Hesi Comprehensive 2 exam review

Comprehensive Exam 2 Review 1.ID: Which biological practices are federally regulated for healthcare workers? (Select all that apply.) A. Correct Standard precautions. B. Correct N-95 tuberculosis standard. C. Correct Blood-borne pathogen standard. D. Biological product exposure limit (BPEL). E. Correct Resource Conservation and Recovery Act (RCRA). F. As Low as Reasonably Allowable standard (ALARA). 2.ID: Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) A. Correct Economics. B. Workforce. C. Correct Technology. D. Interventions. E. Socio-economic status. F. Correct Legislation/regulation. 3.ID: A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first? A. Prednisone (Deltasone) 10 mg PO. B. Albuterol (Proventil) 0.5% solution per nebulizer. C. Correct Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. BASIC HOSPICE CARE! D. Oxygen 2 to 6 liters per minute using a nasal cannula. HE IS DYING: SOB AND ANXIETY PERSISTS… 4.ID: During the initial home visit, the nurse performs a family assessment. Which component is most important for the nurse to consider? A. The legal definition of family in the United States. B. Members of the group that are direct descendents or bonded by marriage. C. Correct An exploration of the group relationships, structure, functions, and roles. D. Cultural differences among members of the extended family. 5.ID: Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? A. African-American women who are 30 to 35 years of age. B. Correct Survivors of violence that occurred at least 5 years ago. C. Active armed forces reserve unit returning from Europe. D. Full-time students who are attending public colleges. 6.ID: Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? A. Promote hygiene by ensuring that children's faces and hair are kept clean. B. Correct Ensure that all enrolled children have been immunized for Hepatitis A. MOST EFFECTIVE! C. Put a strip bandage on bleeding injuries to prevent contamination of others. D. Teach children the correct handwashing technique to use after toileting. 7.ID: When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? A. Correct Record these findings in the client's record. B. Observe closely for possible dehiscence. OCCUR AFTER 3RD TO 5TH DAY: GUSH OF SEROSANGUINEOUS C. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. D. Increase the IV fluid rate and encourage the client to eat more ice chips. 8.ID: When culturing a wound, the nurse should obtain the sample from which part of the wound? A. The outer edges of the wound. SKIN NORMAL FLORA B. All necrotic sections of the wound. C. Correct Areas containing purulent or pooled exudates. D. Any particularly painful area of the wound. 9.ID: While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? A. Correct Continue the interview process and record the findings. B. Refer the client to a psychiatric outpatient clinic. C. Determine if there is a family history of emotional disorders. D. Encourage the woman to attend citizenship classes. 10.ID: After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? A. Replace the empty tank without reporting the situation to any members of the agency. B. Correct Complete an adverse occurrence report and submit it to the nurse-manager. C. Send an anonymous letter explaining the situation to the family of the client. D. Advise the flight crew of the situation, then suggest that no further discussion be held. 11.ID: A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? A. Nurses use their best judgment based on the client's condition. B. Correct The healthcare team must honor the written wishes of the client. C. Notify the healthcare provider of the family's wishes, so a decision can be made. D. Every effort must be made to honor the family's wishes about their loved one. 12.ID: The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? A. Page the unit manager to address the situation. B. Correct Close the demographic screen on the computer. C. Instruct the UAP to end the phone call immediately. D. Send a UAP into the client's room to relieve the nurse. 13.ID: A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? A. Correct Encourage the student to associate with non-smokers only while attempting to stop smoking. B. Tell the student that he is still young and should continue to try various smoking cessation methods. C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. D. Provide the student with the latest research data describing the long-term effects of tobacco use. 14.ID: A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? A. Write the correct prescription as a verbal order received from the healthcare provider. B. Correct the misspelled medication in the written prescription and initial the change. C. Consult with the pharmacist to determine the best medication for the client. D. Correct Contact the healthcare provider to clarify the prescription intended for the client. 