HESI MID-CURRICULAR -QUESTIONS & ANSWERS

HESI MID-CURRICULAR -QUESTIONS & ANSWERS The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which of the following instructions by the nurse is MOST important? 1. The client should decrease caloric intake. 2. The client should eliminate all salt from her diet. 3. The client should ensure adequate protein. 4. The client should increase her intake of iron. The client should ensure adequate protein. A client comes to the prenatal clinic for her first visit. The nursing history reveals that the client's last menstrual period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Which of the following responses byt he nurse is BEST? 1. "Since you have felt fetal movement, I am sure that you are pregnant." 2. "Lie down so that I can listen for fetal heart tones with the Doppler." 3. "We'll collect a urine specimen for testing to confirm that you are pregnant." 4. "Have you noticed feeling more fatigued lately?" "Lie down so that I can listen for fetal heart tones with the Doppler." The nurse notes that a two-day old infant shows a tendency to bleed. The nurse understands this is MOST likely caused by which of the following? 1. Hemophilia. 2. Absence of intestinal bacteria needed for the production of vitamin K. 3. Immature liver that is unable to synthesize clotting factors. 4. Excessive breakdown of red blood cells coupled with a delayed production of new ones. Absence of intestinal bacteria needed for the production of vitamin K. The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions? 1. Apply ice to the area. 2. Reposition the patient for comfort 3. Carefully transport the specimen to the lab 4. Observe for bleeding. Observe for bleeding. The nurse admits a patient to the postpartum unit two hours after a vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in amount of bleeding is due to which of the following? 1. The lochia pooled in the patient's vagina when she was lying in bed. 2. The patient has a tear in her cervix that needs to be repaired. 3. The patient's fundus is relaxed and requires massaging. 4. The patient's bladder is distended because she needs to void. The lochia pooled in the patient's vagina when she was lying in bed. A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is the MOST important response by the nurse? 1. "You can continue your activities but rest when you get tired." 2. "You should take a brisk walk daily." 3. "You can exercise as much as you want but limit household activities." 4. "What is your usual type of exercise?" "What is your usual type of exercise?" The health care provider orders a colposcopy for the client. The nurse explains to the client that which is the purpose of this procedure? 1. Magnify the tissue for examination 2. Directly examine ovaries, fallopian tubes, uterus, and small intestine. 3. View structures in the pelvic cavity, 4. Visualize the bladder. Magnify the tissue for examination The nurse monitors a client at 30 weeks gestation, and the client states that she has periodic heartburn. It is MOST important for the nurse to make which of the following recommendations? 1. Lie down after eating a meal. 2. Eat frequent small meals. 3. Take Alka-Seltzer as needed. 4. Sip iced tap water. Eat frequent small meals. The nurse instructs the woman about how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation the woman's basal body temperature will change in which direction? 1. Lowers significantly 2. Rises significantly 3. Is unchanged 4. Rises slightly Rises slightly A nurse accidentally bumps into a newborn's bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which of the following reflexes? 1. Tonic neck 2. Moro's 3. Babinski's 4. Rooting Moro's When administering phototherapy to a newborn with jaundice, it is MOST important for the nurse to take which of the following actions? 1. Expose only the infant's back to the light. 2. Remove the infant from the light for 15 minutes each hour. 3. Cover the infant's eyes with protective pads during therapy. 4. Check the infant's temp every hour. Cover the infant's eyes with protective pads during therapy. The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take FIRST? 1. Instruct the patient to take a deep breath and bear down. 2. Apply pressure to the patient's fundus. 3. Coach the patient in relaxation techniques. 4. Encourage the patient to pant with pursed lips. Encourage the patient to pant with pursed lips. A 25-year-0ld primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following? 1. Insulin requirements will increase during pregnancy and decrease after delivery. 2. Insulin requirements will decrease during pregnancy and increase after delivery. 