HESI ADVANCED PATHOPHYSIOLOG Y

C   ATI fundamental proctored exam 2019 1. is caring for a client who has restraints to each extrey. which should the nurse perform first? peripheral pulses 2. dosage 4. A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein? A. Instruct the client to flex their arm with the hand open B. Stroke the skin near the vein in an upward direction C. Apply a cool compress to the vein for 10 min D. Dangle the client's arm over the edge of the bed 6. A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis which of the following actions should the nurse take a.Cover the area of percussion with a towel b. perform percussion over the lower back c. schedule postural drainage after meal d. instructs the client to exhale quickly during vibration 7. a nurse is obtaining a prescription for wrist restrains for a client who is trying pull out his NG tube. which of the following action should the nurse take? Allow room for two fingers to fit between client’s skin and restrains 10.A nurse is teaching a client about home care of oxygen equipment. Which of following information should the nurse include in the teaching? (Select all that apply) a. Align the middle of the ball in the flow meter with the line of the prescribed flow rate b. Lay the oxygen tank flat when storing c. Keep the oxygen delivery system 0.6 m (2 feet) from any heat source d. Check the oxygen delivery rate at least once per day e. Avoid using wool blankets when receiving oxygen 11. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? A. Measure the pH of the gastric aspirate B. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water C. Place the end of the NG tube in the water to observe for bubblingD. Assess the client for a gag reflex 12. A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief? A. Anger. B. Acceptance C. Denial D. Bargaining 14. A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take? A. Discuss alternative treatments with the client. B. Express approval of the client's decision to not have the procedure. C. Document the client's decision in the medical record. D. Explain to the client the risks involved with not having the procedure. 15. A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? A. "I should perform my self-exam the week that my period starts." B. "I should make different patterns on each breast when I do my self-exam." C. "I should make circular motions with my fingertips under my arms D. "I should use the palm of my hand to apply pressure to each breast."????????? 16. A nurse is caring for a client who has a new prescription for negative - pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention? A. The material safety data sheet B. The nurse practice act C. The client's plan of care D. The policy and procedure manual 17. 18. A nurse is planning care for client with a new prescription for parenteral nutrition in 20% dextrose and fat emulsions. Which is an appropriate action: prepare client for a central venous line 19. A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? A. Administer metronidazole B. Place the client in a negative airflow room C. Wear a mask when working within 3 feet of the client D. Don protective eyewear before entering the room 20. To ensure client safety, a nurse manger is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? A. Client educator B. Client advocate C. Client care provider D. Case manager 21. A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? A. Apply adhesive tape when securing an IV insertion site B. Use plastic syringe for medication administration. C. Wear powdered gloves when providing care for the client. D. Cover the blood pressure cuff with a stockinette . 22. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which of the following situations requires the completion of an incident report? A. A nurse transfused a unit of packed RBCs in 2 hr. B. An oncoming nurse arrived to work late C. A client's prescribed laboratory testing was not obtained D. A client withdrew consent for a procedure 23. A nurse is teaching a client who has diabetes mellitus about mixing regular insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should draw up the NPH insulin before the regular insulin." B. "I should inject air into the vial of regular insulin first." C. "I should roll the vial of NPH insulin between my hands before drawing it up." D. "I should wait 3 minutes after mixing the insulin to inject it." 24. A nurse is assessing the body temperature of an adult client using a temporal arety thermometer. Which of the following actions should the nurse take? (Select all that apply). A. Slide the probe across the client's forehead B. Document the client's temperature with "AX" next to the value C. Hold the client's hair aside while performing the procedure D. Move the probe in a circular motion to obtain the reading E. Pull the client's pinna up and back 25. A nurse on a medical- surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? A. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. B. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. C. The family of a client who has a terminal illness asks the provider not to tell the client the diagnosis. D. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like them." 26. A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take? A. Hyperoxygenate the client manually for 30 to 60 seconds before suctioning. B. Suction the client's airway for 20 seconds with each pass C. Decrease suction pressure to 150 mm Hg the oxygen saturation level drop during suctioning D. Apply intermittent suction during catheter insertion. 