Hesi rn exit examv4 full 160 answers Exam (elaborations) - latest

1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 25 ml of fullstrength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200m 2.An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an external condom catheter 3. A male Muslim client with pneumonia isscheduled to receive a dose of an intravenous antibiotic but refusesto allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he completes his prayers 4.UAP using a hand sanitzersthat is alcohol for 2 minutes- tell that hand sanitizer use isless 2min 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer. Answer: 800 Rationale: First, convert the child’s weight to kg: 44 pounds divided by 2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client’s vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? Compare current vital signs with previous vital signs 7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? Have the parent take the child for emergency help 8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of “Altered thought processes, secondary to” what condition? Postpartum psychosis 9. The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? Regular aerobic exercise. 10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst 11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium 12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room 13. Leadership- Interpreter informed consent – Pt should sign the consent 14. Geriatrics/Emergency Rib fractures fall – Pulmonary embolism 15. A client diagnosed with major depression is being allowed a weekend passfrom the psychiatric unit. Which instruction should the nurse provide to the client’sfamily? Involve the client in usual at home activities 16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which ofthe following doesthis assessment finding suggest to the nurse? Coagulation disorders 17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? Assess vital signs. 18. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? Clamp the tube 19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? Determine if Client B has two units of packed cells available in the blood bank. 20. Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what isthe priority ranking for these cases? (arrange these cases in order or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) A mother and father have just arrived on the . A crying child being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is wandering around 21. (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine didn’t have a middle age woman bleeding, instead it had an old man wandering and correct order is: wandering old man, woman w/blanket, man holding baby, and mother & father) 22. The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? A yellow disaster tag means critical injuries and require immediate intervention. 23. What makes a baby frontal bulge or rises= crying 24. Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8 hours that has an order for fluid restriction? Do not allow the child to drink fluids 25. The ear, where do u pull to give a ear drop= it a picture so look it up online (KNOW CHILD & ADULT) (pull the pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of ear and put it on the lobule of the pinnae it is the ear lobe). The eye picture asked to find the macula or the fovea centralis (there are 2 prominent spots on the eye – choose the DARK spot to the left not the spot where the light is) 26. Know your serum levels? K- 3.5-5.1, Na – 135-145, Ca 9-11, BUN – 10-20 27. When to use drug for motion sickness drug question – Take Zofran 4 hours before going on trip via sea. 28. Pt with DM= she statesthat she hasto eat lunch rite afterthe gets her insulin to prevent going to hypoglycemia 29. Electrical burn pt= put himin a cardiac telemetry monitor 30. Which discharge instruction has the greatest priority for the mother of a 6-year-old who was diagnosed with Type 1 diabetes mellitus one week ago? “Always carry a quick source of sugar 31. A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being admitted. Which of the following symptoms would the nurse most likely NOT expect to find with this client? severe over-or under-weight 32. 12yrs pt coming for surgery= have a tour of the OR with the a week before with the family 33. The charge nurse is developing the nursing guidelines for a coronary care unit. Which references is likely to be the most useful in developing these guidelines? The Scope of Standards of Practice from the American Nurses Association 34. Which assessment finding indicates a client's readiness to leave the nursing unit for a Bronchoscopy? On-call sedation administered. 35. A nurse-manager is preparing an annual budget for the unit.Nursing salaries should be included in which component of the budget? Operating budget 36. The nurse has not finished administering routine oral medication because on e client experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding 37. What is manntiol drug used for? To promote diuresis in prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema in CHF. 38. The nurse is caring for a 42 year old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? Edema 39. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? Anemia 40. A pt on a trachea/endotrach with gurgling sound= always pick suctioning 41. Know how the chest tube vac machine works – there is a picture of a chest tube vac machine. Answer this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage 42. Child w/ hemophila= have parent pad the corners of the furniture due to bleeding. 43. You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been told that surgery is necessary. With consideration to the client's religious preferences in development of the plan of care, you would document what? The administration of blood and blood products isforbidden 44. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for what? Drug toxicity 45. A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him onto the bedpan/with the urinal. 46. Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of Mr. Miller. Nurse Jones has committed which of the following? Libel. 47. A client is prescribed Zolpidem (Ambien). Which of the following side effects should be monitored while the client istaking this medication? Daytime drowsiness 48. Translator is working with the nurse who is giving discharge instructions to a non-English client. When the translatorrestates what the nurse issaying it appearsthat he is saying much more than what the nurse said. What action should the nurse take? Ask the translator if there is a reason for the lengthiness of the translation 49. Who is at risk for rib fracture - Elderly pt. 50. Splint- Chest compression or chest splint after surgery – they used it for comfor