HESI V1EXAM QUESTIONS AND
ANSWERS
While assessing a client with diabetes mellitus, the nurse observes an absence of ha
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ir growth on the client's legs. What additional assessment provides further data to su
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pport this finding? rv rv
a. Palpate for the presence of femoral pulses bilaterally.
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b. Assess for the presence of a positive Homan's sign.
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c. Observe the appearance of the skin on the client's legs.
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d. Watch the client's posture and balance during ambulation. - ANS: C
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Signs of chronic arterial insufficiency include decreased hair growth in the legs and f
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eet, absent or decreased pedal pulses, infection in the foot, poor wound healing, thic
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kened nails, and a shiny appearance of the skin (C). Femoral pulses (A) should still b
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e palpable in the diabetic with chronic arterial insufficiency. A positive Homan's sign i
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s an indicator of deep vein thrombosis (B). (D) would probably not be affected signifi
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cantly by chronic arterial insufficiency.
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The healthcare provider prescribes 15 mg/
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kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D
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5W to run over 8 hours. How much Streptomycin will the infant receive?
rv rv rv rv rv rv rv rv rv rv rv rv
a. 9 mg. rv rv
b. 18 mg. rv rv
c. 27 mg. rv rv
d. 36 mg. - ANS: C
rv rv rv rv rv
4 lbs /
rv rv
2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25 ml of
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D5W, is not relevant to the calculation requested.
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In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurs
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e determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/
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minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/
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dl. Based on these findings, what intervention should the nurse implement?
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a. Continue the magnesium sulfate infusion as prescribed.
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b. Decrease the magnesium sulfate infusion by one-half.
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c. Stop the magnesium sulfate infusion immediately.
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d. Administer calcium gluconate immediately. - ANS: C
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The client is exhibiting symptoms of magnesium sulfate toxicity--
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decreased reflexes (normal is +2), a low normal respiratory rate (normal is 12 to 20 b
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reaths/min), a less than average urinary output (30 ml/ rv rv rv rv rv rv rv rv
hour is average), and a low magnesium sulfate level (normal is 4 to 8mg/
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dl). Based on these findings, the nurse should stop the infusion (C). (A) is contraindic
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ated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D) (the
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antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
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than 12 breaths/minute.
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A client is on a mechanical ventilator. Which client response indicates that the neuro
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muscular blocker tubocurarine chloride (Tubarine) is effective?
rv rv rv rv rv rv
,a. The client's extremities are paralyzed.
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b. The peripheral nerve stimulator causes twitching.
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c. The client clinches fist upon command.
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d. The client's Glasgow Coma Scale score is 14. - ANS: A
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This medication causes paralysis (A) following intravenous injection. Peak effects pe
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rsist for 35 to 60 minutes. (B and C) would not be possible if the medication is effecti
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ve. The Glasgow coma scale is used to evaluate the neurological status of the client
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and does not evaluate the effectiveness (D) of this medication.
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An elderly female client comes to the clinic for a regular check-
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up. The client tells the nurse that she has increased her daily doses of acetaminophe
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n (Tylenol) for the past month to control joint pain. Based on this client's comment, w
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
hat previous lab values should the nurse compare with today's lab report?
rv rv rv rv rv rv rv rv rv rv rv
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today du
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e to dehydration.
rv rv
b. Look for an increase in today's LDH compared to the previous one to assess for p
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ossible liver damage. rv rv
c. Expect to find an increase in today's APTT as compared to last quarter's due to bl
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
eeding.
d. Determine if there is a decrease in serum potassium due to renal compromise. -
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ANS: B
rv rv
Frequent and/ rv
or large doses of acetaminophen can cause an increase in liver enzymes, indicating
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possible liver damage (B). If the client reported unusual bleeding, or an increase in a
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spirin usage, it would be important for the nurse to assess for increased bleeding an
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d monitor (A and/or C). (D) is not affected by increases in acetaminophen doses.
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Aspirin is prescribed for a 9-year-rv rv rv rv rv
old child with rheumatic fever to control the inflammatory process, promote comfort,
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and reduce fever. What intervention is most important for the nurse to implement?
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a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge b
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ath.
b. Administer the aspirin with at least two ounces of water or juice.
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c. Notify the healthcare provider if the child complains of ringing in the ears.
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d. Advise the parents to question the child about seeing yellow halos around objects.
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- ANS: C
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Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and shoul
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d be reported immediately. Though a tepid sponge bath may lower the child's temper
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ature, the prescription for aspirin should not be held (A). Aspirin should be taken with
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at least eight ounces of water to completely wash the tablet into the stomach and to
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help prevent GI discomfort (B). Yellow halos are associated with Digoxin toxicity, not
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aspirin (D). rv
Which signs or symptoms are characteristic of an adult client diagnosed with Cushin
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g's syndrome? rv
a. Husky voice and complaints of hoarseness.
