HESI-RN Med-Surg Test exam with |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correct answers |||\\\
The nurse is assessing a client with acute pancreatitis. Which finding requires the most
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
immediate intervention by the nurse? |||\\\ |||\\\ |||\\\ |||\\\
A. |||\\\
The client's amylase level is three times higher than the normal level.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
The client has a carpal spasm when taking a blood pressure.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
The client states that she will continue to drink alcohol after going home. - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔B
The nurse is assessing a client with acute pancreatitis. Which finding requires the most
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
immediate intervention by the nurse? |||\\\ |||\\\ |||\\\ |||\\\
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires further |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
assessment and intervention, regardless of the cause (40% to 75% of those with acute |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
higher than the normal value. Severe boring pain is an expected symptom for this diagnosis,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
planning and teaching do not have the same immediate importance as a positive Trousseau
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sign.
A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
obstructive pulmonary disease (COPD). Which risk factor is the most significant in the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
development of this client's COPD? |||\\\ |||\\\ |||\\\ |||\\\
,A.
The client's father was diagnosed with COPD in his 50s.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
A close family member contracted tuberculosis last year.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
The client smokes one to two packs of cigarettes per day.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
The client has been 40 pounds overweight for 15 years. - correct answer✔✔C
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Smoking, considered to be a modifiable risk factor, is the most significant risk factor |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for the development of COPD. The exact mechanism of genetic and hereditary implications for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the development of COPD is still under investigation, although exposure to similar predisposing
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
incidence among family members. Options B and D do not exceed the risks associated with
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
cigarette smoking in the development of COPD. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
test results to indicate a decreased serum level of which substance?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Sodium
|||\\\ B.
Phosphate
|||\\\ C.
Potassium
|||\\\ D.
Glucose - correct answer✔✔C |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Clients with primary aldosteronism exhibit a profound decline in serum levels of |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sodium level is normal or elevated, depending on the amount of water resorbed with the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
primary aldosteronism. |||\\\
The nurse is completing an admission interview for a client with Parkinson disease. Which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
question will provide additional information about manifestations that the client is likely to
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
experience?
A.
"Have you ever experienced any paralysis of your arms or legs?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
"Do you have frequent blackout spells?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
"Have you ever been frozen in one spot, unable to move?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
"Do you have headaches, especially ones with throbbing pain?" - correct answer✔✔C
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Clients with Parkinson disease frequently experience difficulty in initiating, |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
maintaining, and performing motor activities. They may even experience being rooted to the |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
spot and unable to move. Parkinson disease does not typically cause option A, B, or D.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Client census is often used to determine staffing needs. Which method of obtaining census
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
determination for a particular unit provides the best formula for determining long-range |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
staffing patterns? |||\\\
A.
Midnight census |||\\\
|||\\\ B.
Oncoming shift census |||\\\ |||\\\
|||\\\ C.
Average daily census |||\\\ |||\\\
|||\\\ D.
, Hourly census - correct answer✔✔C |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:An average daily census is determined by trend data and takes into account seasonal |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
and daily fluctuations, so it is the best method for determining staffing needs. Options A and B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
provide data at a certain point in time, and that data could change quickly. It is unrealistic to
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
expect to obtain an hourly census, and such data would only provide information about a
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
certain point in time. |||\\\ |||\\\ |||\\\
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Immediately after feeding |||\\\ |||\\\
|||\\\ B.
Just prior to tube feeding |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
Continuous inflation is required |||\\\ |||\\\ |||\\\
|||\\\ D.
