HESI NCLEX- RN EXAMINATION REVIEW
EDITION 4 CH:4 QUESTIONS AND
ANSWERS 100% CORRECT!!
,List four common symptoms of pneumonia the nurse might note on physical
examination. - ANSWER Tachypnea, fever with chills, productive cough, bronchial
breath sounds
State four nursing interventions for assisting the client to cough productively. -
ANSWER Encourage deep breathing; increase fluid intake to 3 L/day; use humidity to
loosen secretions; suction airway to stimulate coughing.
What symptoms of pneumonia might the nurse expect to see in an older client? -
ANSWER Confusion, lethargy, anorexia, rapid respiratory rate
How does the nurse prevent hypoxia during suctioning? - ANSWER Deliver 100% O2
(hyperinflating) before and after each endotracheal suctioning.
During mechanical ventilation, what are three major nursing interventions? - ANSWER
Monitor client's respiratory status and secure connections; establish a communication
mechanism with the client; keep airway clear by coughing and suctioning.
When examining a client with emphysema, what physical findings is the nurse likely to
see? - ANSWER Barrel chest, dry or productive cough, decreased breath sounds,
dyspnea, crackles in lung fields
What is the most common risk factor associated with lung cancer? - ANSWER Smoking
Describe the preoperative nursing care for a client undergoing a laryngectomy. -
ANSWER Involve family and client in manipulation of tracheostomy equipment before
surgery; plan acceptable communication methods; refer to speech pathologist; discuss
rehabilitation program.
List five nursing interventions after chest tube insertion. - ANSWER Maintain a dry
occlusive dressing on chest tube. Keep all tubing connections tight and taped. Monitor
client's clinical status. Encourage the client to breathe deeply periodically. Monitor the
fluid drainage, and mark the time of measurement and the fluid level.
What immediate action should the nurse take when a chest tube becomes disconnected
from a bottle or suction apparatus? - ANSWER Place the end of the tube in a sterile
, water container at a 2-cm level. Apply an occlusive dressing, and notify health care
provider stat.
Identify two nursing interventions for the client on hemodialysis. - ANSWER Do not take
BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess
access site for thrill and bruit.
What is the highest priority nursing diagnosis for clients in any type of renal failure? -
ANSWER Risk for imbalanced fluid volume
A client in renal failure asks why he is being given antacids. How should the nurse
reply? - ANSWER Calcium and aluminum antacids bind phosphates and help to keep
phosphates from being absorbed into bloodstream, thereby preventing rising phosphate
levels; must be taken with meals.
List four essential elements of a teaching plan for clients with frequent urinary tract
infections. - ANSWER Fluid intake 3 L/day; good handwashing; void every 2 to 3 hours
during waking hours; take all prescribed medications; wear cotton undergarments.
What discharge instructions should be given to a client who has had urinary calculi? -
ANSWER Straining all urine is the most important intervention. Other interventions
include accurate I&O documentation and administering analgesics as needed.
What are the most important nursing interventions for clients with possible renal calculi?
- ANSWER Straining all urine is the most important intervention. Other interventions
include accurate I&O documentation and administering analgesics as needed.
Following transurethral resection of the prostate gland (TURP), hematuria should
subside by what postoperative day? - ANSWER The fourth day
After the urinary catheter is removed in the TURP client, what are three priority nursing
actions? - ANSWER Continued strict I&O. Continued observations for hematuria. Inform
client burning and frequency may last for a week.
After kidney surgery, what are the primary assessments the nurse should make? -
ANSWER Respiratory status (breathing is guarded because of pain); circulatory status
(the kidney is very vascular and excessive bleeding can occur); pain assessment;
urinary assessment (most important, assessment of urinary output
How do clients experiencing angina describe that pain? - ANSWER Described as
squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged
EDITION 4 CH:4 QUESTIONS AND
ANSWERS 100% CORRECT!!
,List four common symptoms of pneumonia the nurse might note on physical
examination. - ANSWER Tachypnea, fever with chills, productive cough, bronchial
breath sounds
State four nursing interventions for assisting the client to cough productively. -
ANSWER Encourage deep breathing; increase fluid intake to 3 L/day; use humidity to
loosen secretions; suction airway to stimulate coughing.
What symptoms of pneumonia might the nurse expect to see in an older client? -
ANSWER Confusion, lethargy, anorexia, rapid respiratory rate
How does the nurse prevent hypoxia during suctioning? - ANSWER Deliver 100% O2
(hyperinflating) before and after each endotracheal suctioning.
During mechanical ventilation, what are three major nursing interventions? - ANSWER
Monitor client's respiratory status and secure connections; establish a communication
mechanism with the client; keep airway clear by coughing and suctioning.
When examining a client with emphysema, what physical findings is the nurse likely to
see? - ANSWER Barrel chest, dry or productive cough, decreased breath sounds,
dyspnea, crackles in lung fields
What is the most common risk factor associated with lung cancer? - ANSWER Smoking
Describe the preoperative nursing care for a client undergoing a laryngectomy. -
ANSWER Involve family and client in manipulation of tracheostomy equipment before
surgery; plan acceptable communication methods; refer to speech pathologist; discuss
rehabilitation program.
List five nursing interventions after chest tube insertion. - ANSWER Maintain a dry
occlusive dressing on chest tube. Keep all tubing connections tight and taped. Monitor
client's clinical status. Encourage the client to breathe deeply periodically. Monitor the
fluid drainage, and mark the time of measurement and the fluid level.
What immediate action should the nurse take when a chest tube becomes disconnected
from a bottle or suction apparatus? - ANSWER Place the end of the tube in a sterile
, water container at a 2-cm level. Apply an occlusive dressing, and notify health care
provider stat.
Identify two nursing interventions for the client on hemodialysis. - ANSWER Do not take
BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess
access site for thrill and bruit.
What is the highest priority nursing diagnosis for clients in any type of renal failure? -
ANSWER Risk for imbalanced fluid volume
A client in renal failure asks why he is being given antacids. How should the nurse
reply? - ANSWER Calcium and aluminum antacids bind phosphates and help to keep
phosphates from being absorbed into bloodstream, thereby preventing rising phosphate
levels; must be taken with meals.
List four essential elements of a teaching plan for clients with frequent urinary tract
infections. - ANSWER Fluid intake 3 L/day; good handwashing; void every 2 to 3 hours
during waking hours; take all prescribed medications; wear cotton undergarments.
What discharge instructions should be given to a client who has had urinary calculi? -
ANSWER Straining all urine is the most important intervention. Other interventions
include accurate I&O documentation and administering analgesics as needed.
What are the most important nursing interventions for clients with possible renal calculi?
- ANSWER Straining all urine is the most important intervention. Other interventions
include accurate I&O documentation and administering analgesics as needed.
Following transurethral resection of the prostate gland (TURP), hematuria should
subside by what postoperative day? - ANSWER The fourth day
After the urinary catheter is removed in the TURP client, what are three priority nursing
actions? - ANSWER Continued strict I&O. Continued observations for hematuria. Inform
client burning and frequency may last for a week.
After kidney surgery, what are the primary assessments the nurse should make? -
ANSWER Respiratory status (breathing is guarded because of pain); circulatory status
(the kidney is very vascular and excessive bleeding can occur); pain assessment;
urinary assessment (most important, assessment of urinary output
How do clients experiencing angina describe that pain? - ANSWER Described as
squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged
