Science Medicine Nursing
HESI 799 RN Exit Exam
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Quiz #1 FUNDAMENTALS LECTURE Physical Assesment Points
30 terms 13 terms
55 Preview lexstar1024 Preview s03480741 Preview
Terms in this set (100)
A client presents in the Inability to close the affected eye, raise brow, or smile
emergency room with right-
sided facial asymmetry. The Rationale: Because the motor function controlling eye closure,
nurse asks the client to perform brow movement and smiling are all carried on the 7th cranial
a series of movements that (facial) nerve, the combination of symptoms directly relating to
require use of the facial muscles. an impairment of all branches of the facial nerve indicate that
What symptoms suggest that the Bell's palsy has occurred.
client has most likely experience
a Bell's palsy rather than a
stroke?
a. Slow onset of facial drooping
associated with headache
b. Inability to close the affected
eye, raise brow, or smile
c. A flat nasolabial fold on the
right resulting in facial
asymmetry.
d. Drooling is present on right
side of the mouth, but not on
the left.
,The nurse is teaching a client Keeps the irrigating container less than 18 inches above the
how to perform colostomy stoma
irrigations. When observing the
client's return demonstration, Rationale: Keeping the irrigating container less than 18 inches
which action indicated that the above the stoma permits the solution to flow slowly with little
client understood the teaching? excessive peristalsis does not cause immediate release of stool.
a. Turns to left the side to instill
the irrigating solution into the
stoma
b. Keeps the irrigating container
less than 18 inches above the
stoma
c. Instills 1,200 ml of irrigating
solution to stimulate bowel
evacuation
d. Inserts irrigating catheter
deeper into stoma when
cramping occurs
The nurse should teach the b. Avoid grapefruits and its juice
client to observe which
precaution while taking Rationale: Grapefruit increase the effect of dronedarone thereby
dronedarone? increasing the possibility of serious side effects. A does not
cause a serious effect. C may potentiate lethal arrhythmias and
a. Stay out of direct sunlight should be avoided. D does not directly affect those taking
b. Avoid grapefruits and its juice dronedarone.
c. Reduce the use of herbal
supplements
d. Minimize sodium intake.
A client who sustained a head Confusion and papilledema
injury following an automobile
collision is admitted to the Rationale: papilledema is always an indicator of increased ICP,
hospital. The nurse include the and confusion is usually the first sign of increased ICP. Other
client's risk for developing options do not necessarily reflect increased ICP.
increased intracranial pressure
(ICP) in the plan of care. Which
signs indicate to the nurse that
ICP has increased?
a. Increased Glasgow coma
scale score.
b. Nuchal rigidity and
papilledema.
c. Confusion and papilledema
d. Periorbital ecchymosis.
,The nurse is caring for a client Confirm the necessity for continued use of the CVC
receiving continuous IV fluids
through a single lumen central Rationale: Increase the length of use increase the risk for
venous catheter (CVC). Based infection. The CVC care bundle includes the review of the need
on the CVC care bundle, which for continued use of the CVC. Effective hand hygiene and
action should be completed standard precautions should be maintained but protective
daily to reduce the risk for environment precautions are not needed. B is not needed if
infection? continuous IV fluid are infused, ad may introduce contaminants.
Use of a transparent dressing allows the site to be visualized for
a. Remind staff to follow any signs of infection but changing the dressing daily increases
protective environment the risk for infection.
precautions
b. Gently flush the catheter
lumen with sterile saline solution
c. Cleanse the site and change
the transparent dressing.
d. Confirm the necessity for
continued use of the CVC.
During an annual physical Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L
examination, an older woman's (SI).
fasting blood sugar (FBS) is
determined to be 140 mg/dl or
7.8 mmol/L (SI). Which additional
finding obtained during a
follow-up visit 2 weeks later is
most indicative that the client
has diabetes mellitus (DM)?
a. An increased thirst with
frequent urination
b. Blood glucose range during
past two weeks was 110 to 125
mg/dl or 6.1 to 7.0 mmol/L(SI)
c. Two-hour postprandial
glucose tolerance test (GTT) is
160 mg/dL or 8.9 mmol/L (SI)
d. Repeated fasting blood sugar
(FBS) is 132 mg/dl or 7.4 mmol/L
(SI).