3. Insulin requirements will increase during pregnancy and remain increased after delivery. 4. Insulin requirements decrease during pregnancy and remain decreased after delivery. Insulin requirements will increase during pregnancy and decrease after delivery. By the fifth month of pregnancy, a 32 year old multipara of average prenatal height and weight has gained 14 pounds. Which of the following actions by the nurse is MOST important? 1. Advise the client she has gained too much weight and her diet should be reevaluated. 2. Advise the client she has not gained enough weight and her diet should be reevaluated. 3. Inform the client her weight gain is appropriate and she should continue on her present diet. 4. Inform the client she may have difficulties later in pregnancy and more frequent visits to the physician are indicated. Inform the client her weight gain is appropriate and she should continue on her present diet. The nurse instructs a patient who recently had a modified radical mastectomy. The nurse states that it is important that the patient exercise her arm postoperatively to 1. increase muscle strength and diameter. 2. maintain body balance. 3. limit full range of motion. 4. prevent lymphedema. prevent lymphedema. The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following foods from a menu? 1. Two eggs and 8 oz of milk 2. A 2 oz steak and 10 oz of beer. 3. A lettuce and tomato salad and 12 oz of orange juice. 4. One bag of potato chips and 16 oz of cola. Two eggs and 8 oz of milk The nurse prepares the client for a total abdominal hysterectomy with bilateral salpingo-oophorectomy due to uterine cancer. The nurse observes that the client is talking continuously and has difficulty maintaining eye contact. Which response by the nurse is BEST? 1. "What are your concerns about the surgery?" 2. "Why isn't your husband here with you?" 3. "Are you afraid that you are going to die?" 4. "You seem to be coping with the surgery very well." "What are your concerns about the surgery?" A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a "dry labor." Which of the following responses by the nurse is MOST appropriate? 1. "Amniotic fluid does not function as lubrication for the labor process." 2. "The sac actually impedes the progress of labor and if it had not ruptured, the doctor would have to do it artificially." 3. "Labor is only slightly more difficult with early rupture of the amniotic sac." 4. "Now that there is limited amniotic fluid, you may have to have a cesarean section." "Amniotic fluid does not function as lubrication for the labor process." The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food? 1. Chicken livers 2. Pork 3. Hamburger 4. Tofu Chicken livers The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant? 1. Red, wrinkled skin, lanugo, and hypotonic muscles. 2. Vernix caseosa,silky hair, and facial edema. 3. Absent nose bridge, depressed fontanels, and absent lanugo. 4. Mottled skin, meconium stools, and hypertonic muscles. Red, wrinkled skin, lanugo, and hypotonic muscles. A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take FIRST? 1. Contact the physician 2. Coach the patient in proper breathing and relaxation techniques. 3. Administer an analgesic. 4. Remove the fetal monitor to allow the client to move around. Coach the patient in proper breathing and relaxation techniques. A woman arrives at the hospital in labor. The midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains to the client this means which of the following? 1. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal 2. The cervix is 4 cm short in dilation and 60% thinner than normal. 3. The walls of the cervix are 4 cm thick and 60% shorter than normal 4. The cervix is 4 cm long and 60% wider than normal. The opening of the cervix is 4 cm wide and the cervical canal is 60% shorter than normal The nurse should place the HIGHEST priority on monitoring a woman after a cesarean section for which of the following? 1. Infection and pain. 2. Hemorrhage and shock. 3. Hemorrhage and pain management. 4. Dehydration and infection. Hemorrhage and shock. To assess an apical pulse on a 8 lb, 4 oz newborn infant, the nurse should take which of the following actions? 1. Place the diaphragm of the stethoscope between the nipple line and the sternal notch. 2. Place the diaphragm of the stethoscope between the second and third intercostal spaces, the midaxillary line. 3. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, the midclavicular line. 4. Place the bell of the stethoscope between the second and third intercostal spaces, the midsternal line. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, the midclavicular line. The nurse prepares a client for an abdominal hysterectomy. The client asks why she has to have a Foley catheter. Which statement by the nurse is MOST appropriate? 1. "This will help you since you will be temporarily incotinent." 2. "This will enable us to measure your output accurately." 3. "This will allow you to heal by keeping your bladder decompressed." 4. "This will allow your bladder to recover after the surgery." "This will allow you to heal by keeping your bladder decompressed." An infant is born by vaginal delivery. At birth, the infant is crying and respiration and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record baby's one-minute and five-minute Apgar scores as which of the following? 1. 8 and 9, respectively 2. 8 and 10, respectively 3. 9 and 10, respectively 4. 9 and 7, respectively 9 and 10, respectively A woman complains to the nurse that during the client's menstrual period she gains weight and gets muscle cramps. The nurse should suggest which of the following measures to alleviate the client's symptoms? 1. Take over the counter analgesics, restrict caffeine, exercise moderately. 2. Avoid analgesics and exercise. 3. Restrict fluid intake, exercise moderately, increase caffeine intake. 4. Restrict sodium intake, restrict exercise, sedatives. Take over the counter analgesics, restrict caffeine, exercise moderately. The nurse cares for a woman in labor. Which method should the nurse use to measure the frequency of a uterine contraction? 1. Timing the contractions from the end of one contraction to the end of the next contraction. 2. Timing the contraction from the beginning of one contraction to the end of the same contraction. 3. Timing the contraction from the peak of one contraction to the beginning of the next contraction. 4. Timing the contraction from the beginning of one contract to the beginning of the next contraction. Timing the contraction from the beginning of one contract to the beginning of the next contraction. The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take FIRST? 1. Observe the lochial flow. 2. Palpate the fundus. 3. Obtain a warming blanket. 4. Obtain vital signs. Observe the local flow. An adult male client has a history of diabetes insipidus. The nurse identifies which imbalance is MOST likely to develop if this medical problem recurs? 1) Hypernatremia 2) Hyponatremia 3) Hyperkalemia 4) Hypokalemia Hypernatremia The nurse understands fatigue, weakness, and nausea and vomiting are signs of which? 1) Hypernatremia 2) Hyponatremia 3) Hyperkalemia 4) Hypokalemia Hypokalemia The emergency department nurse knows that which is the MOST frequent underlying cause of tetany? 1) Hypocalcemia 2) Puncture wound from dirty and rusty metal 3) Hypermagnesemia 4) Genetric cardiac defect Hypocalcemia The nurse monitors a patient receiving a blood transfusion. The nurse should intervene if which is observed? 1) The blood infuses in three hours. 2) The blood is started with normal saline 3) The blood is started 15 min after arriving from the blood bank 4) The blood infuses at 10 mL/min for the first 15 mins. The blood infuses at 10 mL/min for the first 15 mins. A central venous pressure line is inserted in a patient. Following the catheter insertion, the patient complains of dyspnea, shortness of breath, and chest pain. The nurse understands the MOST probable cause of these symptoms is which? 1) Fluid overload 2) Pneumothorax 3) Hypokalemia 4) Pneumonia Pneumothorax In order to administer 1,000 mL of D5W, 40 mEq of KCl at 100 mL/hour using an administer set that delivers 60 drops/mL, the nurse should adjust the flow rate to deliver how many drops/minute? 100 ggts/min The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics likely causes which electrolyte imbalance? 1) Hypernatremia 2) Hyperkalemia 3) Hyponatremia 4) Hypokalemia Hypokalemia The nurse performs an assessment on a patient sustaining burn injury in an apartment fire. The nurse is most concerned if which is observed? 1) The patient has signed nasal hair 2) The patient's blood pressure is 106/62 3) The patient has blisters on the hands 4) The patient's capillary refill time is less than 3 seconds. The patient has signed nasal hair When any type of transfusion reaction occurs, the nurse's FIRST action should be what? 1) Recheck the type and cross-match 2) Slow down the transfusion 3) Stop the transfusion 4) Notify the physician Stop the infusion The nurse cares for a patient during the shock phase after suffering a full thickness burn injury. The nurse understands which finding is expected during this phase? 1) Increased blood pressure 2) Decreased urine output 3) Hypokalemia 4) Decreased pulse Decreased urine output The nurse identifies which central venous pressure (CVP) reading indicates fluid overload? 