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b. Warm, soft, moist, salmon-colored skin.
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c. Visible swelling of the neck, with no pain.
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d. Central-type obesity, with thin extremities. - ANS: D
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,The classic picture of Cushing's syndrome in the adult is central-
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type obesity with thin extremities (D), along with a "buffalo hump" in the supraclavicul
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ar area, heavy trunk, and thin fragile skin. The symptoms described in (A) are clinical
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vmanifestations of hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a g rv rv rv rv rv rv rv rv rv rv rv rv
oiter or a tumor of the thyroid gland.
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A charge nurse agrees to cover another nurse's assignment during a lunch break. B
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ased on the status report provided by the nurse who is leaving for lunch, which client
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vshould be checked first by the charge nurse? The client:
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a. admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 19
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5 mg/dl.
rv
b. with an ileal conduit created two days ago with a scant amount of blood in the drai
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nage pouch. rv
c. post-
rv
triple coronary bypass four days ago who has serosanguinous drainage in the chest t
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ube.
d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter
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vreading of 90%. - ANS: D rv rv rv rv rv
A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to 10
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0 and should be assessed immediately (D). (A) is an expected finding. (B) is not an u
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nusual finding. (C) is an expected finding for this client.
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An outcome for treatment of peripheral vascular disease is, "the client will have decr
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eased venous congestion." What client behavior would indicate to the nurse that this
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outcome has been met? rv rv rv
a. Avoids prolonged sitting or standing.
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b. Avoids trauma and irritation to skin.
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c. Wears protective shoes.
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d. Quits smoking. - ANS: A
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Client behaviors indicating that the expected outcome of, "decreased venous conges
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tion" has been met would include elevating the legs, increasing walking time, and an
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observable decrease in edema of the lower extremities (A). (B and C) would be appr
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opriate for outcomes for, "Attains or maintains tissue integrity." (D) would be an appr
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opriate outcome for, "Demonstrates an increase in arterial blood supply to extremitie
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s."
The healthcare provider performs a paracentesis on a client with ascites and 3 liters
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of fluid are removed. Which assessment parameter is most critical for the nurse to m
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onitor following the procedure?rv rv rv
a. Pedal pulses.
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b. Breath sounds.
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c. Gag reflex.
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d. Vital signs. - ANS: D
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Life-
threatening complications such as hypovolemia and sepsis can occur following a par
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acentesis, and measurement of vital signs (D) will provide assessment data that will
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help detect the occurrence of such complications. (A) might be assessed to check for
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circulation in the lower extremities, but are not indicated for postparacentesis assess
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ment. Reduction of (B) may occur as the result of decreased fluid in the peritoneal ca
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, vity, but is a desired outcome, not a complication, of this procedure. (C) is not affecte
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d by a paracentesis procedure.
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The nurse is administering sevelamer (RenaGel) during lunch to a client with end sta
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ge renal disease (ESRD). The client asks the nurse to bring the medication later. Th
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e nurse should describe which action of RenaGel as an explanation for taking it with
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meals?
a. Prevents indigestion associated with ingestion of spicy foods.
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b. Binds with phosphorus in foods and prevents absorption.
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c. Promotes stomach emptying and prevents gastric reflux.
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d. Buffers hydrochloric acid and prevents gastric erosion. - ANS: B
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RenaGel is an intestinal phosphate binder and should be taken with meals to prevent
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contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are
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not the therapeutic actions of RenaGel.
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The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearan
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ce" for a client with myasthenia gravis. What is the most likely etiology for this nursin
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g diagnosis?
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a. Pain when coughing.
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b. Diminished cough effort.
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c. Thick dry secretions.
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d. Excessive inflammation. - ANS: B
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The client with myasthenia gravis experiences fatigue and muscle weakness, which i
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s likely to result in a diminished cough effort (B). (A, C, and D) are not common in cli
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ents with myasthenia gravis.
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Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bo
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wel sounds and firm, distended abdomen. Which prescription for the client should th
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e nurse question?
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a. Continous tube feeding at 65 ml/hr via gastrostomy.
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b. Total parenteral nutrition to be infused at 125 ml/hour.
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c. Nasogastric tube connected to low intermittent suction.
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d. Metoclopramide (Reglan) intermittent piggyback. - ANS: A
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The nurse should question the administration of a tube feeding into the GI tract (A),
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which may result in vomiting and aspiration, because the client is exhibiting signs of
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decreased peristalsis and possible bowel obstruction. (B) provides a means of safely
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providing nutrition while GI tract function is inhibited. (C) benefits the client by reduci
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ng any excess gastric contents. (D) helps stimulate peristalsis.