, A new mother tells the nurse Determine if she can ask for support from family, friend, or the
that she is unsure if she will be baby's father
able to transition into
parenthood. What action should Rationale: Emotional support of significant family and friends can
the nurse take? help a new mother cope with anxiety about transitioning to
parenthood. The nurse should ask the client who is available to
a. Provide reassurance to the support her.
client that these feeling are
normal after delivery
b. Discuss delaying the client's
discharge from the hospital for
another 24 hrs.
c. Determine if she can ask for
support from family, friend, or
the baby's father.
d. Explain the differences
between postpartum blues and
postpartum depression.
A client who was admitted Stop the normal saline infusion.
yesterday with severe
dehydration is complaining of Rationale: If the IV has infiltrated or become dislodges, the fluid
pain a 24 gauge IV with normal is infusing into surrounding tissue and not into the vein. Stopping
saline is infusing at a rate of 150 the infusion C is the priority action. Establishing another IV site is
ml/hour. Which intervention necessary for fluid resuscitation after the infiltrated infusion is
should the nurse implement discontinuing the IV (D) is necessary due to the pain, and a large
first? gauge needle is preferable.
a. Establish the second IV site
b. Asses the IV for blood return
c. Stop the normal saline
infusion.
d. Discontinue the 24-gauge IV
An elderly female is admitted Ensure proper alignment of the leg in traction.
because of a change in her level
of sensorium. During the Rationale: A fractured hip results in external rotation and
evening shift, the client attempts shortening of the affected extremity. With the application of
to get out bed and falls, Buck's skin traction proper alignment ensures the transaction
breaking her left hip. Buck's skin S pull is exerted to align the fracture hip with the distal leg,
traction is applied to the left leg immobilize the fractured bone, and minimize muscle spasms and
while waiting for surgery. Which surrounding tissue injury related to the fracture. A should be
intervention is most important implement but improper pull of traction can increase pain and
for the nurse to include in this soft tissue damage. B and C should be implemented but the
client's plan care? greatest risk is improper alignment of the traction.
a. Evaluate her response to
narcotic analgesia
b. Asses the skin under the
traction moleskin
c. Place a pillow under the
involved lower left leg
d. Ensure proper alignment of
the leg in traction.
HESI 799 RN Exit Exam
5.0 (1 review)
Save
Students also studied
Flashcard sets Study guides
Quiz #1 FUNDAMENTALS LECTURE Physical Assesment Points
30 terms 13 terms
55 Preview lexstar1024 Preview s03480741 Preview
Terms in this set (100)
A client presents in the Inability to close the affected eye, raise brow, or smile
emergency room with right-
sided facial asymmetry. The Rationale: Because the motor function controlling eye closure,
nurse asks the client to perform brow movement and smiling are all carried on the 7th cranial
a series of movements that (facial) nerve, the combination of symptoms directly relating to
require use of the facial muscles. an impairment of all branches of the facial nerve indicate that
What symptoms suggest that the Bell's palsy has occurred.
client has most likely experience
a Bell's palsy rather than a
stroke?
a. Slow onset of facial drooping
associated with headache
b. Inability to close the affected
eye, raise brow, or smile
c. A flat nasolabial fold on the
right resulting in facial
asymmetry.
d. Drooling is present on right
side of the mouth, but not on
the left.
,The nurse is teaching a client Keeps the irrigating container less than 18 inches above the
how to perform colostomy stoma
irrigations. When observing the
client's return demonstration, Rationale: Keeping the irrigating container less than 18 inches
which action indicated that the above the stoma permits the solution to flow slowly with little
client understood the teaching? excessive peristalsis does not cause immediate release of stool.
a. Turns to left the side to instill
the irrigating solution into the
stoma
b. Keeps the irrigating container
less than 18 inches above the
stoma
c. Instills 1,200 ml of irrigating
solution to stimulate bowel
evacuation
d. Inserts irrigating catheter
deeper into stoma when
cramping occurs
The nurse should teach the b. Avoid grapefruits and its juice
client to observe which
precaution while taking Rationale: Grapefruit increase the effect of dronedarone thereby
dronedarone? increasing the possibility of serious side effects. A does not
cause a serious effect. C may potentiate lethal arrhythmias and
a. Stay out of direct sunlight should be avoided. D does not directly affect those taking
b. Avoid grapefruits and its juice dronedarone.
c. Reduce the use of herbal
supplements
d. Minimize sodium intake.