1) 0 mm Hg 2) 3 mm Hg 3) 8 mm Hg 4) 15 mm Hg 15 mm Hg The nurse observes a student nurse begin an IV on an elderly patient. The nurse should intervene if which is observed? 1) The student nurse uses a 24 gauge catheter to start the IV 2) The student nurse marks the time on the IV bag with a permanent marker 3) The student nurse inserts the catheter at a 10 degree angle. 4) The student nurse sets the flow rate at 100 mL per hour. The student nurse marks the time on the IV bag with a permanent marker The nurse determines a patient has a deep partial thickness burn injury of the back. Which is the BEST initial nursing action? 1) Break the blisters with scalpel using sterile technique. 2) Gently clean and then leave the area alone. 3) Apply a thin layer of Vaseline to the area. 4) Wrap snugly with sterile gauze. Gently clean and then leave the area alone. The nurse evaluates a patient's fluid balance. Which finding MOST likely requires an intervention? 1) Output is 300 mL less than intake. 2) Output is 800 mL less than intake. 3) Intake is 1,800 mL in 24 hours. 4) Intake and output are equal. Output is 800 mL less than intake. The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menu? 1) Meat and orange juice 2) Whole grain bread and an apple 3) Green vegetables and milk 4) Peanut butter and a banana Meat and orange juice A patient receives magnesium sulfate IV for treatment of preeclampsia.The nurse knows that it is MOST important to have what at the bedside? 1) Oxygen and padded tongue blade. 2) Reflex hammer and calcium gluconate 3) Protamine sulfate and Vitamin K. 4) Particulate respirator and suction equipment Reflex hammer and calcium gluconate The nurse cares for an older man admitted to the hospital for persistent vomiting and abdominal pain. A nasogastric (NG) tube is inserted and connected to suction, and an intravenous infusion of 1,000 ml of D5W with 20 mEq/L of potassium chloride is started to infuse at 200 ml per hour. The nurse understands potassium chloride has been added to the infusion for which reason? 1) Replaces the potassium lost in the gastric fluid 2) Replace decreased dietary potassium due to NPO status 3) Prevent the loss of sodium in the urine 4) Prevent the loss of potassium in the urine. Replaces the potassium lost in the gastric fluid The nurse cares for a patient receiving a blood transfusion. The nurse observes which if fluid overload occurs during the transfusion? 1) Decreased pulse rate, increased BP, decreased respirations 2) Increased pulse rate, increased BP, increased respirations 3) Increased pulse rate, increased BP, decreased respirations 4) Decreased pulse rate, decreased BP, increased respirations Increased pulse rate, increased BP, increased respirations The nurse cares for a patient receiving a blood transfusion. The nurse is MOST concerned if which is observed? 1) Blood pressure is 130/80 2) The patient complains of shortness of breath 3) The patient complains of pruritus 4) Hematuria Hematuria Which laboratory finding should the nurse expect if a patient is diagnosed with fluid volume deficit? 1) Specific gravity 1.020 2) Specific gravity 1.034 3) Potassium 5.8 mEq/L 4) Potassium 4.8 mE2q/L Specific gravity 1.034 The nurse notices that an intravenous infusion is not running. Which action should the nurse take initially? 1) Reposition the patient's arm 2) Check the site 3) Raise the solution 4) Flush the tubing. Check the site The nurse knows which patient is MOST likely to manifest symptoms of fluid volume deficit? 1) A patient diagnosed with Addison's disease 2) A patient diagnosed with cirrhosis of the liver 3) A patient diagnosed with epilepsy 4) A patient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) A patient diagnosed with Addison's disease In order to deliver 3,000 mL of D5W in 24 hours using an administration set that delivers 15 drops/mL, the nurse should regulate the flow rate to deliver how many drops/minute? 31 gtts/min The nurse cares for a patient diagnosed with a fractured right hip. The patient's lab values are: Hbg 15, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L and chloride 100 mEq/L. The nurse is MOST concerned if which is observed? 1) A weight gain of 4 lbs in 1 day 2) An increase in nausea 3) An increase in muscle irritability 4) An episode of ventricular fibrillation An episode of ventricular fibrillation The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction? 1) Hypotension,sudden fever, flushed skin. 2) Kidney pain, hematuria, cyanosis 3) Urticaria, wheezing, flushed skin. 4) Hives, itching, anaphylaxis Kidney pain, hematuria, cyanosis Following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. Which action is MOST appropriate for the nurse to take initially? 