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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Whic
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h assessment finding should the nurse anticipate?
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a. Bounding erratic pulse.
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b. Regularly irregular pulse.
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c. Thready irregular pulse.
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d. No palpable pulse. - ANS: D
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The client would have no palpable pulse (D), because ventricular fibrillation is chaoti
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c electrical activity which does not produce cardiac output. This is a medical emerge
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ncy which requires immediate treatment to prevent death. (A, B, and C) are not typic
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al of pulses in ventricular fibrillation.
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ANSWERS
While assessing a client with diabetes mellitus, the nurse observes an absence of ha
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ir growth on the client's legs. What additional assessment provides further data to su
rv rv rv rv rv rv rv rv rv rv rv rv rv
pport this finding? rv rv
a. Palpate for the presence of femoral pulses bilaterally.
rv rv rv rv rv rv rv rv
b. Assess for the presence of a positive Homan's sign.
rv rv rv rv rv rv rv rv rv
c. Observe the appearance of the skin on the client's legs.
rv rv rv rv rv rv rv rv rv rv
d. Watch the client's posture and balance during ambulation. - ANS: C
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Signs of chronic arterial insufficiency include decreased hair growth in the legs and f
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eet, absent or decreased pedal pulses, infection in the foot, poor wound healing, thic
rv rv rv rv rv rv rv rv rv rv rv rv rv
kened nails, and a shiny appearance of the skin (C). Femoral pulses (A) should still b
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
e palpable in the diabetic with chronic arterial insufficiency. A positive Homan's sign i
rv rv rv rv rv rv rv rv rv rv rv rv rv
s an indicator of deep vein thrombosis (B). (D) would probably not be affected signifi
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
cantly by chronic arterial insufficiency.
rv rv rv rv
The healthcare provider prescribes 15 mg/
rv rv rv rv rv
kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D
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5W to run over 8 hours. How much Streptomycin will the infant receive?
rv rv rv rv rv rv rv rv rv rv rv rv
a. 9 mg. rv rv
b. 18 mg. rv rv
c. 27 mg. rv rv
d. 36 mg. - ANS: C
rv rv rv rv rv
4 lbs /
rv rv
2.2 = 1.8 kg. 1.8 x 15 = 27 mg (C). NOTE, the fact that the drug is diluted in 25 ml of
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D5W, is not relevant to the calculation requested.
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In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurs
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e determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/
rv rv rv rv rv rv rv rv rv rv rv rv rv
minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
dl. Based on these findings, what intervention should the nurse implement?
rv rv rv rv rv rv rv rv rv rv
a. Continue the magnesium sulfate infusion as prescribed.
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b. Decrease the magnesium sulfate infusion by one-half.
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c. Stop the magnesium sulfate infusion immediately.
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d. Administer calcium gluconate immediately. - ANS: C
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The client is exhibiting symptoms of magnesium sulfate toxicity--
rv rv rv rv rv rv rv rv
decreased reflexes (normal is +2), a low normal respiratory rate (normal is 12 to 20 b
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
reaths/min), a less than average urinary output (30 ml/ rv rv rv rv rv rv rv rv
hour is average), and a low magnesium sulfate level (normal is 4 to 8mg/
rv rv rv rv rv rv rv rv rv rv rv rv rv
dl). Based on these findings, the nurse should stop the infusion (C). (A) is contraindic
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ated. (B) would not fully alleviate the magnesium sulfate toxicity symptoms. (D) (the
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antagonist for magnesium sulfate) would be indicated if the respiratory rate were less
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than 12 breaths/minute.
rv rv rv
A client is on a mechanical ventilator. Which client response indicates that the neuro
rv rv rv rv rv rv rv rv rv rv rv rv rv
muscular blocker tubocurarine chloride (Tubarine) is effective?
rv rv rv rv rv rv
,a. The client's extremities are paralyzed.
rv rv rv rv rv
b. The peripheral nerve stimulator causes twitching.
rv rv rv rv rv rv
c. The client clinches fist upon command.
rv rv rv rv rv rv
d. The client's Glasgow Coma Scale score is 14. - ANS: A
rv rv rv rv rv rv rv rv rv rv rv
This medication causes paralysis (A) following intravenous injection. Peak effects pe
rv rv rv rv rv rv rv rv rv rv
rsist for 35 to 60 minutes. (B and C) would not be possible if the medication is effecti
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ve. The Glasgow coma scale is used to evaluate the neurological status of the client
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
and does not evaluate the effectiveness (D) of this medication.
