Hesi lpn adn entrance exam mobility e xams
2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type
II has a syncopal episode. Her vital signs are within normal limits and her sugar is
325 mg/dL. what intervention should the nurse implement first? - ANSWER
administer regular insulin per sliding scale
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What
interventions should the nurse expect to implement to establish hydration in the
immediate postoperative period? - ANSWER nipple feedings with glucose water
a 3 year-old admitted with fever of unknown (FUO) has begun vomiting in the past
half hour. The child's temp. is 101.8F, and the last does of antipyretic medication
was given 5 hours ago. the child has prescriptions of acetaminophen (Tylenol) 160
mg per 5 mL elixir or 16o mg suppositories PRN fever or pain. what action should
the nurse take at this time? - ANSWER make the child NPO and hold all mediations
until the vomiting has stopped.
4 hours after administration of 20U of regular insulin, the client becomes shaky and
diaphoretic. what action should the nurse take? - ANSWER give the client crackers
and milk
a 6-month child with bronchiolitis is admitted to the hospital. In monitoring the
respiratory status of this child, which symptom indicates the nurse that he is
experiencing respiratory distress? - ANSWER A high pitched cry.
An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast.
Which cereal should the nurse provide? - ANSWER rice
total number of confirmed pregnancies regardless of the outcome - ANSWER
Gravida
number of births after 20 weeks - ANSWER Para
pregnant for the first time - ANSWER primigravida
a 26 year old gravida-4, para-0 had a spontaneous abortion at 9 weeks gestation. at
one house post dilation and curettage (D&C) the nurse assess the vital signs and
vaginal bleeding. the client begins to cry softly. how should the nurse intervene? -
ANSWER express sorrow for the clients grief and offer to sit with her.
A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells
the nurse that she is confused about when she and her husband can return to having
sexual intercourse. What info should the nurse reinforce with this client? - ANSWER
they can have intercourse when the episiotomy is healed and the lochial flow has
stopped
, 36 hours after delivery, the nurse determines a clients fundus is just above the
umbilicus and displaced to the right of midline. what action should the nurse take
first? - ANSWER palpate the bladder for distention
a 60 year old client with cancer of the liver is in hepatic coma and unresponsive.
what should the nurse say to family members were inquiring about the condition of
their loved one? - ANSWER "Your loved ones condition is very critical, and there
has been no response in the last 24 hours"
a 67 year old woman who lives alone tripped on a rug in her home and fractured her
right hip. the nurse knows that which predisposing factor contributes to the
occurrence of hip fractures among elderly women. - ANSWER osteoporosis
resulting from hormonal changes.
a 75 year old male client with Alzheimer disease is admitted to an extended care
facility. what intervention should the nurse include into the his clients Nursing care
plan? - ANSWER plan to have the same nursing staff provide care for the client
whenever possible.
an 82-year old client is admitted to the hospital with a fractured right hip. following
surgical repair, a footboard is placed at the clients feet. what is the reason the nurse
will offer concerning the footboard? - ANSWER footboard is used to prevent foot
drop.
An adult female client is admitted to the psychiatric unit with diagnosis of major
depression. After 2 weeks of antidepressant medication therapy, the nurse notices
the client has more energy, is giving her belongings away to her visitors, and is in an
overall better mood. Which intervention is best for the nurse to implement? -
ANSWER ask the client if she has had any recent thoughts of harming herself.
an adult male client tells the nurse that he believes someone is trying to obtain his
cpu records, which his wife reports are recreational in nature. the client insist that an
elaborate alarm system needs to be installed in his home. the nurse knows that this
client is exhibiting which signs or symptoms? - ANSWER delusions of persecution
After a change of shift report, the nurse makes rounds on a postoperative unit.