15.ID: Which action should the nurse take first when performing tracheostomy care? A. Cleanse around the stoma. B. Suction the tracheostomy. C. Correct Oxygenate with 100% oxygen. D. Secure the new neck strap. 16.ID: When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? A. Place a sterile drape under the client's buttocks. B. Instruct the client to inhale and then exhale slowly. C. Discard the gloves and apply new sterile gloves. D. Correct Apply a sterile lubricant to the end of the catheter. 17.ID: What is the most effective way to implement a teaching plan? A. Correct Teach the information that the client wants to learn first. B. Streamline the teaching plan to include only essential information. C. Present to the client all the information necessary to meet the objectives. D. Provide the client with written material to review before teaching sessions. 18.ID: A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? A. Use disposable plates and utensils. B. Stay in a room with the door closed. C. Correct Dispose of soiled dressings in plastic bags that are securely closed. D. Others who are in the same room with the client should wear a mask. 19.ID: A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) Correct 1.Airway and breathing. 2.Pain management. 3. Sleep and rest. 4Definitive therapy. 20.ID: The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) Correct1.Raise bed to a comfortable working height. 2.Lower the side rail between the nurse and the client. 3.Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin. 21.ID: The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numerical value only. If rounding is required, round to the nearest whole number.) The correct response is "111" diastolic + 1/3 (pulse pressure: systolic – diastolic) = 90 + (152-90)/3 22.ID: A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numerical value only.) The correct response is "90" 23.ID: Which action should the nurse implement when using the confrontation technique during a vision exam? A. Use an ophthalmoscope to watch the client's pupil constrict when a strong light is shown on it. B. Stand behind the client and direct the client to tell the nurse when an object enters the peripheral field of vision. C. Show the client a series of four cards with printing of varying sizes and ask which card the client sees most clearly. D. Correct Sit facing the client and while look directly at the client's face, move an object inward from the periphery. (ONE EYE AT EACH TIME) 24.ID: When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip (OR IF A TORNIQUETE IS APPLIED). What action should the nurse implement? A. Lower the extremity below the level of the client's heart. B. Correct Gather the supplies needed to discontinue the IV fluid. BEST PROOF OF INFILTRATION C. Obtain an intravenous infusion pump to regulate the rate of infusion. D. Convert the IV to a saline lock until the healthcare provider is notified. 25.ID: The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? A. Use an electronic sphygmomanometer to take the BP every 30 minutes. B. Correct Retake the blood pressure in the same arm, deflating the cuff slowly. C. Ask another nurse to recheck the blood pressure to compare results. D. Obtain another blood pressure cuff and retake the blood pressure. 26.ID: The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.) Correct 1. Clamp the drainage tubing. YES, TO MAKE URINE POOL IN THE TUBE AND THEN DRAW IT 2. Label the urine specimen. 3. Place in a biohazard bag. 4. Document the procedure. 27.ID: The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? A. Hand washing prior to preparation of the injection. B. Correct Method used to aspirate medication from a vial. KEEP NEEDLE STERILE! C. Selection and rotation of injection sites. D. Proper disposal of injection equipment. 28.ID: The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged? A. Review the client's most recent serum calcium level. B. Verify that the crutches fit snugly under the axilla. C. Correct Observe the client while demonstrating crutch walking. D. Determine if the client lives alone or with others. 29.ID: The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? A. Document the change in pulse rate on the graphics sheet. B. Review the client's medical history for cardiac problems. C. Correct Reassess the rate and characteristics of the client's pulse. D. Ask the UAP to recheck the client's pulse in thirty minutes. 30.ID: A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? A. Determination of the compatibility of the intravenous fluids and prescribed antibiotics. B. Provision of nursing staff education about safe administration of IV antibiotics. C. Maintenance of data related to the number of IV infiltration occurrences in the hospital. D. Correct Evaluation of the need for continued IV antibiotics to achieve the desired outcomes.