HESI RN MED SURG VERSION A &
VERSION B 2024-2025 ACTUAL EXAM |
VERIFIED ANSWERS WITH RATIONALES
| ALREADY A+GRADE
Theaxnurseaxisaxassessingaxaaxclientaxwithaxacuteaxpancreatitis.axWhichaxfindingaxrequiresaxtheaxm
ostaximmediateaxinterventionaxbyaxtheaxnurse?
A.
Theaxclient'saxamylaseaxlevelaxisaxthreeaxtimesaxhigheraxthanaxtheaxnormalaxlevel.
ax B.
Theaxclientaxhasaxaaxcarpalaxspasmaxwhenaxtakingaxaaxbloodaxpressure.
ax C.
Onaxaax1axtoax10axscale,axtheaxclientaxtellsaxtheaxnurseaxthataxheraxepigastricaxpainaxisaxatax7.
ax D.
Theaxclientaxstatesaxthataxsheaxwillaxcontinueaxtoaxdrinkaxalcoholaxafteraxgoingaxhome.ax-axB
Theaxnurseaxisaxassessingaxaaxclientaxwithaxacuteaxpancreatitis.axWhichaxfindingaxrequiresaxtheaxm
ostaximmediateaxinterventionaxbyaxtheaxnurse?
Rationale:AaxpositiveaxTrousseauaxsignaxindicatesaxhypocalcemiaaxandaxalwaysaxrequiresaxfurt
heraxassessmentaxandaxintervention,axregardlessaxofaxtheaxcauseax(40%axtoax75%axofaxthoseaxwit
haxacuteaxpancreatitisaxexperienceaxhypocalcemia,axwhichaxcanaxhaveaxserious,axsystemicaxeff
ects).axAaxkeyaxdiagnosticaxfindingaxofaxpancreatitisaxisaxserumaxamylaseaxandaxlipaseaxlevelsaxth
ataxareaxtwoaxtoaxfiveaxtimesaxhigheraxthanaxtheaxnormalaxvalue.axSevereaxboringaxpainaxisaxanaxexp
ectedaxsymptomaxforaxthisaxdiagnosis,axbutaxdealingaxwithaxtheaxhypocalcemiaaxisaxaaxpriorityaxov
eraxadministeringaxanaxanalgesic.axLong-
termaxplanningaxandaxteachingaxdoaxnotaxhaveaxtheaxsameaximmediateaximportanceaxasaxaaxposit
iveaxTrousseauaxsign.
Aax55-year-
oldaxmaleaxclientaxhasaxbeenaxadmittedaxtoaxtheaxhospitalaxwithaxaaxmedicalaxdiagnosisaxofaxchron
icaxobstructiveaxpulmonaryaxdiseaseax(COPD).axWhichaxriskaxfactoraxisaxtheaxmostaxsignificantaxin
axthe axdevelopment axofaxthisaxclient'saxCOPD?
A.
Theaxclient'saxfatheraxwasaxdiagnosedaxwithaxCOPDaxinaxhisax50s.
ax B.
Aaxcloseaxfamilyaxmemberaxcontractedaxtuberculosisaxlastaxyear.
ax C.
Theaxclientaxsmokesaxoneaxtoaxtwoaxpacksaxofaxcigarettesaxperaxday.
ax D.
Theaxclientaxhasaxbeenax40axpoundsaxoverweightaxforax15axyears.ax-axC
Rationale:Smoking,axconsideredaxtoaxbeaxaaxmodifiableaxriskaxfactor,axisaxtheaxmostaxsignificanta
xriskaxfactoraxforaxthe axdevelopmentaxofaxCOPD.axTheaxexactaxmechanismaxofaxgeneticaxandaxher
editaryaximplicationsaxforaxtheaxdevelopmentaxofaxCOPDaxisaxstillaxunderaxinvestigation,axalthoug
haxexposureaxtoaxsimilaraxpredisposingaxfactorsax(e.g.,axsmokingaxoraxinhalingaxsecondhandaxs
moke)axmayaxincreaseaxtheaxlikelihoodaxofaxCOPDaxincidenceaxamongaxfamilyaxmembers.axOpti
onsaxBaxandaxDaxdoaxnotaxexceedaxtheaxrisksaxassociatedaxwithaxcigaretteaxsmokingaxinaxtheaxdeve
lopmentaxofaxCOPD.
,Inaxassessingaxaaxclientaxdiagnosedaxwithaxprimaryaxaldosteronism,axtheaxnurseaxexpectsaxtheaxla
boratoryaxtestaxresultsaxtoaxindicateaxaaxdecreasedaxserumaxlevelaxofaxwhichaxsubstance?
A.
Sodium
axB.axPhosph
ate
axC.axPotas
sium
ax D.
Glucoseax-axC
Rationale:Clientsaxwithaxprimaryaxaldosteronismaxexhibitaxaaxprofoundaxdeclineaxinaxserumaxlev
elsaxofaxpotassium;axhypokalemia;axhypertensionaxisaxtheaxmostaxprominentaxandaxuniversalaxsig
n.axTheaxserumaxsodiumaxlevelaxisaxnormalaxoraxelevated,axdependingaxonaxtheaxamountaxofaxwate
raxresorbedaxwithaxtheaxsodium.axOptionaxBaxisaxinfluencedaxbyaxparathyroidaxhormoneax(PTH).ax
OptionaxDaxisaxnotaxaffectedaxbyaxprimaryaxaldosteronism.
TheaxnurseaxisaxcompletingaxanaxadmissionaxinterviewaxforaxaaxclientaxwithaxParkinsonaxdisease.a
xWhichaxquestion axwillaxprovide axadditionalaxinformationaxaboutaxmanifestations axthataxthe axclien
taxisaxlikelyaxtoaxexperience?
A.
"Haveaxyouaxeveraxexperiencedaxanyaxparalysisaxofaxyouraxarmsaxoraxlegs?"
ax B.
"Doaxyouaxhaveaxfrequentaxblackoutaxspells?"
ax C.
"Haveaxyouaxeveraxbeenaxfrozenaxinaxoneaxspot,axunableaxtoaxmove?"
ax D.
"Doaxyouaxhaveaxheadaches,axespeciallyaxonesaxwithaxthrobbingaxpain?"ax-
axCaxRationale:ClientsaxwithaxParkinson axdisease axfrequentlyaxexperience axdifficultyaxinaxiniti
ating,
maintaining,axandaxperformingaxmotoraxactivities.axTheyaxmayaxevenaxexperienceaxbeingaxroote
daxtoaxtheaxspotaxandaxunableaxtoaxmove.axParkinsonaxdiseaseaxdoesaxnotaxtypicallyaxcauseaxoptio
naxA,axB,axoraxD.
Clientaxcensusaxisaxoftenaxusedaxtoaxdetermineaxstaffingaxneeds.axWhichaxmethodaxofaxobtai
ningaxcensusaxdeterminationaxforaxaaxparticularaxunitaxprovidesaxtheaxbestaxformulaaxforaxde
terminingaxlong-rangeaxstaffingaxpatterns?
A.
Midnightaxcensus
ax B.
Oncomingaxshiftaxcensus
ax C.
Averageaxdailyaxcensus
ax D.
Hourlyaxcensusax-axC
Rationale:Anaxaverageaxdailyaxcensusaxisaxdeterminedaxbyaxtrendaxdataaxandaxtakesaxintoaxacc
ountaxseasonalaxandaxdailyaxfluctuations,axsoaxitaxisaxtheaxbestaxmethodaxforaxdeterminingaxstaffi
ngaxneeds.axOptionsaxAaxandaxBaxprovideaxdataaxataxaaxcertainaxpointaxinaxtime,axandaxthataxdataax
couldaxchange
,quickly.axItaxisaxunrealisticaxtoaxexpectaxtoaxobtainaxanaxhourlyaxcensus,axandaxsuchaxdataaxwouldax
onlyaxprovideaxinformationaxaboutaxaaxcertainaxpointaxinaxtime.
Aaxmaleaxclientaxhasaxjustaxundergoneaxaaxlaryngectomyaxandaxhasaxaaxcuffedaxtracheostomyaxtu
beaxinaxplace.axWhenaxinitiatingaxbolusaxtubeaxfeedingsaxpostoperatively,axwhenaxshouldaxtheaxn
urseaxinflateaxtheaxcuff?
A.
Immediatelyaxafteraxfeeding
ax B.
Justaxprioraxtoaxtubeaxfeeding
ax C.
Continuousaxinflationaxisaxrequired
ax D.
Inflationaxisaxnotaxrequiredax-axB
Rationale:Theaxcuffaxshouldaxbeaxinflatedaxbeforeaxtheaxfeedingaxtoaxblockaxtheaxtracheaaxandaxp
reventaxfoodaxfromaxenteringaxifaxoralaxfeedingsaxareaxstartedaxwhileaxaaxcuffedaxtracheostomyaxt
ubeaxisaxinaxplace.axItaxshouldaxremainaxinflatedaxthroughoutaxtheaxfeedingaxtoaxpreventaxaspirati
onaxofaxfoodaxintoaxtheaxrespiratoryaxsystem.axOptionsaxAaxandaxDaxplaceaxtheaxclientaxataxriskaxfora
xaspiration.
OptionaxCaxplacesaxtheaxclientaxataxriskaxforaxtrachealaxwallaxnecrosis.
Aaxclientaxwithaxaaxnasogastricaxtubeaxattachedaxtoaxlowaxsuctionaxstatesaxthataxsheaxisaxnause
ated.axTheaxnurseaxassessesaxthataxthereaxhasaxbeenaxnoaxdrainageaxthroughaxtheaxnasogast
ricaxtubeaxinaxtheaxlastax2axhours.axWhichaxactionaxshouldaxtheaxnurseaxtakeaxfirst?
A.
Irrigateaxtheaxnasogastricaxtubeaxwithaxsterileaxnormalaxsaline.
ax B.
Repositionaxtheaxclientaxonaxheraxside.
ax C.
Advanceaxtheaxnasogastricaxtubeax5axcm.
ax D.
Administeraxanaxintravenousaxantiemeticaxasaxprescribed.ax-axB
Rationale:Theaximmediateaxpriorityaxisaxtoaxdetermineaxifaxtheaxtubeaxisaxfunctioningaxcorrectly,a
xwhichaxwould axthenaxrelieveaxtheaxclient'saxnausea.axTheaxleastaxinvasiveaxintervention, axrepos
itioningaxtheaxclient,axshouldaxbeaxattemptedaxfirst,axfollowedaxbyaxoptionsaxAaxandaxC,axunlessaxe
itheraxofaxtheseaxinterventionsaxisaxcontraindicated.axIfaxtheseaxmeasuresaxareaxunsuccessful,axt
heaxclientaxmayaxrequireaxoptionaxD.
Theaxnurseaxisaxconductingaxanaxosteoporosisaxscreeningaxclinicaxataxaaxhealthaxfair.axWhataxinfor
mationaxshouldaxtheaxnurseaxprovideaxtoaxindividualsaxwhoaxareaxataxriskaxforaxosteoporosis?ax(Se
lectaxallaxthataxapply.)
A.
Encourageaxalcoholaxandaxsmokingaxcessation.
ax B.
SuggestaxsupplementingaxdietaxwithaxvitaminaxE.
ax C.
Promoteaxregularaxweight-bearingaxexercises.
, ax D.
Implementaxaaxhomeaxsafetyaxplanaxtoaxpreventaxfalls.
ax E.
Proposeaxaaxregularaxsleepaxpatternaxofax8axhoursaxnightly.ax-axA,axC,axD
Rationale:OptionsaxA,axC,axandaxDaxareaxfactorsaxthataxdecreaseaxtheaxriskaxforaxdevelopingaxost
eoporosis.axVitaminaxDaxandaxcalciumaxareaximportantaxsupplementsaxtoaxaidaxinaxtheaxdecrease
axofaxboneaxloss.axRegularaxsleepaxpatternsaxareaximportant axtoaxoverallaxhealthaxbutaxareaxnotaxide
ntifiedaxwithaxaaxdecreasingaxriskaxforaxosteoporosis.