1) Check the type and cross-match with another nurse. 2) Leave the blood at the patient's bedside until the doctor checks it 3) Flush tubing with normal saline and hang next unit 4) Run first 50 mL of blood rapidly to check for any reaction. Check the type and cross-match with another nurse. The nurse knows that medication is best absorbed by a patient with a major burn injury via which route? 1) Intramuscularly 2) Orally 3) Intravenously 4) Topically Intravenously When measuring the central venous pressure, it is MOST important for the nurse to take action? 1) Find out about the previous reading 2) Place the manometer at level of the right atrium 3) Position the patient in an upright position 4) Instruct the patient hold his breath during the reading Place the manometer at level of the right atrium A nurse assesses a patient who has sustained a burn injury. The burn area is blistered and painful. Which classification best describes the burned area? 1) Third degree 2) Full thickness 3) Deep partial thickness 4) Superficial partial thickness. Deep partial thickness The nurse identifies which sign or symptom as an early indication of fluid volume excess? 1) Cyanosis 2) Diarrhea 3) Edema 4) Shock Edema On the first postoperative day, a patient develops a fever. The nurse auscultates crackles bilaterally in the lower lobes. The nurse understands which of the following complications of the surgery is probably developing? a) heart failure b) thrombophebitis c) pulmonary embolism d) atelectatis d atelectasis The nurse identifies which finding is characteristic of chronic pain? a) weight loss or gain, fatigue b) obesity, restlessness, and thirst c) anxiety, insomnia, and memory loss d) quick response to anaglesics weight loss or gain, fatigue The nurse prepares four patients for surgery, The nurse is most concerned about the psychological adjustment of which of the following patients? a) a 13 y/o girl scheduled to have a wart removed from her nose b) a 26 y/o man scheduled for the Whipple procedure due to cancer of the pancreas c) a 42 y/o woman scheduled to have a benign cyst removed from the left breast d) an 80 y/o scheduled for colostomy due to severe diverticular disease b) a 26 y/o man scheduled for the Whipple procedure due to cancer of the pancreas Which of the following actions is essential for the nurse to take after administration of a preoperative medication to the patient? a) ensure the operative permit is signed b) discuss the patient's feelings about the surgery c) raise the side rails of the bed d) tell the patient what to expect in the operating room c) raise the side rails of the bed A client returns from abdominal surgery with an order for morphine sulfate IV q 3 hours prn for pain. During the first 24 hours of surgery, which action by the nurse is BEST? a) offer pain medication every 4 hours b) administer pain medication every 3 hours c) offer pain medication every 3 hours d) administer pain medication every 4 hours b) administer pain medication every 3 hours The nurse identifies which of the lab findings reflects the signs and symptoms of infection? a) serum creatine level of 2.4 mg/dL b) AST (SGOT) 15 u/L c) white blood cell count of 16,000/mm^3 d) white blood cell count of 4,000/mm^3 c) white blood cell count of 16,000/mm^3 A client is admitted to the hospital with a temperature of 101° F (38.3°C) and a WBC count of 3000/mm^3. The nurse should insitute which of the following precautions? a) contact precautions b) airborne precautions c) droplet precautions d) neutropenic precautions d) neutropenic precautions To promote evening rest and sleep for patients who are immobilized and in bed, it is MOST important for the nurse to provide which of the following? a) privacy b) back rubs c) daily baths d) daytime activities d) daytime activities The nurse knows that aspirin, if given in high, prolonged dosages, may precipitate which of the following physiological changes? a) urinary frequency b) hypoventilation c) GI bleeding d) hemoconcentration c) GI bleeding The nurse cares for a postoperative client with a nasogastric tube. Which observation by the nurse is the MOST reliable indication the nasogastric tube is correctly positioned? a) absence of respiratory distress b) pH of aspirate is 3 c) the marking of the tube designating the correct length remains visible just outside the nares d) the tube is securely taped b) pH of aspirate is 3 The home care nurse cares of a client diagnosed with a fractured humerus due to a fall in the home. Which of the following observations, if made by the nurse, requires an immediate