rv rv rv rv rv rv rv rv rv
An elderly female client comes to the clinic for a regular check-
rv rv rv rv rv rv rv rv rv rv rv
up. The client tells the nurse that she has increased her daily doses of acetaminophe
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
n (Tylenol) for the past month to control joint pain. Based on this client's comment, w
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
hat previous lab values should the nurse compare with today's lab report?
rv rv rv rv rv rv rv rv rv rv rv
a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today du
rv rv rv rv rv rv rv rv rv rv rv rv
e to dehydration.
rv rv
b. Look for an increase in today's LDH compared to the previous one to assess for p
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ossible liver damage. rv rv
c. Expect to find an increase in today's APTT as compared to last quarter's due to bl
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
eeding.
d. Determine if there is a decrease in serum potassium due to renal compromise. -
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ANS: B
rv rv
Frequent and/ rv
or large doses of acetaminophen can cause an increase in liver enzymes, indicating
rv rv rv rv rv rv rv rv rv rv rv rv rv
possible liver damage (B). If the client reported unusual bleeding, or an increase in a
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
spirin usage, it would be important for the nurse to assess for increased bleeding an
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
d monitor (A and/or C). (D) is not affected by increases in acetaminophen doses.
rv rv rv rv rv rv rv rv rv rv rv rv rv
Aspirin is prescribed for a 9-year-rv rv rv rv rv
old child with rheumatic fever to control the inflammatory process, promote comfort,
rv rv rv rv rv rv rv rv rv rv rv rv
and reduce fever. What intervention is most important for the nurse to implement?
rv rv rv rv rv rv rv rv rv rv rv rv
a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge b
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
ath.
b. Administer the aspirin with at least two ounces of water or juice.
rv rv rv rv rv rv rv rv rv rv rv rv
c. Notify the healthcare provider if the child complains of ringing in the ears.
rv rv rv rv rv rv rv rv rv rv rv rv rv
d. Advise the parents to question the child about seeing yellow halos around objects.
rv rv rv rv rv rv rv rv rv rv rv rv rv r
- ANS: C
v rv rv
Ringing in the ears (tinnitus) (C) is an important sign of aspirin overdosage and shoul
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
d be reported immediately. Though a tepid sponge bath may lower the child's temper
rv rv rv rv rv rv rv rv rv rv rv rv rv
ature, the prescription for aspirin should not be held (A). Aspirin should be taken with
rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
at least eight ounces of water to completely wash the tablet into the stomach and to
v rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
help prevent GI discomfort (B). Yellow halos are associated with Digoxin toxicity, not
rv rv rv rv rv rv rv rv rv rv rv rv rv
aspirin (D). rv
Which signs or symptoms are characteristic of an adult client diagnosed with Cushin
rv rv rv rv rv rv rv rv rv rv rv rv
g's syndrome? rv
a. Husky voice and complaints of hoarseness.
rv rv rv rv rv rv
b. Warm, soft, moist, salmon-colored skin.
rv rv rv rv rv
c. Visible swelling of the neck, with no pain.
rv rv rv rv rv rv rv rv
d. Central-type obesity, with thin extremities. - ANS: D
rv rv rv rv rv rv rv rv
,The classic picture of Cushing's syndrome in the adult is central-
rv rv rv rv rv rv rv rv rv rv
type obesity with thin extremities (D), along with a "buffalo hump" in the supraclavicul
rv rv rv rv rv rv rv rv rv rv rv rv rv
ar area, heavy trunk, and thin fragile skin. The symptoms described in (A) are clinical
rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
vmanifestations of hypothyroidism, and in (B) of hyperthyroidism. (C) may indicate a g rv rv rv rv rv rv rv rv rv rv rv rv
oiter or a tumor of the thyroid gland.
rv rv rv rv rv rv rv
A charge nurse agrees to cover another nurse's assignment during a lunch break. B
rv rv rv rv rv rv rv rv rv rv rv rv rv
ased on the status report provided by the nurse who is leaving for lunch, which client
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv r
vshould be checked first by the charge nurse? The client:
rv rv rv rv rv rv rv rv rv
a. admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 19
rv rv rv rv rv rv rv rv rv rv rv rv
5 mg/dl.
rv
b. with an ileal conduit created two days ago with a scant amount of blood in the drai
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
nage pouch. rv
c. post-
rv
triple coronary bypass four days ago who has serosanguinous drainage in the chest t
rv rv rv rv rv rv rv rv rv rv rv rv rv
ube.