A client who sustained a head Confusion and papilledema
injury following an automobile
collision is admitted to the Rationale: papilledema is always an indicator of increased ICP,
hospital. The nurse include the and confusion is usually the first sign of increased ICP. Other
client's risk for developing options do not necessarily reflect increased ICP.
increased intracranial pressure
(ICP) in the plan of care. Which
signs indicate to the nurse that
ICP has increased?
a. Increased Glasgow coma
scale score.
b. Nuchal rigidity and
papilledema.
c. Confusion and papilledema
d. Periorbital ecchymosis.
,The nurse is caring for a client Confirm the necessity for continued use of the CVC
receiving continuous IV fluids
through a single lumen central Rationale: Increase the length of use increase the risk for
venous catheter (CVC). Based infection. The CVC care bundle includes the review of the need
on the CVC care bundle, which for continued use of the CVC. Effective hand hygiene and
action should be completed standard precautions should be maintained but protective
daily to reduce the risk for environment precautions are not needed. B is not needed if
infection? continuous IV fluid are infused, ad may introduce contaminants.
Use of a transparent dressing allows the site to be visualized for
a. Remind staff to follow any signs of infection but changing the dressing daily increases
protective environment the risk for infection.
precautions
b. Gently flush the catheter
lumen with sterile saline solution
c. Cleanse the site and change
the transparent dressing.
d. Confirm the necessity for
continued use of the CVC.
During an annual physical Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L
examination, an older woman's (SI).
fasting blood sugar (FBS) is
determined to be 140 mg/dl or
7.8 mmol/L (SI). Which additional
finding obtained during a
follow-up visit 2 weeks later is
most indicative that the client
has diabetes mellitus (DM)?
a. An increased thirst with
frequent urination
b. Blood glucose range during
past two weeks was 110 to 125
mg/dl or 6.1 to 7.0 mmol/L(SI)
c. Two-hour postprandial
glucose tolerance test (GTT) is
160 mg/dL or 8.9 mmol/L (SI)
d. Repeated fasting blood sugar
(FBS) is 132 mg/dl or 7.4 mmol/L
(SI).
, A new mother tells the nurse Determine if she can ask for support from family, friend, or the
that she is unsure if she will be baby's father
able to transition into
parenthood. What action should Rationale: Emotional support of significant family and friends can
the nurse take? help a new mother cope with anxiety about transitioning to
parenthood. The nurse should ask the client who is available to
a. Provide reassurance to the support her.
client that these feeling are
normal after delivery
b. Discuss delaying the client's
discharge from the hospital for
another 24 hrs.
c. Determine if she can ask for
support from family, friend, or
the baby's father.
d. Explain the differences
between postpartum blues and
postpartum depression.
A client who was admitted Stop the normal saline infusion.
yesterday with severe
dehydration is complaining of Rationale: If the IV has infiltrated or become dislodges, the fluid
pain a 24 gauge IV with normal is infusing into surrounding tissue and not into the vein. Stopping
saline is infusing at a rate of 150 the infusion C is the priority action. Establishing another IV site is
ml/hour. Which intervention necessary for fluid resuscitation after the infiltrated infusion is
should the nurse implement discontinuing the IV (D) is necessary due to the pain, and a large
first? gauge needle is preferable.
a. Establish the second IV site
b. Asses the IV for blood return
c. Stop the normal saline
infusion.
d. Discontinue the 24-gauge IV
An elderly female is admitted Ensure proper alignment of the leg in traction.
because of a change in her level
of sensorium. During the Rationale: A fractured hip results in external rotation and
evening shift, the client attempts shortening of the affected extremity. With the application of
to get out bed and falls, Buck's skin traction proper alignment ensures the transaction
breaking her left hip. Buck's skin S pull is exerted to align the fracture hip with the distal leg,
traction is applied to the left leg immobilize the fractured bone, and minimize muscle spasms and
while waiting for surgery. Which surrounding tissue injury related to the fracture. A should be
intervention is most important implement but improper pull of traction can increase pain and
for the nurse to include in this soft tissue damage. B and C should be implemented but the
client's plan care? greatest risk is improper alignment of the traction.
a. Evaluate her response to
narcotic analgesia
b. Asses the skin under the
traction moleskin
c. Place a pillow under the
involved lower left leg
d. Ensure proper alignment of
the leg in traction.