27. A nurse is preparing a client who has terminal cancer for discharge. Which of the Following questions should the nurse ask when assessing the client's psychosocial history? A. "Have any of your relatives been diagnosed with cancer?" B. "Are you experiencing any pain?" C. "What medications are you currently taking?" D. "What techniques do you use to cope with stress?" 28. . A nurse is documenting client care. Which of the following abbreviations should the nurse use? A. "SS" for sliding scale B. "SQ" for subcutaneous C. "Oj" for orange juice D. "BRP" for bathroom privileges. 29. A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements? A. "I use garlic for my menopausal symptoms" B. "I take echinacea to control my cholesterol." C. "I use ginger when I get car sick." D. "I take ginkgo biloba for a headache 30. A nurse preparing to administer several medications which of the following data should the nurse plan to use to confirm the client's identity? A. The client's admitting diagnosis B. The name of the client's next of kin C. The client's telephone number D. The client's room number 31. A nurse is assessing an older adult client. Which of the following findings should the nurse expect? A. Decreased sense of balance B. Increased nighttime sleeping C. Nighttime urinary incontinence D. Heightened sense of pain 32. A nurse on a medical-surgical unit is receiving a changed of shift report for four clients. Which of the following clients should the nurse see first? A. A client who has urinary tract infection and low-grade fever B. A client who has acute abdominal pain of 4 on a scale from o to 10 C. A client who has pneumonia and an oxygen saturation of 96% D. A client who has new onset of dyspnea 24 hrs after a total hip arthroplasty 33. A nurse is providing teaching to a client about reducing the adverse effect of immobility. Which of the following statements by the client indicates an understanding of the teaching? A. "I will remove my anti-embolic stockings while I am in bed." B. "I will have my partner help change position every 4 hours." C. "I will hold my breath when rising from a sitting position." D. "I will perform ankle and knee exercises every hour 34. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (select all that apply). A. "Use povidone iodine to clean around the stoma." B. "Empty the ostomy pouch when it becomes one-third full of contents." C. "Cut the opening of the pouch ½ of an inch larger than the stoma." D. "Place a piece of gauze over the stoma while changing the pouch." E. "Expect the stoma to turn a purple blue color as it heals." 35. A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn? -The client's belief that his needs will be met through education -The nurse explaining the need for education to the client -The client seeking family approval by agreeing to a teaching plan -The nurse's empathy about the client having to self-inject 36. 37. A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? Place an activated tuning fork in the middle of the client's forehead (should just be head not forehead technically) 38. A nurse is caring for a client who has pneumonia. The nurse should recognize that which of the following should be discarded in a biohazard bag? A. An emesis basin filled with blood from severe coughing B. A calibrated toilet inset filled with urine C. A disposable tissue containing expected sputum D. A bedpan containing diarrhea --= a client who was receiving antibiotics 39. A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose, and I'm worried I will be lost it if it falls off." Which of the following is an appropriate response by the nurse? A. "I can pin it to your hospital gown, so you won't lost it." B. "I will place it in your drawer, so it won't get lost." C. "I can put it in a locked storage unit for you." D. "I will hold onto it until a family member can take it home." 40. A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse' priority? A. Distended bladder B. Last bowel movement was 3 days ago C. Respiratory rate 7/min D. Report’s pain of 8 on scale from 0 to 10. 41. a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea, and vomiting for the past 48 hours? Which of the following actions should the nurse take first? -Offer pain medication -Palpate the abdomen -Auscultate bowel sounds -Administer an antiemetic 42. A nurse is collaborating with risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence? A. An assistive personnel discuses client care in the facility with victors' present B. Assistive personnel prevent a client from leaving the facility C. A nurse begins a blood transfusion without obtaining consent from a client. D. A nurse administers a medication without first identifying the client 43. 44. a nurse is caring for a client who has tracheostomy which of the following actions should the nurse take? -Cotton tip applicator to clean the inside of the cannula -Soak the outer cannula in warm soapy tap water -Cleanse the skin around the stoma with normal saline -Secure the tracheostomy ties to allow one finger to fit snuggly underneath 45. A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take? A. Avoid documenting direct quotes from the client as a part of subjective data. B. Tell the client the purpose for collecting the information. C. Explain to the client the necessary of full disclosure of information. D. Use the client's first name when initially meeting the client. 