eliminated through the
kidneys. A decreased creatinine clearance suggests impaired renal function, which
can lead to drug accumulation and potential toxicity. The healthcare provider should
be informed so that they can adjust the dose or consider alternative medications if
necessary.
11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrat-
ing Kussmaul breathing and has a severe headache along with nausea. Her
arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24
mmol/L). Which assessment finding warrants Immediate intervention by the
nurse?
a. Muscle stiffness.
b. Abdominal pain.
c. Mental stupor.
d. Fruity breath.: c. mental stupor
DKA can lead to altered mental status due to severe metabolic acidosis and elec-
trolyte imbalances. A mental stupor can indicate a worsening of the client's condition
and may precede more serious complications like diabetic coma. The ABG results
show a pH of 7.50, which is alkalotic, PaCO2 of 30 mmHg (indicating respiratory
compensation), and HCO3- of 24 mEq/L, which is normal. These results, combined
with the clinical picture of DKA, suggest a mixed acid-base disorder, likely with a
