Detailed Answer Key HESI Practice Fall 2024

1. A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? A. Initiate a low-residue diet. Rationale: One of the manifestations of acute pancreatitis is abdominal pain. The nurse should anticipate the provider will prescribe withholding of foods and fluids. This serves to manage the client's pain by limiting gastrointestinal activity and stimulation of the pancreas. B. Pantoprazole 80 mg IV bolus twice daily Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions. C. Ambulate twice daily. Rationale: The nurse should anticipate a provider prescription for bed rest during the acute stage of pancreatitis. Bed rest decreases the metabolic rate and the secretion of pancreatic enzymes. D. Pancrelipase 500 units/kg PO three times daily with meals Rationale: The nurse should identify that pancrelipase, an enzyme replacement medication, is used in the treatment of clients who have chronic pancreatitis. It is not used in the treatment of acute pancreatitis. 2. A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment Rationale: A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room. B. A room with another nonsurgical client Rationale: A two-bed room with another nonsurgical client exposes the other client to tuberculosis. A client who has tuberculosis should have a private room. C. A room in the ICU Rationale: A client who has active tuberculosis and no other comorbidities is not critically ill. D. A room that is within view of the nurses' station Rationale: The client's room should be well ventilated and private, but it is not necessary for it to be close to the nurses' station. 3. A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? A. Hypocalcemia Rationale: Hypercalcemia is a risk factor associated with urolithiasis. B. BMI less than 25 Rationale: Obesity, or having a BMI that is greater than 29, has been found to be a risk factor for the development of urolithiasis. C. Family history Rationale: Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation. D. Diuretic use Rationale: Medications such as antacids, vitamin D, laxatives, and aspirin have been associated with the formation of urolithiasis. However, there is no indication that the use of diuretics place a client at an increased risk for stone formation. 4. A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increase hematocrit E. Increased temperature Rationale: Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid.Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid.Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.Increased hematocrit is incorrect. The nurse should expect the client who has fluid volume deficit to have an elevated hematocrit because of hemoconcentration.Increase temperature is incorrect. The nurse should expect the client who has fluid volume deficit to have an increase in temperature due to fluid loss. 5. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? A. Lower the height of the solution container. Rationale: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed. B. Encourage the client to bear down. Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema. C. Allow the client to expel some fluid before continuing. Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema. D. Stop the enema and document that the client did not tolerate the procedure. Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease the cramping. 6. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow. 7. A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider? A. Blood pressure 102/66 mm Hg Rationale: The nurse should identify this finding as within the expected reference range. B. Straw-colored urine from an indwelling urinary catheter Rationale: Straw-colored urine is an expected finding. More information is needed to determine whether to take action in this case. C. Yellow-green drainage on the surgical incision Rationale: Thick yellow-green drainage is indicative of an infection and should be reported immediately. D. Respiratory rate 18/min Rationale: The nurse should identify this finding as within the expected reference range. 8. A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? A. analgesic Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. B. anti-inflammatory Rationale: Although aspirin does have an analgesic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. C. antiplatelet aggregate Rationale: Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart. D. antipyretic Rationale: Although aspirin does have an antipyretic effect, cardiac clients who take 325 mg daily are taking it for a different purpose. 9. A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin Rationale: Isophane NPH insulin is intermediate-acting. It has an onset of action of 1 to 3 hr and is not appropriate for emergency treatment of ketoacidosis. B. Insulin glargine Rationale: Insulin glargine is a long-acting insulin, with an onset of 2 to 4 hr. It is not appropriate for emergency treatment of ketoacidosis. C. Insulin detemir Rationale: Insulin detemir is an intermediate-acting insulin. It has an onset of action of 1 hr and is not appropriate for emergency treatment of ketoacidosis. D. Regular insulin Rationale: Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis. 10. A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? A. Difficulty reading Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere. B. Inability to recognize his family members Rationale: The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere. C. Right hemiparesis Rationale: The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere. D. Aphasia Rationale: The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere. 11. A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? A. Stop the infusion of blood. Rationale: This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood. B. Inform the provider. Rationale: The nurse should inform the provider so that the provider can give prescriptions for monitoring and medication if needed. However, there is another action the nurse should take first. C. Obtain a urine specimen. Rationale: The nurse should obtain a urine specimen to check for hemolysis; however, there is another action the nurse should take first. D. Notify the laboratory. Rationale: The nurse should notify the blood bank so personnel can assist with checking for errors with the blood component product; however, there is another action the nurse should take first. 