Whichaxnursingaxactionaxwouldaxbeaxappropriateaxforaxaaxclientaxwhoaxisaxnewlyaxdiagnosedaxwitha
xCushingaxsyndrome?
A.
Monitoraxbloodaxglucoseaxlevelsaxdaily.
ax B.
Increaseaxintakeaxofaxfluidsaxhighaxinaxpotassium.
ax C.
Encourageaxadequateaxrestaxbetweenaxactivities.
ax D.
Offeraxtheaxclientaxaaxsodium-enrichedaxmenu.ax-axA
Rationale:Cushingaxsyndromeaxresultsaxfromaxaaxhypersecretionaxofaxglucocorticoidsaxinaxtheaxa
drenalaxcortex.axClientsaxwithaxCushingaxsyndromeaxoftenaxdevelopaxdiabetesaxmellitus.
Monitoringaxofaxserumaxglucoseaxlevelsaxassessesaxforaxincreasedaxbloodaxglucoseaxlevelsaxsoa
xthataxtreatmentaxcanaxbeginaxearly.axAaxcommonaxfindingaxinaxCushingaxsyndromeaxisaxgeneral
izedaxedema.axAlthoughaxpotassiumaxisaxneeded,axitaxisaxgenerallyaxobtainedaxfromaxfoodaxinta
ke,axnotaxbyaxofferingaxpotassium-
enhancedaxfluids.axFatigueaxisaxusuallyaxnotaxanaxoverwhelmingaxfactoraxinaxCushingaxsyndro
me,axsoaxanaxemphasisaxonaxtheaxneedaxforaxrestaxisaxnotaxindicated.axAaxlow-calorie,axlow-
carbohydrate,axlow-sodiumaxdietaxisaxnotaxrecommended.
Aax58-year-
oldaxclientaxwhoaxhasaxnoaxhealthaxproblemsaxasksaxtheaxnurseaxaboutaxreceivingaxtheaxpneumoc
occalaxvaccine.axWhichaxstatementaxgivenaxbyaxtheaxnurseaxwouldaxofferaxtheaxclientaxaccurateaxi
nformationaxaboutaxthisaxvaccine?
A.
Theaxvaccineaxisaxgivenaxannuallyaxbeforeaxtheaxfluaxseasonaxtoaxthoseaxolderaxthanax50axyears.
ax B.
Theaximmunizationaxisaxadministeredaxonceaxtoaxolderaxadultsaxoraxthoseaxataxriskaxforaxillness.
ax C.
Theaxvaccineaxisaxforaxallaxagesaxandaxisaxgivenaxprimarilyaxtoaxthoseaxpersonsaxtravelingaxoversea
saxtoaxareasaxofaxinfection.
ax D.
Theaxvaccineaxwillaxpreventaxtheaxoccurrenceaxofaxpneumococcalaxpneumoniaaxforaxupaxtoax5axyea
rs.
-axB
Rationale:Itaxisaxusuallyaxrecommendedaxthataxpersonsaxolderaxthanax65axyearsaxandaxthoseaxwit
haxaaxhistoryaxofaxchronicaxillnessaxshouldaxreceiveaxtheaxvaccineaxonceaxinaxtheiraxlifetime.axSom
eaxrecommendaxreceivingaxtheaxvaccineaxatax50axyearsaxofaxage.axTheaxinfluenzaaxvaccineaxisaxgi
venaxonceaxaaxyear.axAlthoughaxtheaxvaccineaxmightaxbeaxgivenaxtoaxaaxpersonaxtravelingaxoverse
as,axthataxisaxnotaxtheaxmainaxrationaleaxforaxadministeringaxtheaxvaccine.axTheaxvaccineaxisaxusua
llyaxgivenaxonce
VERSION B 2024-2025 ACTUAL EXAM |
VERIFIED ANSWERS WITH RATIONALES
| ALREADY A+GRADE
Theaxnurseaxisaxassessingaxaaxclientaxwithaxacuteaxpancreatitis.axWhichaxfindingaxrequiresaxtheaxm
ostaximmediateaxinterventionaxbyaxtheaxnurse?
