HESI NCLEX Questions With All Complete And Verified Solution Guide.

A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: Calling the physician Inserting an oral airway Turning the client on her side Noting the time of the seizure - correct answer C If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of: Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools - correct answer C GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER. A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure? Administering oxygen Monitoring the blood pressure Administering antidysrhythmic medications Monitoring the client's level of consciousness - correct answer A Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen. A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first: Ask the client to sign a no-harm contract Ask the client to report any suicidal thoughts immediately Place the client under suicide precautions with 15-minute checks Check the dressings that were placed over the client's wrists in the emergency department - correct answer D The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide. The client would be asked to sign a no-harm contract, but this would not be the first action. Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract. A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply. Normal deep tendon reflexes Improved skeletal muscle tone Absence of paresthesias in the lower extremities Clear sounds in the lower lung fields bilaterally pO2 of 85 mm Hg and Pco2 of 40 mm Hg - correct answer D E Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome. A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. "I should limit activity as much as I possibly can." "If I have trouble breathing, I need to call the doctor." "I need to drink lots of fluids to keep my mucus thin." "I can apply Vaseline to my nose if the oxygen dries it out." "I should wear a scarf over my nose and mouth in cold weather." "If I get a flu shot, I don't have to worry about being around people with colds." - correct answer A D F Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures. A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while