12. A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? A. "These tests help determine the degree of damage to the heart tissues." Rationale: Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels. B. "Cardiac enzymes will identify the location of the MI." Rationale: The nurse should inform the partner and the client of the protocols and prescriptions for the client who has an MI to decrease anxiety. The nurse should include that the 12-lead electrocardiogram may be used to determine the location of the MI in the teaching. C. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." Rationale: An echocardiogram is a diagnostic tool used to determine the heart structure and mobility of the heart valves. It can be used to diagnose cardiomyopathy, valvular disorders, aneurysms and left ventricular function. D. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." Rationale: Pulmonary congestion, a complication of MI, is suspected when crackles or rales are auscultated in the chest. Should this occur, the nurse should inform the client and partner that it is diagnosed by chest x-ray. 13.A A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. Rationale: The nurse should avoid routine catheter changes. The catheter should be changed only to correct a problem, such as a leakage or a blockage. B. Check the catheter tubing for kinks or twisting. Rationale: The nurse should check the catheter for twisting or kinks in the tubing. These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder. C. Irrigate the catheter once each shift. Rationale: The nurse should avoid irrigation of the catheter unless there is an obstruction. D. Clean the perineal area with an antiseptic solution daily. Rationale: The nurse should clean the perineal area with soap and water at least twice per day. 14.A A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? A. History of smoking Rationale: Smoking is a modifiable risk factor, because the client has an ability to change via cessation. B. Obesity Rationale: Obesity is a modifiable risk factor, because the client should have the ability to change via diet. C. History of hypertension Rationale: Hypertension is a modifiable risk factor, because the client should have the ability to change via medication, exercise, and diet. D. Race Rationale: Race is a nonmodifiable risk factor, which the client is unable to control. 15.A A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? A. Medications will need to be taken for the rest of the client's life, even if the client feels better. Rationale: Active TB is usually treated with the simultaneous administration of a combination of medications until the disease is controlled, usually 6 to 9 months but possibly as long as 2 years. B. Medications will need to be taken until the Mantoux test is negative. Rationale: Once the client is diagnosed with active TB, the Mantoux test will remain positive for the remainder of the client's life. C. A typical course of treatment involves 6 to 9 months of consistent medication use. Rationale: Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time. D. The client's family will also need to take medications to prevent infection. Rationale: A client is treated with antitubercular medications only if she tests positive. Because of the serious side effects associated with TB medications and the prevalence of multidrug resistant TB, medications are not given to clients who are merely at risk for developing the disease. 16.A A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible Rationale: Although a semi-Fowler's position can help the client breathe more easily, it will not alter the consistency of secretions. B. Administering oxygen via nasal cannula at 2 L/min Rationale: Administration of oxygen helps correct hypoxemia, but it will not alter the consistency of secretions. C. Helping the client select a low-salt diet Rationale: Although a low-salt diet can help limit peripheral edema, it will not alter the consistency of secretions. D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration. 17.A A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.) A. Polyuria B. Blurred vision C. Polydipsia D. Tachycardia F. Moist, clammy skin Rationale: Polyuria is incorrect. Manifestations of hyperglycemia include polyuria (excessive urination).Blurred vision is correct. Manifestations of hypoglycemia include blurred vision.Polydipsia is incorrect. Manifestations of hyperglycemia include polydipsia (excessive thirst).Tachycardia is correct. Manifestations of hypoglycemia include tachycardia.Moist, clammy skin is correct. Manifestations of hypoglycemia include moist, clammy skin. 18.A A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. Remain on bedrest for the first 24 hr. Rationale: When the client has recovered from sedation, the client will be allowed to walk, as tolerated, but should be instructed not to overuse or strain the joint for a few days. B. Keep the leg in a dependent position. Rationale: Elevating the affected area in the postoperative period (12 – 24 hr) reduces pain and swelling. C. Apply ice to the affected area. Rationale: Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling. D. Begin active range of motion. Rationale: Although the client will be allowed to walk as tolerated, joint use should be minimized for the first few days to reduce postoperative pain and swelling. 19. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave Rationale: Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression. B. Elevated ST segment Rationale: The nurse should identify ST depression as an indication of hypokalemia. C. Wide QRS Rationale: The nurse should identify a widened QRS as an indication of hyperkalemia. D. Inverted P wave Rationale: Inverted P waves are associated with junctional rhythms. 