A.
Theaxclient'saxamylaseaxlevelaxisaxthreeaxtimesaxhigheraxthanaxtheaxnormalaxlevel.
ax B.
Theaxclientaxhasaxaaxcarpalaxspasmaxwhenaxtakingaxaaxbloodaxpressure.
ax C.
Onaxaax1axtoax10axscale,axtheaxclientaxtellsaxtheaxnurseaxthataxheraxepigastricaxpainaxisaxatax7.
ax D.
Theaxclientaxstatesaxthataxsheaxwillaxcontinueaxtoaxdrinkaxalcoholaxafteraxgoingaxhome.ax-axB
Theaxnurseaxisaxassessingaxaaxclientaxwithaxacuteaxpancreatitis.axWhichaxfindingaxrequiresaxtheaxm
ostaximmediateaxinterventionaxbyaxtheaxnurse?
Rationale:AaxpositiveaxTrousseauaxsignaxindicatesaxhypocalcemiaaxandaxalwaysaxrequiresaxfurt
heraxassessmentaxandaxintervention,axregardlessaxofaxtheaxcauseax(40%axtoax75%axofaxthoseaxwit
haxacuteaxpancreatitisaxexperienceaxhypocalcemia,axwhichaxcanaxhaveaxserious,axsystemicaxeff
ects).axAaxkeyaxdiagnosticaxfindingaxofaxpancreatitisaxisaxserumaxamylaseaxandaxlipaseaxlevelsaxth
ataxareaxtwoaxtoaxfiveaxtimesaxhigheraxthanaxtheaxnormalaxvalue.axSevereaxboringaxpainaxisaxanaxexp
ectedaxsymptomaxforaxthisaxdiagnosis,axbutaxdealingaxwithaxtheaxhypocalcemiaaxisaxaaxpriorityaxov
eraxadministeringaxanaxanalgesic.axLong-
termaxplanningaxandaxteachingaxdoaxnotaxhaveaxtheaxsameaximmediateaximportanceaxasaxaaxposit
iveaxTrousseauaxsign.
Aax55-year-
oldaxmaleaxclientaxhasaxbeenaxadmittedaxtoaxtheaxhospitalaxwithaxaaxmedicalaxdiagnosisaxofaxchron
icaxobstructiveaxpulmonaryaxdiseaseax(COPD).axWhichaxriskaxfactoraxisaxtheaxmostaxsignificantaxin
axthe axdevelopment axofaxthisaxclient'saxCOPD?
A.
Theaxclient'saxfatheraxwasaxdiagnosedaxwithaxCOPDaxinaxhisax50s.
ax B.
Aaxcloseaxfamilyaxmemberaxcontractedaxtuberculosisaxlastaxyear.
ax C.
Theaxclientaxsmokesaxoneaxtoaxtwoaxpacksaxofaxcigarettesaxperaxday.
ax D.
Theaxclientaxhasaxbeenax40axpoundsaxoverweightaxforax15axyears.ax-axC
Rationale:Smoking,axconsideredaxtoaxbeaxaaxmodifiableaxriskaxfactor,axisaxtheaxmostaxsignificanta
xriskaxfactoraxforaxthe axdevelopmentaxofaxCOPD.axTheaxexactaxmechanismaxofaxgeneticaxandaxher
editaryaximplicationsaxforaxtheaxdevelopmentaxofaxCOPDaxisaxstillaxunderaxinvestigation,axalthoug
haxexposureaxtoaxsimilaraxpredisposingaxfactorsax(e.g.,axsmokingaxoraxinhalingaxsecondhandaxs
moke)axmayaxincreaseaxtheaxlikelihoodaxofaxCOPDaxincidenceaxamongaxfamilyaxmembers.axOpti
onsaxBaxandaxDaxdoaxnotaxexceedaxtheaxrisksaxassociatedaxwithaxcigaretteaxsmokingaxinaxtheaxdeve
lopmentaxofaxCOPD.