46 47. A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? A. Airborne B. Droplet C. Protective environment D. Contact 48.. A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? A. Thickened outer layer of skin B. Reduced sweat production C. Increased productions of oils D. Increased skin elasticity 49. A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take? A. Use sterile gloves to provide perineal care B. Have the client apply a mask when children are visiting C. Cleanse hands with an alcohol-based hand rub before client contact D. Place the client in a semiprivate room 50. a nurse is teaching a group of newly licensed nurses about the Braden scale. which of the following responses by a newly licensed nurse indicates understanding in the teaching? -Each element has a range 1 to 5 points -the higher the score the higher the pressure ulcer risk -the client age is part of the measurement -the scale measures 6 elements 51. A nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect? A. Postural hypotension B. Bradycardia C. Dependent edema D. Distended neck veins 52. A nurse receives a telephone prescription from a provider for a client who is experiencing pain. which of the following responses should the nurse make? A. "Let me provide you with the client's medical record number for identification." B. "Will you please spell the name of the medication for me?" C. "Let me clarify that you want the medication given qid, correct? " D. "I will sign my name now and leave a space for you to sign you name." 53. A nurse is caring for a client who reports a pain level of 5 on scale from 0 to 10. The client informs the nurse that pain medications are not an option for managing pain. which of the following is an appropriate response by the nurse? A. "Why do you think pain medication is not going to help you?" B. "I'm sure it will work for you if you just give it a chance." C. "You may take any herbal remedies you bring from home" D. "Would you like me to give you a back message 54. A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test? A. Place the base of a vibrating tuning fork on the top of the client's head B. Count how many seconds a client can hear a tuning fork after it has been struck C. Place the base of a vibrating tuning fork on the client's mastoid process D. Move a vibrating tuning fork in front of the client's ear canals one after the other 55. 56. A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take? A. Complete the bath even if the client is distress B. Allow the client to select the temperature of the bath water C. Give detained instructions for the client to follow D. Use distraction when bathing the client 57. A nurse is caring for a client who has urinary incontinence. Which of the following interventions should the nurse take to prevent skin breakdown? A. Request a prescription for an indwelling urinary catheter. B. Apply powder to the client's perineal area. C. Apply a moisture barrier ointment after perineal hygiene. D. Restrict the client's fluid intake. 58. 11. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4 mg IV bolus every 6 hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. (Move the steps into the box on the right. Place them in the order of performance. Use al the steps. A. Perform hand hygiene 2 B. Select the injection port of the IV tubing closest to the client. 1 C. Cleanse the injection port with an antiseptic swab.3 D. Inject the medication 5. E. Aspirate for a blood return.4 Select the injection port of the IV tubing closest to the client. Perform hand hygiene Cleanse the injection port with an antiseptic swab Aspirate for a blood return. Inject the medication 59.. During change- of- shift report, a nurse discovers she overlooked a prescription for a type and cross- match of a client who is to have surgery the next day. Which of the following actions should the nurse take first? A. Obtain the client's type and cross- match B. prepare an incident report for risk managementC. Document the incident in the client's medical record. D. Inform the provider of the delay in obtaining the type and cross - match 60. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? A. offer a wet washcloth for the client to wash her face B. prepare hot cocoa or tea for the client C. provide a late supper D. perform range of motion exercises 61. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a side lying position B. Apply mineral oil to the client's lips C. Brush the client's teeth daily D. Rinse the client's mouth with an alcohol -based mouthwash 62. A nurse is preparing to inset an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? A. The radial vein on the left wrist B. The basilic vein in the right antecubital fossa C. The cephalic vein on the back of the right hand D. The cephalic vein in the left distal forearm 66. A nurse is caring for a client who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the formula? A. Encourage the client to breathe deeply and cough. