HESI 799 RN EXIT EXAM (401-500)-100 QUESTIONS WITH VERIFIED SOLUTIONS

An adult client is exhibit the manic stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? a. Hygiene-self-care deficit b. Imbalance nutrition c. Disturbed sleep pattern d. Self-neglect Imbalance nutrition Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? a. Arrange transport for admission to the hospital. b. Insert saline lock for IV diuretic therapy. c. Assess compliance with routine prescriptions. d. Instruct the client to monitor daily caloric intake. Assess compliance with routine prescriptions. Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%) The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia? Clubbing FLIP for photo!!! clubbing The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is: a. Two days postoperative bladder surgery with continuous bladder irrigation infusing. b. One day postoperative laparoscopic cholecystectomy requesting pain medication. c. Three days postoperative colon resection receiving transfusion of packed RBCs. d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours. Three days postoperative colon resection receiving transfusion of packed RBCs. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? a. Do not read without direct lighting for 6 weeks. b. Avoid straining at stool, bending, or lifting heavy objects. c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. Avoid straining at stool, bending, or lifting heavy objects Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.) 12.5 12.5 Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? a. Encourage the client to turn on her left side. b. Place a pillow under the client's head and knees. c. Explain to the client that her position is not safe. d. Place a wedge under the client's right hip. Place a wedge under the client's right hip Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? a. Reposition the infant every 2 hours. b. Perform diaper changes under the light. c. Feed the infant every 4 hours. d. Cover with a receiving blanket. Reposition the infant every 2 hours. Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? a. Irrigate the indwelling urinary catheter. b. Prepare the client for external pacing. c. Obtain capillary blood glucose measurement. d. Titrate the dopamine infusion to raise the BP. Titrate the dopamine infusion to raise the BP. Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client's capillary blood glucose should be monitored but is not directly indicated at this time. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? a. Determine the client's level of emotional functioning' b. Assess functional ability of the primary support system. c. Evaluate the client's mood, cognition and orientation. d. Review the client's pattern of adaptive coping skill Evaluate the client's mood, cognition and orientation. Rational: the mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client's psychosocial assessment. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) a. Administer a daily dose of lisinopril as scheduled. b. Assess the client for postural hypotension. c. Notify the healthcare provider immediately d. Provide a PRN dose of acetaminophen for headache e. Withhold the next scheduled daily dose of warfarin. a. Administer a daily dose of lisinopril as scheduled. d. Provide a PRN dose of acetaminophen for headache Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client's blood pressure. A PRN dose of acetaminophen should be given for the client's headache. The other options are not indicated for this situation. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) a. Pasta, noodles, rice. b. Egg, tofu, ground meat. c. Mashed, potatoes, pudding, milk. d. Brussel sprouts, blackberries, seeds. e. Corn bran, whole wheat bread, whole grains. a. Pasta, noodles, rice. b. Egg, tofu, ground meat. c. Mashed, potatoes, pudding, milk. Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a. Withhold food and fluid intake. b. Initiate IV fluid replacement. c. Administer antiemetic as needed. d. Evaluate intake and output ratio. Withhold food and fluid intake Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. Conversion of the client's PPD test from negative to positive. b. Length of time of the exposure to tuberculosis. c. Current diagnosis of hepatitis B. d. History of intravenous drug abuse. Current diagnosis of hepatitis B Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. Daily medications include furosemide for hypertension and heart failure, and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) a. Decrease laxative use to every other day and use oil retention enemas as needed. b. Include oatmeal with stewed pruned for breakfast as often as possible. c. Increase fluid intake by keeping water glass next to recliner. d. Recommend seeking help with regular shopping and meal preparation. e. Report constipation to healthcare provider related to cardiac medication side effects. b. Include oatmeal with stewed pruned for breakfast as often as possible. c. Increase fluid intake by keeping water glass next to recliner. d. Recommend seeking help with regular shopping and meal preparation. Rational: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? a. Report the incident to the local child protective services. b. Find a home health agency that specializes in brain injuries. c. Determine the mother's basic skill level in providing care. d. Consult the ethics committee to determine how to proceed. Determine the mother's basic skill level in providing care Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother's skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart beating during the procedure. What action should the nurse take? a. Explain the procedure again in detail and clarify any