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HESI II 266 QUESTIONS AND CORRECT ANSWERS

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HESI II 266 QUESTIONS AND CORRECT ANSWERS

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Which milestone indicates to the nurse successful achievement of young adulthood?


Demonstrates a conceptualization of death and dying.
Completes education and becomes self-supporting.
Creates a new definition of self and roles with others.
Develops a strong need for parental support and approval.


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Completes education and becomes self-supporting.

Transitioning through young adulthood is characterized by establishing
independence as an adult, and includes developmental tasks such as
completing education, beginning a career, and becoming self-supporting
(B). (A and C) are characteristic of adolescence. Although strong bonds
with parents are an expected finding for this age group, the need for
support and approval (D) indicates dependency, which is a developmental
delay.

,When teaching diaphragmatic breathing to a client with chronic obstructive
pulmonary disease (COPD), which information should the nurse provide?


Place a small book or magazine on the abdomen and make it rise while inhaling
deeply.
Purse the lips while inhaling as deeply as possible and then exhale through the nose.
Wrap a towel around the abdomen and push against the towel while forcefully
exhaling.
Place one hand on the chest, one hand the abdomen and make both hands move
outward.


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Place a small book or magazine on the abdomen and make it rise while
inhaling deeply.




A client with diabetes mellitus is experiencing polyphagia. Which outcome statement
is the priority for this client?


Fluid and electrolyte balance.
Prevention of water toxicity.
Reduced glucose in the urine.
Adequate cellular nourishment.


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Adequate cellular nourishment.




The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning
treatment. Which subjective information is most important for the nurse to note?

,A history of obesity.
An allergy to sulfa drugs.
Cessation of smoking three years ago.
Numbness in the soles of the feet.


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An allergy to sulfa drugs.




An elderly male client comes to the geriatric screening clinic complaining of pain in
his left calf. The nurse notices a reddened area on the calf of his right leg which is
warm to the touch and suspects it might be thrombophlebitis. Which type of pain
would further confirm this suspicion?


Pain in the calf awakening him from a sound sleep.
Calf pain on exertion which stops when standing in one place.
Pain in the calf upon exertion which is relieved by rest and elevating the extremity.
Pain upon arising in the morning which is relieved after some stretching and exercise.


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Pain in the calf upon exertion which is relieved by rest and elevating the
extremity.




During suctioning, a client with an uncuffed tracheostomy tube begins to cough
violently and dislodges the tracheostomy tube. Which action should the nurse
implement first?


Notify the healthcare provider for reinsertion.
Attempt to reinsert the tracheostomy tube.
Position the client in a lateral position with the neck extended.
Ventilate client's tracheostomy stoma with a manual bag-mask.

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Attempt to reinsert the tracheostomy tube.




The nurse formulates the nursing diagnosis of, "Urinary retention related to
sensorimotor deficit" for a client with multiple sclerosis. Which nursing intervention
should the nurse implement?


Teach the client techniques of intermittent self-catheterization.
Decrease fluid intake to prevent over distention of the bladder.
Use incontinence briefs to maintain hygiene with urinary dribbling.
Explain that anticholinergic drugs will decrease muscle spasticity.


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Teach the client techniques of intermittent self-catheterization.




A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which assessment finding should the nurse expect this client to exhibit?



Lower left quadrant pain and a low-grade fever.
Severe pain at McBurney's point and nausea.
Abdominal pain and intermittent tenesmus.
Exacerbations of severe diarrhea.


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Lower left quadrant pain and a low-grade fever.

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