intervention. a) The bathroom is equipped with grab bars b) Throw rugs have been removed c) The client ambulates wearing socks d) The stairs are well lighted c) The client ambulates wearing socks The nurse understands the purpose of a drain in a wound is to a) keep the tissues close together so that the healing can occur b) prevent infection by providing a means for bacteria to escape c) evaluate the effectiveness of hemostasis d) create a space that will facilitate reconstructive surgery at a later date a) keep the tissues close together so that the healing can occur A client comes in to the emergency room after puncturing a foot with a dirty, rusty nail. The client states the last Td immunization was 6 years ago. Which of the following actions should the nurse take FIRST? a) administer tetanus toxoid b) determine how many Td immunizations the client has received c) administer tetanus immune globulin d) monitor for lock jaw b) determine how many Td immunizations the client has received The home care nurse visits an elderly client living alone on a limited income. The client's diet consists primarily of carbohydrates. Based on an understanding of nutritional needs of the elderly, which of these interpretations of the client's diet by the nurse is most justified? a) The patient should increase the intake of protein b) The patient should reduce the intake of fat c) The patient should increase the caloric intake d) The patient should decrease the fluid intake a) The patient should increase the intake of protein The nurse helps a patient to cough and deep breath after surgery. It is desirable for the patient to assume which of the following positions? a) side-lying b) prone c) supine with pillow d) high fowler's d) high fowler's The nurse notes that an elderly patient has a reddened area on the coccyx. Which of the following actions should the nurse take FIRST? a) continue the assessment of the area b) reposition the patient every 2 hours c) massage the reddened are four times per day d) place the patient in the semireclining position b) reposition the patient every 1-2 hours The nurse explain to the client the most vitamin C can be found in which juice? a) canned apple juice b) canned tomato juice c) frozen grapefruit juice d) fresh orange juice d) fresh orange juice The nurse instructs a patient about how to successfully establish a regular exercise program. The nurse determines further teaching is needed if the patient makes which of the following statements? a) "I should choose an exercise that suits my lifestyle" b) " I should incorporate exercise into my daily routine" c) " I should make a commitment to exercise regularly" d) "I should start by running 5 miles everyday" d) "I should start by running 5 miles everyday" Several days postoperatively, a client reports pain, tenderness, and redness of the right calf. Which signs and symptoms are critical for the nurse to assess next? a) Nausea and abdominal distention b) Back pain and hematuria c) Chest pain and shortness of breath d) Similar findings in the right arm c) Chest pain and shortness of breath The nurse observes a staff member prepare to leave the room of a patient on droplet precautions. The nurse should intervene if which of the following is observed? a) The staff member removes the gloves by pulling off inside out b) the staff member holds onto the surface of the face mask while pulling mask away from face c) The staff member unties the gown and removes it without touching the outside of the gown d) The nurse performs hand hygiene b) the staff member holds onto the surface of the face mask while pulling mask away from face The nurse identifies which diet BEST meets the needs of a person with multiple wounds? a) high protein, low fat, high iron diet b) high vitamin C, high protein, high carbohydrate diet c) high vitamin A, high calcium, high fat diet d) high vitamin B, high protein, low carbohydrate diet b) high vitamin C, high protein, high carbohydrate diet The nurse cares for a client with body mass index of 38 kg/m^2. What is the best description of the client's body weight? a) underweight b) normal weight c) overweight d) obese d) obese The nurse observes a staff member enter the patient's room wearing a protective respiratory device. The nurse determines care is appropriate if the staff member is caring for which of the following patients? a) patient diagnosed with varicella b) patient diagnosed with mumps c) patient diagnosed with vancomycin- resistant d) patient diagnosed with pneumonia a) patient diagnosed with varicella The nurse counsels a patient about how to maintain an adequate intake of protein. The nurse determines that further teaching is required