,Inaxassessingaxaaxclientaxdiagnosedaxwithaxprimaryaxaldosteronism,axtheaxnurseaxexpectsaxtheaxla
boratoryaxtestaxresultsaxtoaxindicateaxaaxdecreasedaxserumaxlevelaxofaxwhichaxsubstance?
A.
Sodium
axB.axPhosph
ate
axC.axPotas
sium
ax D.
Glucoseax-axC
Rationale:Clientsaxwithaxprimaryaxaldosteronismaxexhibitaxaaxprofoundaxdeclineaxinaxserumaxlev
elsaxofaxpotassium;axhypokalemia;axhypertensionaxisaxtheaxmostaxprominentaxandaxuniversalaxsig
n.axTheaxserumaxsodiumaxlevelaxisaxnormalaxoraxelevated,axdependingaxonaxtheaxamountaxofaxwate
raxresorbedaxwithaxtheaxsodium.axOptionaxBaxisaxinfluencedaxbyaxparathyroidaxhormoneax(PTH).ax
OptionaxDaxisaxnotaxaffectedaxbyaxprimaryaxaldosteronism.
TheaxnurseaxisaxcompletingaxanaxadmissionaxinterviewaxforaxaaxclientaxwithaxParkinsonaxdisease.a
xWhichaxquestion axwillaxprovide axadditionalaxinformationaxaboutaxmanifestations axthataxthe axclien
taxisaxlikelyaxtoaxexperience?
A.
"Haveaxyouaxeveraxexperiencedaxanyaxparalysisaxofaxyouraxarmsaxoraxlegs?"
ax B.
"Doaxyouaxhaveaxfrequentaxblackoutaxspells?"
ax C.
"Haveaxyouaxeveraxbeenaxfrozenaxinaxoneaxspot,axunableaxtoaxmove?"
ax D.
"Doaxyouaxhaveaxheadaches,axespeciallyaxonesaxwithaxthrobbingaxpain?"ax-
axCaxRationale:ClientsaxwithaxParkinson axdisease axfrequentlyaxexperience axdifficultyaxinaxiniti
ating,
maintaining,axandaxperformingaxmotoraxactivities.axTheyaxmayaxevenaxexperienceaxbeingaxroote
daxtoaxtheaxspotaxandaxunableaxtoaxmove.axParkinsonaxdiseaseaxdoesaxnotaxtypicallyaxcauseaxoptio
naxA,axB,axoraxD.
Clientaxcensusaxisaxoftenaxusedaxtoaxdetermineaxstaffingaxneeds.axWhichaxmethodaxofaxobtai
ningaxcensusaxdeterminationaxforaxaaxparticularaxunitaxprovidesaxtheaxbestaxformulaaxforaxde
terminingaxlong-rangeaxstaffingaxpatterns?
A.
Midnightaxcensus
ax B.
Oncomingaxshiftaxcensus
ax C.
Averageaxdailyaxcensus
ax D.
Hourlyaxcensusax-axC
Rationale:Anaxaverageaxdailyaxcensusaxisaxdeterminedaxbyaxtrendaxdataaxandaxtakesaxintoaxacc
ountaxseasonalaxandaxdailyaxfluctuations,axsoaxitaxisaxtheaxbestaxmethodaxforaxdeterminingaxstaffi
ngaxneeds.axOptionsaxAaxandaxBaxprovideaxdataaxataxaaxcertainaxpointaxinaxtime,axandaxthataxdataax
couldaxchange
,quickly.axItaxisaxunrealisticaxtoaxexpectaxtoaxobtainaxanaxhourlyaxcensus,axandaxsuchaxdataaxwouldax
onlyaxprovideaxinformationaxaboutaxaaxcertainaxpointaxinaxtime.
