INET HESI RN V3 ACTUAL TEST SCREENSHOTS PROCTORED EXAM 2024/2025 SOLUTION GUARANTEED GRADE A+

INET HESI RN V3 ACTUAL TEST SCREENSHOTS PROCTORED EXAM 2024/2025 SOLUTION GUARANTEED GRADE A+ Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a colostomy bag? Observe insertion site A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness and fatigue. Which lab test should the nurse monitor? Hemoglobin A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. Which action should the nurse take? Review the need for the UAP to wear a face mask while in close contact with the client. A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? Serum electrolytes. A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? Withhold this dose. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? Practice using muscle relaxation techniques. The lower limit for normal plasma glucose levels during the first 72 hours after birth is 40 to 45 mg/dL (2.2 to 2.5 mmol/L). Hypoglycemia is most common in the macrocosmic or LGA infant, but the nurse should monitor blood glucose levels in all infants of mothers with known or suspected diabetes. Hypoglycemia most frequently occurs within the first 1 to 6 hours after birth. Signs of hypoglycemia include jitteriness, apnea, tachypnea, hypotonia, decreased activity, and cyanosis. A Ballard score maturity assessment of 37 corresponds to 37 weeks gestation, which is a early term. Early term (37 0/7 through 38 6/7 weeks). Compared with full-term infants, early-term infants are at increased risk for morbidity and mortality. Normal findings include acrocyanosis, soft fontanelles, Mongolian spots, and Apgar scores of 7 to 10. The nurse is reviewing the possible complications that can occur for an infant of a diabetic mother. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the infant of a diabetic mother is at risk for hyperbilirubinemia, respiratory distress syndrome, and cardiomyopathy Glucose level immediately after birth and then at 30 min, 1 hour, 2 hours, 4 hours, 8 and 12 hours and if symptoms suggest hypoglycemla. • Breastfeed Immediately once stable, then on demand. If unstable, may feed breast milk via orogastric tube. • If two feeding attempts fall to increase the glucose levels or if symptoms of hypoglycemia develop, apply dextrose (sugar) gel Inside the baby's cheek. • If the above are ineffective, IV glucose should be administered to maintain glucose levels above 45 mg/dL (2.5 mmol/L). Monitor for Respiratory distress, contact respiratory therapy for ABG and oxygen therapy, blood glucose level, keep in warmer with Bilirubin lights, monitor temperature every 30 minutes, feed immediately The nurse is reviewing lab work and nurses' notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? Select all that apply. A Keep infant In warmer with bilirubin lights to maintain temperature of 97.6° B Inform the mother that the baby is stable enough to take out of the warmer D Explain to the mother that the baby's respiratory rate needs to be below 60 1 E Observe for signs of respiratory distress and monitor oxygenation by pulse c Day 1 1800: The client Is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational dlabetes. Following a spontaneous vaginal birth, she received Apgar scores of 7 at 1 min and 8 at 5 min. The client weighs 4036.97 g (8 Ibs. 9 oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30 min of age. Axillary temperature 96° F (35.6° C), pulse 140, respiratory rate 80. Blood glucose 35 mg/dL (1.9 mmol/L), bilirubin level 7 mg/dL (119.73 umol/L). Fontanelles soft, Mongolian spot noted on lower back, Ballard maturity rating 37 weeks. Proactive lactation management, strategies, support, and follow-up for late-preterm infants and some early term infants are important components that affect breastfeeding success. Prophylactic phototherapy is often used in preterm infants to prevent a significant increase in serum bilirubin levels. It is also recommended that healthy late-preterm and term infants (23S weeks of gestation) receive follow-up care and assessment of bilirubin within 3 days of discharge. Late preterm infants of a diabetic mother need to be monitored more closely. Parents are taught to evaluate the number of voids and evidence of adequate breastfeeding after the infant is home. Notify the primary care practitioner if there are indications the infant is not feeding well, is difficult to arouse for feedings, or is not voiding and stooling adequately. Seeing the obstetrician at 8 weeks is contraindicated, as most postpartum visits are between 4 and 6 wecks. ACOG recommends that postpartum care be an ongoing process in which each woman's individual needs determine the services and support she receives. Early follow-up is warranted for women who experienced complications such as hypertensive disorders of pregnancy, those with chronic health conditions, women at high risk for depression, and breastfeeding mothers who are experiencing feeding problems, Click to highlight the notes that demonstrate a positive outcome. Day 2 0630: Vitals have remained stable throughout the night. Oxygen 98% on nasal canal. Mother to breastfeed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60 mg/dL (3.3 mmol/L), temp 97.8° F (36.6° C) when returned to warmer and Bili light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal llmits, Direct bilirubin 5 mg/dI(5 umol/L), Discharge teaching Initlated, with goal of discharging infant and mother on day 3. Studies confirm the importance of maintaining serum glucose levels above 45 mg/dL (25 mmol/1) in hyper insulinemic infants with hypoglycemia to prevent serious neurologic sequel. Blood glucose levels continue to improve. Direct bilirubin improved. Other signs of improvement include a normal temperature for at least 8 hours, improved respiratory status with no signs of respiratory distress syndrome and feedings are well tolerated. A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet? Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. -The warfarin dose is prescribed and adjusted based on the client's normal consumption of foods containingvitamin K (an essential clotting factor that counteracts the effects of warfarin), so the client should eat a consistent amount of vitamin K food sources on a daily basis. The nurse is planning care for a client who admits having suicidal thoughts. Which client behaviour indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of Improvement in affect. A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (PAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmH. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement? Prepare for rapid sequence Intubation. The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding care of this client? Avoid urinary catheterization. The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement? Allow time for the behavior and then redirect the client to other activities. A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? What are the voices saying?" The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize? Neurovascular checks. A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behaviour, which client problem should the nurse include in the plan of care? Ineffective coping related to denial. .while making rounds, charge nurse notices that a young adult client with asthma who was admitted Esther day he sitting on the side of the bed and loaning over the bedside table the client is currently receiving oxygen at 2 L per minute via Nasal Cannula the client please wheezing and is Pursed-lip Breathing. which intervention should the nurse implement? administer a nebuliser treatment The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understands the prescribed diet? Roasted turkey, canned vegetables. The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? Push the undiluted Dextrose slowly through the currently infusing IV. Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress Measure BP, encourage the client to drink, dehydration, urine output, capillary refill The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? Encourage the parents to allow the child to continue attending swimming lessons with supervision A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Persistent coughing while drinking A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counselling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, which action is best for the charge nurse to take? Allow the impaired nurse to return to work and monitor medication administration. .The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and radial pulses that are weak and thready. Which action should the nurse take? Place the oximeter clip on the earlobe to obtain the oxygen saturation reading. After receiving report, the nurse can most safely plan to assess which client last? An adult client with no postoperative dralnage in the Jackson-Pratt drain with the bulb compressed. The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? Ensure that the infant's crib mattress is firm. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) Stridor Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A disoriented client removed the mesh wrapped IV line for the second time. À male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should he nurse take? Reassure the client that skin flushing is a common side effect of the medication. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? Reference Range White Blood Cell (WBC) [Reference Range: 5000-10,000/mm° (5-10 x 109/L)] Moderate amount of foul-smelling lochia The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet? Low fat dairy products. A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? Measure urinary output every hour. The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action? Start two large bore IV catheters and review Inclusion criteria for IV Abrinolytic therapy. Three hours after birth, a new born becomes jittery and tachypneic. What should the nurse do first? Obtain a capillary glucose level. .A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? Position bedside table so the client can lean across It. The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression she only gets 2-3 hours of sleep due to nightmares about the crash . She feels that she is "jumpy" after the accident, especially when she is in the car. I feel so sad that I can't seem to feel anything at all. After the examination by the physician, the client was diagnosed with depression and post-traumatic stress disorder. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnosis and medication. How can the nurse build a therapeutic relationship with the client? B The nurse can communicate acceptance of the client as she is. C The nurse can be open, honest, and sincere. D The nurse can establish a meaningful connection During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing from the statement by selecting from the list of options provided. client represents suicidal Ideation and should be followed up with an assessment of risk factors for sulcide What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? Select all that apply. Help the client enlist the help of friends and family. Refer the client for cognitive behavioural therapy. Have the client sign a no-suicide contract. The nurse observes an unlicensed assistive personnel (UP) who is preparing to provide personal care for a client who requires contact precautions. The UP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? Confirm that the gown is tied securely at the neck and waist. An unlicensed assistive personal lives the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP behavior place the action in the order from first on top to last on the bottom Note date and time of the behaviour discuss the issue privately with the UAP plan for scheduled break times evaluate the UNP for signs of improvement A client is receiving continuous ambulatory peritoneal dialysis since the arteryVenous graft in the right of is no longer available to use were haemodialysis the client has lost weight, has increasing peripheral Edema, and has a serum albumin level of 1.5 GB deal which intervention is the priority for the nurse to implement? Ensure the client receives frequent small meals containing complete proteins What nursing intervention is particularly indicated for the second stage of labour? Assisting the client to push effectively so that expulsion of the fetus can be achieved The nurse leading a care team in any medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which task should the nurse assign to the PN? Titrate oxygen to prescribe parameters. CONTINUED..