d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter
rv rv rv rv rv rv rv rv rv rv rv rv rv r
vreading of 90%. - ANS: D rv rv rv rv rv
A pulse oximeter reading of 90% indicates an arterial blood gas of less than 80 to 10
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
0 and should be assessed immediately (D). (A) is an expected finding. (B) is not an u
rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv rv
nusual finding. (C) is an expected finding for this client.
rv rv rv rv rv rv rv rv rv
An outcome for treatment of peripheral vascular disease is, "the client will have decr
rv rv rv rv rv rv rv rv rv rv rv rv rv
eased venous congestion." What client behavior would indicate to the nurse that this
rv rv rv rv rv rv rv rv rv rv rv rv rv
outcome has been met? rv rv rv
a. Avoids prolonged sitting or standing.
rv rv rv rv rv
b. Avoids trauma and irritation to skin.
rv rv rv rv rv rv
c. Wears protective shoes.
rv rv rv
d. Quits smoking. - ANS: A
rv rv rv rv rv
Client behaviors indicating that the expected outcome of, "decreased venous conges
rv rv rv rv rv rv rv rv rv rv
tion" has been met would include elevating the legs, increasing walking time, and an
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
observable decrease in edema of the lower extremities (A). (B and C) would be appr
rv rv rv rv rv rv rv rv rv rv rv rv rv rv
opriate for outcomes for, "Attains or maintains tissue integrity." (D) would be an appr
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opriate outcome for, "Demonstrates an increase in arterial blood supply to extremitie
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s."
The healthcare provider performs a paracentesis on a client with ascites and 3 liters
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of fluid are removed. Which assessment parameter is most critical for the nurse to m
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onitor following the procedure?rv rv rv
a. Pedal pulses.
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b. Breath sounds.
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c. Gag reflex.
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d. Vital signs. - ANS: D
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Life-
threatening complications such as hypovolemia and sepsis can occur following a par
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acentesis, and measurement of vital signs (D) will provide assessment data that will
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help detect the occurrence of such complications. (A) might be assessed to check for
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circulation in the lower extremities, but are not indicated for postparacentesis assess
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ment. Reduction of (B) may occur as the result of decreased fluid in the peritoneal ca
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, vity, but is a desired outcome, not a complication, of this procedure. (C) is not affecte
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d by a paracentesis procedure.
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The nurse is administering sevelamer (RenaGel) during lunch to a client with end sta
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ge renal disease (ESRD). The client asks the nurse to bring the medication later. Th
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e nurse should describe which action of RenaGel as an explanation for taking it with
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meals?
a. Prevents indigestion associated with ingestion of spicy foods.
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b. Binds with phosphorus in foods and prevents absorption.
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c. Promotes stomach emptying and prevents gastric reflux.
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d. Buffers hydrochloric acid and prevents gastric erosion. - ANS: B
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RenaGel is an intestinal phosphate binder and should be taken with meals to prevent
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contributing to the hyperphosphatemia (B), associated with ESRD. (A, C, and D) are
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not the therapeutic actions of RenaGel.
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The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearan
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ce" for a client with myasthenia gravis. What is the most likely etiology for this nursin
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g diagnosis?
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a. Pain when coughing.
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b. Diminished cough effort.
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c. Thick dry secretions.
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d. Excessive inflammation. - ANS: B
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The client with myasthenia gravis experiences fatigue and muscle weakness, which i
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s likely to result in a diminished cough effort (B). (A, C, and D) are not common in cli
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ents with myasthenia gravis.
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Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bo
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wel sounds and firm, distended abdomen. Which prescription for the client should th
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e nurse question?
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a. Continous tube feeding at 65 ml/hr via gastrostomy.
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b. Total parenteral nutrition to be infused at 125 ml/hour.
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c. Nasogastric tube connected to low intermittent suction.
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d. Metoclopramide (Reglan) intermittent piggyback. - ANS: A
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The nurse should question the administration of a tube feeding into the GI tract (A),
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which may result in vomiting and aspiration, because the client is exhibiting signs of
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decreased peristalsis and possible bowel obstruction. (B) provides a means of safely
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providing nutrition while GI tract function is inhibited. (C) benefits the client by reduci
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ng any excess gastric contents. (D) helps stimulate peristalsis.
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A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Whic
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h assessment finding should the nurse anticipate?
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a. Bounding erratic pulse.
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b. Regularly irregular pulse.
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c. Thready irregular pulse.
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d. No palpable pulse. - ANS: D
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The client would have no palpable pulse (D), because ventricular fibrillation is chaoti
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c electrical activity which does not produce cardiac output. This is a medical emerge
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ncy which requires immediate treatment to prevent death. (A, B, and C) are not typic
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al of pulses in ventricular fibrillation.
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