Hesi Exit RN - OB HESI Test Bank

1. After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next? Remove the wet blankets and linen from the isolette 2. A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement? Record the respiratory finding in the clients chart as normal 3. A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? Instruct family to offer client only soft bland foods 4. A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should the nurse implement? Verify correct placement of the nasogastric tube 5. The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the clients clinical recovery? Lipase 6. While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first? take vital signs 7. The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? Avoid large crowded areas during the colder months of the year 8. The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? Position the infant on the stomach occasionally when awake and active 9. A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? Perform a fundal massage 10. A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? Decrease serum creatine 11. A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse? Fruity breath 12. When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD), which approach should the nurse use? Explain that the client may be placed in five positions 13. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? Initiate an ethics committee review 14. In observing a clients face, which assessment finding requires the most immediate intervention by the nurse? Oral mucosa is cyanotic Blue lips 15. The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? Complete a thorough neurological assessment 16. Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? Ensure continued sterility of the specimen container 17. The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? Hold the chair 18. A client with cancer complains of fever, chills, malaise, and headache following administration of a colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? Monitor lab values for an increase in WBCs 19. Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? Serum liver enzymes 20. Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? I have a headache that gets worse when I sit up 21. The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? Advise to sit up slowly from a reclining position 22. A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history form the child's mother, the recent occurrence of what illness is most significant? Sore throat 23. Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 24. The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? hyperaldosteronism caused by decreased degradation of the hormone by the liver. 25. The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological mechanism supports the client's clinical presentation? A weakened diaphragm with high abdominal pressure 26. An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client? Maintain prescribed eye drop regimen 27. The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A new graduate should be able to complete a pre-procedural checklist and get this client to the catheterization lab. 28. Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL should the nurse administer? 0.4 D/HX2ml 29. A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? knee chest position 30. A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? Position client with head flat and feet elevated 31. The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)> the nurse includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? Exercise in the swimming pool 32. The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? The protein intake should be decreased to prevent nitrogenous waste Buildup 33. A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which neurovascular assessment requires immediate intervention by the nurse? Unequal bilateral hand grip strengths 34. As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids on which pathophysiological process? Decreasing the formation and secretion of pancreatic enzymes 35. A male client being treated for testicular cancer with chemotherapy has decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? Advise the client that the treatment is having beneficial effect 36. The nurse plans to administer a bolus dose of IV heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer? 9000 37. A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? stress and caffine 38. A 6-year old child who has a medical diagnosis of attention deficit hyperactivity disorder ADHD has been talking has been taken the psychostimulant methylphenidate Ritalin for two weeks which assessment finding providing by the child mothers most significant in planning nursing care for this child has not had a bm in 2 days 39. A client is receiving a continuous infusion of normal saline at 125 mL/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL .. ***** 40. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? The pain and swelling can be controlled by taking this drug every day 41. The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? The nurse at night is trying to poison me with pills 42. A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates that the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the client's dressing? place sterile gauze dressing under the penrose drain 43. The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? monitor blood pressure 44. An older client with cirrhosis of the liver and hepatic failure is places on a lowsodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? decreased abdominal girth 45. Which assessment finding places a client at risk for problems associated withimpaired skin integrity? Capillary refill of 5 seconds 46. The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform? Set daily goals in the community meeting 47. A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. Normal Saline (NS) at 20 mL/hr 48. While admitting a client to the surgical unit who had a pneumonectomy 4 Hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? Ask a coworker to respond to the client whose call bell is alarming 49. A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse take? Confirmation of the autoimmune disease process 50. Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's Syndrome? Eliminate caffeine intake 51. A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung... A high pitched course sound over the trachea 52. When is the best time for the nurse to assess a client for residual urine? Immediately after the client voids 53. The nurse is reviewing a clients urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? The nurse should make the client to drink a lot of water since when the specific gravity is 1.035 it indicates that the urine is tending on the side of being concentrated and has many substances in less water in the body. 54. A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? Measure urine output 55. An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain? Fatigue 56. Which client is the most likely candidate for total parenteral nutrition? A client experiencing an acute exacerbation of Chrons disease 57. A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102.. Notify the healthcare provider and obtain a tracheostomy tray 58. An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement? Encourage the client to weight herself daily at bedtime 59. An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Recommend installing gran bars by toilets, bathtub, and shower Have the home health nurse assess the home for fall risk & Wear an emergency response pendant at home 60. A client arrives in the emergency department (ED) with deep, full-thickness burns over the anterior surface of both upper legs. Which priority intervention should the nurse implement? Give IV bolus of normal saline 61. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? ST elevation in three leads 62. The charge nurse is making client assignments in the intensive care department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12- week internship, which client should the nurse assign the new graduate RN A client with chest tubes secondary to a stab wound to the chest 63. The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition... Reassure the mother that beginning to replace the prepared foods with some table foods can provide the needed nutrients 64. During an evening shift on a medical unit, the only nurse on the unit is busy with unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personal (UAP), reports to the nurse that a healthcare provider is on the telephone... Tell the healthcare provider the nurse will return the phone call as soon as possible 65. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first? Elevate the client's right hand on one or two pillows 66. A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care... Peritonitis 67. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol how should the nurse respond? This mediation will have no effect on your unborn child 68. The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side Tennis shoes with Velcro 69. A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? An distended bladder 70. During the admission assessment of a terminally ill client, the client expresses being an agnostic... Document the statement in the clients spiritual assessment 71. An older client has been diagnosed with chronic venous insufficiency. To promote venous return, which action should the nurse encourage the client to take? Wear cotton socks and enclosed toe shoes whenever outside 72. A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective? Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm). 73. A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client rations, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the states board of nursing? Consult with appropriate state legislative representative 74. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which is most important for the nurse to implement? Continue resuscitative efforts 75. A client tells the nurse that he is "very nervous" about the surgery he is scheduled to have in the morning. Which actions should the nurse implement? Notify the healthcare provider about the clients expressed fears and anxiety 76. The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling... Ankle brachial index 77. The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? An adult who has a collapsed lung relatd to a fall from a ladder 8 hours ago.. 78. A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior... Ignores other children in the play area 79. A client who in an avid hiker expresses concern about losing too much potassium while hiking... Dried apricots Seedless raisins Dried bananas 80. The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups? Designation of clinics conveniently located in target neighborhoods 81. While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing... Insert the catheter an additional inch 82. A client who takes nonsteriodal anti-inflammatory drugs (NSAIDs) every day for rheumatoid arthritis is being treated for anemia... protect skin from bruising 83. Which long-term outcome is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis? Manages activities of daily living independently 84. A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority? Risk for injury related to uterine atony 85. A client is hospitalized with inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid... Monitor for bloody diarrheal stools 86. When is it most important for the nurse to assess a pregnancy clients deep tendon reflexes (DTRs)? If the client has an elevated blood pressure 87. When preparing a client who is to undergo a resection of a lelomyosarcoma of the uterus, the nurse notices that aplxaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention? Bleeding gums 88. In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include? Observe client during movement of the affected joints 89. When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? Increases the amount of dopamine available for muscles to function correctly 90. A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition... Encourage the client to reflect on personal goals and priorities 91. The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? Kidney beans 92. The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficle in the stool. Which action should the nurse take before administering the first dose? Assess body temperature 93. An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused Start intravenous of normal saline 94. While interviewing an elderly client, the nurse observes that the clients hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding? Muscle flaccidity 95. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client? Risk for injury 96. The charge nurse is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignments is the best to assign to the PN? one-on-one observation of a suicidal client 97. A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125... Maintain prescribed fluid restriction 98. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? Serum sodium level of 120 mg/Dl 99. Prior to obtaining an axillary temperature, the nurse should perform which action? Place a protective sheath over the thermometer 100. A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. The promote parent-infant attachment behaviors, which intervention should the nurse implement?... Encourage rooming-in while in the hospital 101. A client with uremia is experiencing uremic frost. Which action should the nurse implement? Explain that hemodialysis is needed 102. A client with a history of heart failure and type 1 diabetes mellitus is admitted with unstable angina. Which problem requires the most immediate intervention by the nurse? Acute anginal pain 103. The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been ... Stop using the ointment and encourage complete drying of feet and wearing clean socks 104. While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement? Reduce the stimuli in the area before continuing the teaching 105. In assessing a 70-year-old client with Alzheimer's disease, the nurse notes that the client has deep inflamed cracks at the corners of the mouth. What intervention should the nurse include in this clients plan of care? Ensure that the client gets adequate B vitamins in foods or supplements 106. A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care? Airway, Monitor for tracheal deviation and swelling at biopsy site 107. A client with HIV begins active labor at 38 weeks gestation and recieves a prescription for Zidovvudine 2mg/kg IV, to be administered over 1 hour. The client weighs 185 lbs. Based on the clients weight, how many mg should the nurse prepare to administer... 168 If 1 lb = 0.452 kg Then 185lbs into kg = 84 kg If ordered dose is 2mg/kg zidovudine , which means for -1 kg of weight of patient ordered dose = 2 mg Then 84 kg of patient will have dose of = 84×2 = 168 mg Thus dose which is given to patient by nurse in mg = 168 mg Answer is 168 mg. 108. The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? Monitor for signs of bleeding 109. The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete? Auscultate the client's bowel sounds 110. The nurse determines that an older female client has kyphosis, has lost two inches of height in the last three years, and has a recent history of spinal vertebral fractures... Progressive weakening of the muscle fibers of the lower back 111. The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be retrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager?... Advise the staff nurse to remove the restrains from the client's wrists 112. The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfram. What information should the client acknowledge understanding? Remain alcohol free for 12 hours prior to the first dose 113. A client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. The client states, "I just had a little case of the sniffles and a bit of a sore throat Muscle weakness is an elderly sign of crisis and means that you need more rest 114. After falling down the basement steps, a client is brought to the emergency room. X-rays confirm that the client's right leg is fractured... Change in color 115. A client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left fields... a. Elevate the head of the bed 45 degrees Apply a high-glow oxygen by face mask Place in Trendelenburg position & Obtain a chest tube insertion kit