Inflation is not required - correct answer✔✔B |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:The cuff should be inflated before the feeding to block the trachea and prevent food |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
remain inflated throughout the feeding to prevent aspiration of food into the respiratory
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
system. Options A and D place the client at risk for aspiration. Option C places the client at risk
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for tracheal wall necrosis.
|||\\\ |||\\\ |||\\\
A 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 nasogastric tube in the last 2 hours.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Which action should the nurse take first? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Irrigate the nasogastric tube with sterile normal saline. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
Reposition the client on her side. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correct answers |||\\\
The nurse is assessing a client with acute pancreatitis. Which finding requires the most
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
immediate intervention by the nurse? |||\\\ |||\\\ |||\\\ |||\\\
A. |||\\\
The client's amylase level is three times higher than the normal level.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
The client has a carpal spasm when taking a blood pressure.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
The client states that she will continue to drink alcohol after going home. - correct
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answer✔✔B
The nurse is assessing a client with acute pancreatitis. Which finding requires the most
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
immediate intervention by the nurse? |||\\\ |||\\\ |||\\\ |||\\\
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires further |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
assessment and intervention, regardless of the cause (40% to 75% of those with acute |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
higher than the normal value. Severe boring pain is an expected symptom for this diagnosis,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
planning and teaching do not have the same immediate importance as a positive Trousseau
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sign.
A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
obstructive pulmonary disease (COPD). Which risk factor is the most significant in the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
development of this client's COPD? |||\\\ |||\\\ |||\\\ |||\\\
,A.
The client's father was diagnosed with COPD in his 50s.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
A close family member contracted tuberculosis last year.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
The client smokes one to two packs of cigarettes per day.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
The client has been 40 pounds overweight for 15 years. - correct answer✔✔C
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Smoking, considered to be a modifiable risk factor, is the most significant risk factor |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for the development of COPD. The exact mechanism of genetic and hereditary implications for
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
the development of COPD is still under investigation, although exposure to similar predisposing
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
incidence among family members. Options B and D do not exceed the risks associated with
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
cigarette smoking in the development of COPD. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
test results to indicate a decreased serum level of which substance?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Sodium
|||\\\ B.
Phosphate
|||\\\ C.
Potassium
|||\\\ D.
Glucose - correct answer✔✔C |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Clients with primary aldosteronism exhibit a profound decline in serum levels of |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
sodium level is normal or elevated, depending on the amount of water resorbed with the
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
primary aldosteronism. |||\\\
The nurse is completing an admission interview for a client with Parkinson disease. Which
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
question will provide additional information about manifestations that the client is likely to
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
experience?
A.
"Have you ever experienced any paralysis of your arms or legs?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
"Do you have frequent blackout spells?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
"Have you ever been frozen in one spot, unable to move?"
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ D.
"Do you have headaches, especially ones with throbbing pain?" - correct answer✔✔C
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:Clients with Parkinson disease frequently experience difficulty in initiating, |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
maintaining, and performing motor activities. They may even experience being rooted to the |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
spot and unable to move. Parkinson disease does not typically cause option A, B, or D.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Client census is often used to determine staffing needs. Which method of obtaining census
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
determination for a particular unit provides the best formula for determining long-range |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
staffing patterns? |||\\\
A.
Midnight census |||\\\
|||\\\ B.
Oncoming shift census |||\\\ |||\\\
|||\\\ C.
Average daily census |||\\\ |||\\\
|||\\\ D.
, Hourly census - correct answer✔✔C |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:An average daily census is determined by trend data and takes into account seasonal |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
and daily fluctuations, so it is the best method for determining staffing needs. Options A and B
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
provide data at a certain point in time, and that data could change quickly. It is unrealistic to
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
expect to obtain an hourly census, and such data would only provide information about a
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
certain point in time. |||\\\ |||\\\ |||\\\
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Immediately after feeding |||\\\ |||\\\
|||\\\ B.
Just prior to tube feeding |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ C.
Continuous inflation is required |||\\\ |||\\\ |||\\\
|||\\\ D.
Inflation is not required - correct answer✔✔B |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Rationale:The cuff should be inflated before the feeding to block the trachea and prevent food |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
remain inflated throughout the feeding to prevent aspiration of food into the respiratory
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
system. Options A and D place the client at risk for aspiration. Option C places the client at risk
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
for tracheal wall necrosis.
|||\\\ |||\\\ |||\\\
A 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 nasogastric tube in the last 2 hours.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Which action should the nurse take first? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A.
Irrigate the nasogastric tube with sterile normal saline. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
|||\\\ B.
Reposition the client on her side. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