Aaxmaleaxclientaxhasaxjustaxundergoneaxaaxlaryngectomyaxandaxhasaxaaxcuffedaxtracheostomyaxtu
beaxinaxplace.axWhenaxinitiatingaxbolusaxtubeaxfeedingsaxpostoperatively,axwhenaxshouldaxtheaxn
urseaxinflateaxtheaxcuff?
A.
Immediatelyaxafteraxfeeding
ax B.
Justaxprioraxtoaxtubeaxfeeding
ax C.
Continuousaxinflationaxisaxrequired
ax D.
Inflationaxisaxnotaxrequiredax-axB
Rationale:Theaxcuffaxshouldaxbeaxinflatedaxbeforeaxtheaxfeedingaxtoaxblockaxtheaxtracheaaxandaxp
reventaxfoodaxfromaxenteringaxifaxoralaxfeedingsaxareaxstartedaxwhileaxaaxcuffedaxtracheostomyaxt
ubeaxisaxinaxplace.axItaxshouldaxremainaxinflatedaxthroughoutaxtheaxfeedingaxtoaxpreventaxaspirati
onaxofaxfoodaxintoaxtheaxrespiratoryaxsystem.axOptionsaxAaxandaxDaxplaceaxtheaxclientaxataxriskaxfora
xaspiration.
OptionaxCaxplacesaxtheaxclientaxataxriskaxforaxtrachealaxwallaxnecrosis.
Aaxclientaxwithaxaaxnasogastricaxtubeaxattachedaxtoaxlowaxsuctionaxstatesaxthataxsheaxisaxnause
ated.axTheaxnurseaxassessesaxthataxthereaxhasaxbeenaxnoaxdrainageaxthroughaxtheaxnasogast
ricaxtubeaxinaxtheaxlastax2axhours.axWhichaxactionaxshouldaxtheaxnurseaxtakeaxfirst?
A.
Irrigateaxtheaxnasogastricaxtubeaxwithaxsterileaxnormalaxsaline.
ax B.
Repositionaxtheaxclientaxonaxheraxside.
ax C.
Advanceaxtheaxnasogastricaxtubeax5axcm.
ax D.
Administeraxanaxintravenousaxantiemeticaxasaxprescribed.ax-axB
Rationale:Theaximmediateaxpriorityaxisaxtoaxdetermineaxifaxtheaxtubeaxisaxfunctioningaxcorrectly,a
xwhichaxwould axthenaxrelieveaxtheaxclient'saxnausea.axTheaxleastaxinvasiveaxintervention, axrepos
itioningaxtheaxclient,axshouldaxbeaxattemptedaxfirst,axfollowedaxbyaxoptionsaxAaxandaxC,axunlessaxe
itheraxofaxtheseaxinterventionsaxisaxcontraindicated.axIfaxtheseaxmeasuresaxareaxunsuccessful,axt
heaxclientaxmayaxrequireaxoptionaxD.
Theaxnurseaxisaxconductingaxanaxosteoporosisaxscreeningaxclinicaxataxaaxhealthaxfair.axWhataxinfor
mationaxshouldaxtheaxnurseaxprovideaxtoaxindividualsaxwhoaxareaxataxriskaxforaxosteoporosis?ax(Se
lectaxallaxthataxapply.)
A.
Encourageaxalcoholaxandaxsmokingaxcessation.
ax B.
SuggestaxsupplementingaxdietaxwithaxvitaminaxE.
ax C.
Promoteaxregularaxweight-bearingaxexercises.
, ax D.
Implementaxaaxhomeaxsafetyaxplanaxtoaxpreventaxfalls.
ax E.
Proposeaxaaxregularaxsleepaxpatternaxofax8axhoursaxnightly.ax-axA,axC,axD
Rationale:OptionsaxA,axC,axandaxDaxareaxfactorsaxthataxdecreaseaxtheaxriskaxforaxdevelopingaxost
eoporosis.axVitaminaxDaxandaxcalciumaxareaximportantaxsupplementsaxtoaxaidaxinaxtheaxdecrease
axofaxboneaxloss.axRegularaxsleepaxpatternsaxareaximportant axtoaxoverallaxhealthaxbutaxareaxnotaxide
ntifiedaxwithaxaaxdecreasingaxriskaxforaxosteoporosis.