20. While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion Rationale: When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers. B. Alteration in body image Rationale: The nurse should address the client's alteration in body image because the client can consider the appearance of varicose veins, edema, and the ulcerations unattractive. However, another diagnosis is the priority. C. Alteration in activity tolerance Rationale: The nurse should assess the client for decreased ability to tolerate activity because the presence of varicose veins and edema can be painful and present a feeling of fullness in the legs. However, another diagnosis is the priority. D. Impaired skin integrity Rationale: The nurse should address the presence of venous stasis ulcers and edema because these factors can lead to infection, increased tissue breakdown, and delayed healing. However, another diagnosis is the priority. 21. A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? A. Montgomery straps Rationale: Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips. B. Enzymes Rationale: The nurse should use enzymes to debride a wound that contains eschar. C. Alcohol swabs Rationale: The nurse should recognize that alcohol has a drying effect on the skin. D. A transparent dressing Rationale: The nurse should use a transparent dressing to protect a client from shearing forces. The transparent dressing should be used on intact skin. This type of dressing would cause damage each time it is removed, as the entire surface contains adhesive. 22. A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? A. To prevent fluid from accumulating in the wound Rationale: The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures. B. To limit the amount of bleeding from the surgical site Rationale: A JP drain does not limit the amount of bleeding. C. To provide a means for medication administration Rationale: A JP drain does not provide a means for medication administration. D. To eliminate the need for wound irrigations Rationale: A JP drain is not used as a substitute for wound irrigation. 23.A A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? A. "An MRI scan is not distorted by movement, so you do not have to lie still." Rationale: An MRI scan is distorted by movement. It is important that the client is informed of the need to lie still during the procedure. B. "An MRI scan is a short procedure and should take no longer than 30 minutes." Rationale: An MRI scan is a lengthy procedure that lasts between 60 and 90 min. C. "The MRI contrast dye contains iodine and can cause your skin to itch." Rationale: MRI contrast dye does not contain iodine and therefore is not subject to hypersensitivity reactions like contrast dye used in a traditional CT scan. D. "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner." Rationale: The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort. 24. A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? A. Review the client's electrolyte values. Rationale: The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea. B. Check the client's perianal skin integrity. Rationale: The nurse should check the client's perianal skin integrity to identify areas of breakdown or excoriation; however, the nurse should take a different action first. C. Investigate the client's emotional concerns. Rationale: The nurse should investigate the client's emotional concerns to assist the client with the psychosocial coping of her condition; however, the nurse should take a different action first. D. Obtain a dietary history from the client. Rationale: The nurse should obtain a dietary history from the client to identify triggers for inflammation of the colon; however, the nurse should take a different action first. 25.A A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? A. Notify the provider. Rationale: The nurse may need to notify the provider if unable to induce fluid flow from the catheter, or if the output is bright rad and thick; however, the nurse should attempt a different intervention first. B. Check the tubing for kinks. Rationale: When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen. C. Adjust the rate of the bladder irrigant. Rationale: The nurse may need to increase the rate of bladder irrigant to stimulate removal of urine and clots; however, the nurse should use a less restrictive intervention first. D. Irrigate the catheter. Rationale: The nurse may need to irrigate the catheter to check for an internal obstruction; however, the nurse should use a less restrictive intervention first. 26.A A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet Rationale: Elevating the feet can help improve circulation by decreasing dependent pooling of the blood and promoting venous return to the heart. B. Massaging her legs Rationale: Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication. C. Flexing her ankles Rationale: Ankle- and calf-pumping exercises can help reduce the risk of VTE postoperatively. D. Ambulating soon after surgery Rationale: Early ambulation after surgery does not increase the risk of VTE, and might help reduce the client's fear of life-threatening complications. 27. A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) Rationale: S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle. B. A friction rub Rationale: A friction rub is a high-pitched, scratchy sound that is heard can be heard in both systole and diastole. C. The third heart sound (S3) Rationale: S3 occurs early in diastole during filling of the ventricles. D. A split second heart sound S2 Rationale: A split S2 heart sound results from an audible delay between the closing of the aortic and pulmonic valves. 28.A A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. Rationale: The client should be instructed to sleep on the back or the unaffected side to lessen pressure on the affected eye. Sleeping on the abdomen is not recommended. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery. C. Bend at the waist to pick objects up from the floor. Rationale: The nurse should instruct the client to avoid activities that increase intraocular pressure, such as bending at the waist. The client should bend at the knees to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids. Rationale: White, crusty drainage on the eye lid is an expected finding. The client should notify the surgeon if she has green or yellow drainage on the eyelids or eyelashes. 29. A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown. B. Decreased level of serum lipids Rationale: An increase serum lipid level is an expected finding for FES, although the reason for this finding is unknown. C. Decreased erythrocyte sedimentation rate (ESR) Rationale: An increased ESR is an expected finding for FES, although the reason for this finding is unknown. D. Increased platelet count Rationale: A decreased platelet count is an expected finding for FES, although the reason for this finding is unknown. 30.A A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? A. "Don't worry; most clients dislike the prep more than the procedure itself." Rationale: This response is an example of unwarranted or false reassurance. It does not encourage the client to explain his feelings. B. "Before the examination, your provider will give you a sedative that will make you sleepy." Rationale: This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure. C. "I know you’re anxious, but this procedure is recommended for people your age." Rationale: This statement is true. Routine screening for polyps and colon cancer is recommended starting at age 50; however, the nurse is changing the subject and this does not encourage the client to explain his feelings. D. "After you have signed the consent form, we can talk more about this." Rationale: The nurse should ensure that the client understands and agrees to the procedure before the client signs the consent form. 31. A nurse is caring for an older adult client who has had surgery for an intestinal obstruction and has an NG tube to wall suction. Which of the following interventions should the nurse include in the client's postoperative plan of care? (Select all that apply.) A. Discontinue suction when assessing for peristalsis B. Irrigate the NG tube with 0.9% sodium chloride irrigation solution. C. Place sequential compression devices on the bilateral lower extremities. D. Reposition the client from side to side every 2 hr. E. Encourage the use of an incentive spirometer every 2 hr while the client is awake. Rationale: Discontinue suction when assessing for peristalsis is correct. The nurse should turn off suction while auscultating the abdomen to determine the return of peristalsis because the suction masks any present bowel sounds.Irrigate the NG tube with 0.9% sodium chloride irrigation solution is correct. The client requires the NG tube for gastric decompression, so the nurse must make sure it remains patent. Irrigating the NG tube with normal saline irrigation solution every 4 hr will ensure patency.Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow for clients who have mobility limitations and help prevent venous thromboembolism in the lower extremities.Reposition the client from side to side every 2 hr is correct. The nurse should reposition the client from side to side at least every 2 hr but should also assist with early ambulation to improve ventilation and help mobilize secretions.Encourage the use of an incentive spirometer every 2 hr while the client is awake is incorrect. Use of the incentive spirometer helps prevent atelectasis. The client should use the device each hour while awake. 32.A A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis. The nurse should expect that the provider will prescribe which of the following diagnostic tests first? A. Sputum culture for acid-fast bacillus (AFB) Rationale: A sputum culture is used to confirm a diagnosis of tuberculosis, but it is not the first diagnostic test the provider will prescribe. B. Nucleic acid amplification test (NAAT) Rationale: The CDC recommends that the NAAT test replace other diagnostic screening tests for tuberculosis. The test is performed on a client's sputum. C. CT scan Rationale: A CT scan aids in confirmation of a diagnosis of pulmonary tuberculosis, but it is not the first diagnostic test the provider will prescribe. D. Chest x-ray Rationale: A chest x-ray is used for diagnosis of active pulmonary tuberculosis as well as for the detection of old, healed lesions, but it is not the first diagnostic test the provider will prescribe. 33.A A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis? A. Myringotomy Rationale: A myringotomy is a procedure that takes about 15 min. An incision is made in the tympanic membrane to reduce pressure and promote fluid drainage. Clients who undergo this procedure are not at risk for deep-vein thrombosis. B. Laparoscopic appendectomy Rationale: Laparoscopic appendectomy is a low risk procedure. Clients who undergo this procedure are not at risk for deep-vein thrombosis. C. Hip arthroplasty Rationale: Clients who are postoperative following orthopedic procedures of the lower extremities and clients who were placed in the lithotomy position for a procedure, such as for gynecological or urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively. D. Cataract extraction Rationale: Clients who are postoperative following cataract extraction are at risk for a number of complications, including infection and damage to the eye due to increased intraocular pressure, but are not at risk for deep-vein thrombosis. 34.A A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? A. Serosanguineous drainage Rationale: Purulent drainage, not serosanguineous drainage, from the pin sites is an indication of infection. B. Mild erythema Rationale: Redness is an expected finding after pin insertion. Severe redness at the pin sites is an indication of infection. C. Warmth Rationale: Warmth is an expected finding after pin insertion. Coolness of the extremity, however, could indicate neurovascular compromise. D. Fever Rationale: Manifestations of inflammation and infection at the pin sites include fever, purulent drainage, odor, loose pins, and tenting of the skin around the pin sites.