Exit HESI Precious 4 Exam After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? - Answer Hold oral intake until swallow evaluation is done. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) - Answer Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implemen t? - Answer Transfer the client to the surgical floor. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) - Answ er Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide th e client about future antibiotic prescriptions? - Answer Be alert for possible cross-
sensitivity to cephalosporin agents. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, wh at priority action should the nurse implement? - Answer The client's need for pain medication should be determined. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) - Answer Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? - Answer Report weight gain of 2 pounds (0.9kg) in 24 hours Which problem, noted in the client's history, is important for the nurse to be a ware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? - Answer Aural migraine headaches. When implementing a disaster intervention plan, which intervention should the nurs e implement first? - Answer Identify a command center where activities are coordinated The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate t he need for this diagnosis? - Answer Fever and dysuria. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? - Answer Maintain both lower extremities elevated on pillows. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most importan t for the nurse to include in the client's plan of care? - Answer Teach family proper range of motion exercises. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include w hen teaching this client about osteoporosis prevention? - Answer Postmenopausal wome n need an intake of at least 1,500 mg of calcium daily. When evaluating a client's rectal bleeding, which findings should the nurse document? - Answer Color characteristics of each stool. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? - Answer High pitched or fine crackles. An adult male is admitted to the emergency department after falling from a ladd er. While waiting to have a computed tomography (CT) scan, he requests something for a seve re headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? - Answer Explain the reason for using only non-narcotics. The nurse is managing the care of a client with Cushing's syndrome.
sensitivity to cephalosporin agents. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, wh at priority action should the nurse implement? - Answer The client's need for pain medication should be determined. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) - Answer Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? - Answer Report weight gain of 2 pounds (0.9kg) in 24 hours Which problem, noted in the client's history, is important for the nurse to be a ware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? - Answer Aural migraine headaches. When implementing a disaster intervention plan, which intervention should the nurs e implement first? - Answer Identify a command center where activities are coordinated The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate t he need for this diagnosis? - Answer Fever and dysuria. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? - Answer Maintain both lower extremities elevated on pillows. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most importan t for the nurse to include in the client's plan of care? - Answer Teach family proper range of motion exercises. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include w hen teaching this client about osteoporosis prevention? - Answer Postmenopausal wome n need an intake of at least 1,500 mg of calcium daily. When evaluating a client's rectal bleeding, which findings should the nurse document? - Answer Color characteristics of each stool. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? - Answer High pitched or fine crackles. An adult male is admitted to the emergency department after falling from a ladd er. While waiting to have a computed tomography (CT) scan, he requests something for a seve re headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? - Answer Explain the reason for using only non-narcotics. The nurse is managing the care of a client with Cushing's syndrome.