Which client finding necessitates the immediate attention of the nurse? - ANSWER
A. A client who is having bright red drainage from the rectum following a
colonoscopy with a polyp removal
After a client returns from Hemodialysis, the nurse measures the client's weight and
notes a 3-poundweight loss from the pre-dialysis weight. The client reports feeling
weak and fatigued. What action should the nurse take next? - ANSWER A. Measure
the client's blood pressure
After morning dressing changes are completed, a male client who has paraplegia
contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best
for the nurse to assign to the unlicensed assistive personnel? - ANSWER B. Provide
perianal care and collect clean linens for the dressing change
2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type
II has a syncopal episode. Her vital signs are within normal limits and her sugar is
325 mg/dL. what intervention should the nurse implement first? - ANSWER
administer regular insulin per sliding scale
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What
interventions should the nurse expect to implement to establish hydration in the
immediate postoperative period? - ANSWER nipple feedings with glucose water
a 3 year-old admitted with fever of unknown (FUO) has begun vomiting in the past
half hour. The child's temp. is 101.8F, and the last does of antipyretic medication
was given 5 hours ago. the child has prescriptions of acetaminophen (Tylenol) 160
mg per 5 mL elixir or 16o mg suppositories PRN fever or pain. what action should
the nurse take at this time? - ANSWER make the child NPO and hold all mediations
until the vomiting has stopped.
4 hours after administration of 20U of regular insulin, the client becomes shaky and
diaphoretic. what action should the nurse take? - ANSWER give the client crackers
and milk
a 6-month child with bronchiolitis is admitted to the hospital. In monitoring the
respiratory status of this child, which symptom indicates the nurse that he is
experiencing respiratory distress? - ANSWER A high pitched cry.
An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast.
Which cereal should the nurse provide? - ANSWER rice
total number of confirmed pregnancies regardless of the outcome - ANSWER
Gravida
number of births after 20 weeks - ANSWER Para
pregnant for the first time - ANSWER primigravida
a 26 year old gravida-4, para-0 had a spontaneous abortion at 9 weeks gestation. at
one house post dilation and curettage (D&C) the nurse assess the vital signs and
vaginal bleeding. the client begins to cry softly. how should the nurse intervene? -
ANSWER express sorrow for the clients grief and offer to sit with her.
A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells
the nurse that she is confused about when she and her husband can return to having
sexual intercourse. What info should the nurse reinforce with this client? - ANSWER
they can have intercourse when the episiotomy is healed and the lochial flow has
stopped
, 36 hours after delivery, the nurse determines a clients fundus is just above the
umbilicus and displaced to the right of midline. what action should the nurse take
first? - ANSWER palpate the bladder for distention
a 60 year old client with cancer of the liver is in hepatic coma and unresponsive.
what should the nurse say to family members were inquiring about the condition of
their loved one? - ANSWER "Your loved ones condition is very critical, and there
has been no response in the last 24 hours"
a 67 year old woman who lives alone tripped on a rug in her home and fractured her
right hip. the nurse knows that which predisposing factor contributes to the
occurrence of hip fractures among elderly women. - ANSWER osteoporosis
resulting from hormonal changes.
a 75 year old male client with Alzheimer disease is admitted to an extended care
facility. what intervention should the nurse include into the his clients Nursing care
plan? - ANSWER plan to have the same nursing staff provide care for the client
whenever possible.
an 82-year old client is admitted to the hospital with a fractured right hip. following
surgical repair, a footboard is placed at the clients feet. what is the reason the nurse
will offer concerning the footboard? - ANSWER footboard is used to prevent foot
drop.
An adult female client is admitted to the psychiatric unit with diagnosis of major
depression. After 2 weeks of antidepressant medication therapy, the nurse notices
the client has more energy, is giving her belongings away to her visitors, and is in an
overall better mood. Which intervention is best for the nurse to implement? -
ANSWER ask the client if she has had any recent thoughts of harming herself.
an adult male client tells the nurse that he believes someone is trying to obtain his
cpu records, which his wife reports are recreational in nature. the client insist that an
elaborate alarm system needs to be installed in his home. the nurse knows that this
client is exhibiting which signs or symptoms? - ANSWER delusions of persecution
After a change of shift report, the nurse makes rounds on a postoperative unit.
Which client finding necessitates the immediate attention of the nurse? - ANSWER
A. A client who is having bright red drainage from the rectum following a
colonoscopy with a polyp removal
After a client returns from Hemodialysis, the nurse measures the client's weight and
notes a 3-poundweight loss from the pre-dialysis weight. The client reports feeling
weak and fatigued. What action should the nurse take next? - ANSWER A. Measure
the client's blood pressure
After morning dressing changes are completed, a male client who has paraplegia
contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best
for the nurse to assign to the unlicensed assistive personnel? - ANSWER B. Provide
perianal care and collect clean linens for the dressing change