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation D. Encourage the client to take sips of water 67. A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority? -Determine the client's reading ability -Review the use of an artificial larynx -With the client schedule a support session -For the client explain the techniques of esophageal speech 68. A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? -Eat a light carbohydrate snack before bedtime -Exercise 1 hour before bedtime -Drink a cup of hot cocoa before bedtime -Take a 30 min nap daily 69. A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify that which of the following medication can interact adversely with this supplement? A. Albuterol B. Warfarin C. Atorvastatin D. Levothyroxine 70. A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen. B. Collect 1 mL of sputum. C. Collect the specimen in the evening. D. Offer the client oral hygiene after collection A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, "I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? A. "The social worker will help answer those questions." B. "Try to help your dad enjoy this time as much as he can." C. "I think that you should discuss this with the hospice nurse." D. "Let's talk more about your dad's condition." A nurse is caring for a client who has colostomy. which of the following actions should the nurse take? Ennsure the pouch is 0.32 cm (1/8inc) in larger than a stoma. A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Avoid using gesture when speaking to the client B. Request that assistive personnel interpret the information for the client C. Offer written information in the client's language D. Use proper medial terms when giving information to the client A nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will wear an N95 respirator mask when caring for the client." B. "I will tell the client's visitors to wear a mask when they are within 3 feet of the client." C. "I will remove my gown before my gloves after providing client care." D. "I will place the client in a private room the nurse is admitting a client who is at risk of falls to a medical-surgical unit. Which of the following action should the nurse take? Provide the client with the night light A nurse is providing teaching to a client about the need to increase iron in their diet. Which of the following should the nurse include as the best source of iron? Scramble eggs A nurse manager overhears a nurse telling the client “I will administer your medication by injection if you don’t swallow your pills” the nurse manager should identify that the nurse is committing which of the following torts? Defamation Assaults Invasion of privacy Battery A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first? A. Help the client lie on the floor B. Turn the client onto their side C. Loosen the client's clothing D. Move items in the room away from the client the nurse is documenting a client’s medical record. Which of the following entries should the nurse record? Administered pain medication Incision without redness and drainage Drank adequate amounts of fluid with meals Oral temperature slightly elevated at 800 A nurse is preparing to transfer a client who is partially weight- bearing from the bed to a chair. Which of the following actions should the nurse take? A. Keep his knees straight when moving the client B. Position the chair next to the bed at a 90" angle. C. Have the client bear weight on her strong leg D. Stand with his feet together when lifting the client A nurse is preparing to provide tracheostomy care for a client. which of the following action should the nurse plan to take? Wear a clean glove while cleaning cannula . A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? A. Provide brochures about the procedure B. Notify the provider C. Describe the surgery to the client D. complete an incident report a nurse is planning to discharge a client who had stroke and has difficulty holding utensils at mealtime. which of the following referrals should the nurse anticipate ? Occupation therapy A nurse is caring for a client who is postoperative and has a new prescription for advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? A. Scrambled eggs B. Oatmeal C. Applesauce D. Plain yogurt A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health cate team? A. Occupational therapist B. Social worker C. Primary care providerD. Registered dietician . a charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? A. "Delirium does not affect a client's sleep cycle." B. "Delirium does not affect a client's perception of her environment." C. "Delirium has a slow progression." D. "Delirium has an abrupt onset." A home health nurse is caring for a client who has a chronic illness and recently moved in with their adult child. which of the following statements by the client should indicate to the nurse that that client has adapted to their new situational role? a. I am looking forward to being able to be independent again b. I've never been the kind of person to ask others for help c. I really don't know what I'm supposed to do all day d. It's nice having other people cook for me. A nurse is creating a plan of care for a client who has left sided hemiplegia Which of the following interventions should the nurse include? A) instruct the pt remove forward to the left side whom ambulating to avoid falls. B) rest the client left arm over their chest. C) apply an orthotic boot on the client left foot. D) Place a thick pillow behind the client head to increase cervical flexion limit your talk 8 and 440 dosage