Study for Hesi 3rd semester questions and answers well illustrated.

Study for Hesi 3rd semester questions and answers well illustrated. he nurse teaches sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. The nurse concludes that further teaching is needed when the family member performs what action during a return demonstration? 1 Sets the sterile field on the client's linens at the foot of the bed 2 Touches the outer inch of the sterile field when placing it on a flat surface 3 Checks expiration dates on the sterile packages before d - correct answers.1 The field should be placed on a clean, dry table near the client. A client's bed surface may not be clean and the client's movements may cause the field to become contaminated. The outer inch of the sterile field is considered contaminated. Sterile objects must be kept within the one-inch border of the sterile field. Expired equipment must be discarded. Sterile gloves are donned after the soiled dressing is removed and contained, the hands washed, and the sterile field is prepared. Holding the tips lower than the wrist is the correct technique if using forceps to hold wet gauze. This keeps the flow of the sterile solution in the direction of sterile equipment. If forceps are held with the tips higher than the wrist, sterile solution will flow in the direction of the caregiver and may become contaminated by flowing onto an unsterile surface. A client who weighs 176 pounds is to receive 8 mg/kg of cyclosporine (Sandimmune) daily to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. ___ mg/day - correct answers.640 First compute the client's weight in kilograms and then compute the dosage. Solve the problem using ratio and proportion. The nurse is caring for a client that is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit level - correct answers.4 Vitamin B12 is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H&H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia. Normal serum electrolytes, healthy skin integrity, and resolution of peripheral edema if present would be secondary to improved hemoglobin and hematocrit levels. A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? 1 Accept the client's behavior. 2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions. - correct answers.2 At this time the client is using this behavior as a defense mechanism. Acceptance can be an effective interpersonal technique because it is nonjudgmental. Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies non-acceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered. The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. In doing so, the nurse is aware that in the problem-etiology-signs and symptoms (PES) format: 1 Signs and symptoms come last in the diagnostic process. 2 Nursing interventions are derived from the etiology statement. 3 The only allowable diagnoses are nursing diagnoses. Nursing diagnoses deal only with actual or potential illness problems. - correct answers.2 The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired. . A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. Correct 1 Dry cerumen 2 Tears in the tympanic membrane Correct 3 Difficulty hearing high-pitched voices Incorrect 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining - correct answers.1,3 Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier. A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? 1 Number of fatalities 2 Cost of nurse overtime 3 Nurse-to-client ratio on units 4 Completion of critical pathways - correct answers.4 During a disaster, nursing coverage on all units should remain appropriate for client safety. Disaster nursing is concerned with providing care for clients in imminent danger and requires mobilization of people and resources from other areas. Number of fatalities is not the basis for evaluating the effectiveness of care; during a disaster, many clients may be dead on arrival. Cost is not the concern during a disaster. Completion of critical pathways is not the basis for evaluation of care during a disaster. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answe After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1 Stop the heparin, flush the line, and administer the vancomycin. 2 Use a piggyback setup to administer the vancomycin into the heparin. 3 Start an - correct answers.3