Hesi Exam version 1

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? A. “I have a headache that gets worse when I sit up” B. “I am having pain in my lower back when I move my legs” C. “My throat hurts when I swallow” D. “I feel sick to my stomach and am going to throw up” A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? E. Cleanse the foot with soap and water and apply an antibiotic ointment F. Provide teaching about the need for a tetanus booster within the next 72 hours. G. have the mother check the child's temperature q4h for the next 24 hours H. transfer the child to the emergency department to receive a gamma globulin injection A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? A. Auscultate the client's bowel sounds B. Observe for edema around the ankles C. Measure the client’s capillary glucose level D. Count the apical and radial pulses simultaneously After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? A. Capillary refill of 8 seconds B. bruises on arms and legs C. round and tight abdomen D. pitting edema in lower legs The client with which type of wound is most likely to need immediate intervention by the nurse? A. Laceration B. Abrasion C. Contusion D. Ulceration When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A. To reduce abdominal pressure on the diaphragm B. to promote retraction of the intercostal accessory muscle of respiration C. to promote bronchodilation and effective airway clearance D. to decrease pressure on the medullary center which stimulates breathing When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? A. The client is too obese B. Palpating in the wrong abdominal quadrant C. Deeper palpation technique is needed D. The gallbladder is normal A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? A. describe the transmission of drugs to the infant through breast milk B. encourage her to use stress relieving alternatives, such as deep breathing exercises C. Inform her that some antianxiety medications are safe to take while breastfeeding D. Explain that anxiety is a normal response for the mother of a 3-week- old An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? A. Start an intravenous (IV) infusion of normal saline B. obtain a serum potassium level C. administer the client's usual dose of insulin D. assess pupillary response to light