Whichaxnursingaxactionaxwouldaxbeaxappropriateaxforaxaaxclientaxwhoaxisaxnewlyaxdiagnosedaxwitha
xCushingaxsyndrome?
A.
Monitoraxbloodaxglucoseaxlevelsaxdaily.
ax B.
Increaseaxintakeaxofaxfluidsaxhighaxinaxpotassium.
ax C.
Encourageaxadequateaxrestaxbetweenaxactivities.
ax D.
Offeraxtheaxclientaxaaxsodium-enrichedaxmenu.ax-axA
Rationale:Cushingaxsyndromeaxresultsaxfromaxaaxhypersecretionaxofaxglucocorticoidsaxinaxtheaxa
drenalaxcortex.axClientsaxwithaxCushingaxsyndromeaxoftenaxdevelopaxdiabetesaxmellitus.
Monitoringaxofaxserumaxglucoseaxlevelsaxassessesaxforaxincreasedaxbloodaxglucoseaxlevelsaxsoa
xthataxtreatmentaxcanaxbeginaxearly.axAaxcommonaxfindingaxinaxCushingaxsyndromeaxisaxgeneral
izedaxedema.axAlthoughaxpotassiumaxisaxneeded,axitaxisaxgenerallyaxobtainedaxfromaxfoodaxinta
ke,axnotaxbyaxofferingaxpotassium-
enhancedaxfluids.axFatigueaxisaxusuallyaxnotaxanaxoverwhelmingaxfactoraxinaxCushingaxsyndro
me,axsoaxanaxemphasisaxonaxtheaxneedaxforaxrestaxisaxnotaxindicated.axAaxlow-calorie,axlow-
carbohydrate,axlow-sodiumaxdietaxisaxnotaxrecommended.
Aax58-year-
oldaxclientaxwhoaxhasaxnoaxhealthaxproblemsaxasksaxtheaxnurseaxaboutaxreceivingaxtheaxpneumoc
occalaxvaccine.axWhichaxstatementaxgivenaxbyaxtheaxnurseaxwouldaxofferaxtheaxclientaxaccurateaxi
nformationaxaboutaxthisaxvaccine?
A.
Theaxvaccineaxisaxgivenaxannuallyaxbeforeaxtheaxfluaxseasonaxtoaxthoseaxolderaxthanax50axyears.
ax B.
Theaximmunizationaxisaxadministeredaxonceaxtoaxolderaxadultsaxoraxthoseaxataxriskaxforaxillness.
ax C.
Theaxvaccineaxisaxforaxallaxagesaxandaxisaxgivenaxprimarilyaxtoaxthoseaxpersonsaxtravelingaxoversea
saxtoaxareasaxofaxinfection.
ax D.
Theaxvaccineaxwillaxpreventaxtheaxoccurrenceaxofaxpneumococcalaxpneumoniaaxforaxupaxtoax5axyea
rs.
-axB
Rationale:Itaxisaxusuallyaxrecommendedaxthataxpersonsaxolderaxthanax65axyearsaxandaxthoseaxwit
haxaaxhistoryaxofaxchronicaxillnessaxshouldaxreceiveaxtheaxvaccineaxonceaxinaxtheiraxlifetime.axSom
eaxrecommendaxreceivingaxtheaxvaccineaxatax50axyearsaxofaxage.axTheaxinfluenzaaxvaccineaxisaxgi
venaxonceaxaaxyear.axAlthoughaxtheaxvaccineaxmightaxbeaxgivenaxtoaxaaxpersonaxtravelingaxoverse
as,axthataxisaxnotaxtheaxmainaxrationaleaxforaxadministeringaxtheaxvaccine.axTheaxvaccineaxisaxusua
llyaxgivenaxonce