misconceptions. b. Notify the healthcare provider of the client's lack of understanding. c. Call the client's next of kin and have them provide verbal consent. d. Postpone the procedure until the client understands the risk and benefits. b. Notify the healthcare provider of the client's lack of understanding. Rational: the nurse is only witnessing the signature and is not responsible for the client's understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated. In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? a. Elevated thyroid hormone level. b. Hematocrit of 28%. c. Heart rate of 92 beats per minute. d. Systolic murmur. Hematocrit of 28% Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28% is below pregnant norms and could signify iron-deficiency anemia. Other options are normal finding pregnancy A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? a. Total calcium 9 mg/dl (2.25 mmol/L SI) b. Creatinine 4 mg/dl (354 micromol/L SI) c. Phosphate 4 mg/dl (1.293 mmol/L SI) d. Fasting glucose 95 mg/dl (5.3 mmol/L SI) Creatinine 4 mg/dl (354 micromol/L SI A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? a. Ask the client with her children present if she fully understands the decision she has made. b. Discuss success of clinical trials and ask the client to consider participating for one month. c. Explain to the family that they must accept their mother's decision. d. Explore the client's decision to refuse treatment and offer support d. Explore the client's decision to refuse treatment and offer support Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client's decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today? a. Assist client in identifying goals for the day. b. Encourage client to participate for one hour in a team sport. c. Schedule client for a group that focuses on self-esteem. d. Help client to develop a list of daily affirmations. a. Assist client in identifying goals for the day. Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participates in care by identifying goals for the day is the most important intervention for the client's first day at the unit. Other options can be implemented over time, as the depression decreases. An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? a. Examine the client's room for hidden food. b. Assign staff to monitor what the client eats. c. Ask the client if the food provided is being eaten or discarded. d. Provide the client with a high calorie diet. b. Assign staff to monitor what the client eats. Rationale: clients with an eating disorder have an unhealthy obsession with food. The client's continued weight loss, despites indication that the client has consumed 100% of the diet, should raise questions about the client's intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary. During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first? a. Determine when the client last had an influenza vaccination. b. Discuss the concerns expressed by the client about the vaccination. c. Ask about any recent exposure to persons with the flu or other viruses. d. Review the informed consent form for the vaccination with the client. Discuss the concerns expressed by the client about the vaccination Rationale: the nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form. The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? a. Clean up the spilled blood to reduce infection transmission. b. Notify the healthcare provider that the client appears to be bleeding. c. Apply direct pressure to the client's IV site. d. Identify the source and amount of bleeding. Identify the source and amount of bleeding. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? a. Confusion and tremors b. Yellowing and itching of skin. c. Abdominal pain and vomiting d. Anorexia and abdominal distention a. Confusion and tremors Rationale: daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action. Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? a. Transfuse Type A negative blood until type AB negative is available. b. Recheck the client's hemoglobin, blood type and Rh factor. c. Administer normal saline solution until type AB negative is available d. Obtain additional consent for administration of type A negative blood Transfuse Type A negative blood until type AB negative is available Rationale: those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client's hemoglobin is critically low, and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings? a. Squeeze the nipple base to introduce milk into the mouth b. Position the baby in the left lateral position after feeding c. Alternate milk with water during feeding d. Hold the newborn in an upright position d. Hold the newborn in an upright position Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated using special feeding appliances and nipples such as the Haberman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce a volume that is greater than the neonate can coordinate swallowing. The preferred position of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate's intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate's stomach. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? a. Offer to provide the influenza vaccination to the student while she is at the clinic b. Encourage the student to obtain a vaccination prior to the next influenza season. c. Confirm that a history of asthma can increase risks associated with the vaccine. d. Advise the student that the nasal spray vaccine reduces side effects for people with asthma. a. Offer to provide the influenza vaccination to the student while she is at the clinic Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma, but the nasal spray may result in increased wheezing after receiving that form of the vaccination.