EVOLVE HESI PEDS VERSION EXPERT VERIFIED
SOLUTIONS WITH RATIONALES UPDATED PRACTICE
QUESTIONS HIGH YIELD STUDY GUIDE
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
A.
The client's amylase level is three times higher than the normal level.
B.
The client has a carpal spasm when taking a blood pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol after going home. -
Answer-B
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those
with acute pancreatitis experience hypocalcemia, which can have serious,
systemic effects). A key diagnostic finding of pancreatitis is serum amylase and
lipase levels that are two to five times higher than the normal value. Severe boring
pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia
,is a priority over administering an analgesic. Long-term planning and teaching do
not have the same immediate importance as a positive Trousseau sign.
Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula for
determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census - Answer-C
Rationale:An average daily census is determined by trend data and takes into
account seasonal and daily fluctuations, so it is the best method for determining
staffing needs. Options A and B provide data at a certain point in time, and that
data could change quickly. It is unrealistic to expect to obtain an hourly census,
and such data would only provide information about a certain point in time.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should
the nurse inflate the cuff?
A.
Immediately after feeding
,B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required - Answer-B
Rationale:The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed
tracheostomy tube is in place. It should remain inflated throughout the feeding to
prevent aspiration of food into the respiratory system. Options A and D place the
client at risk for aspiration. Option C places the client at risk for tracheal wall
necrosis.
A client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A.
Irrigate the nasogastric tube with sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic as prescribed. - Answer-B
Rationale:The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive
, intervention, repositioning the client, should be attempted first, followed by
options A and C, unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require option D.
The nurse is conducting an osteoporosis screening clinic at a health fair. What
information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A.
Encourage alcohol and smoking cessation.
B.
Suggest supplementing diet with vitamin E.
C.
Promote regular weight-bearing exercises.
D.
Implement a home safety plan to prevent falls.
E.
Propose a regular sleep pattern of 8 hours nightly. - Answer-A, C, D
Rationale:Options A, C, and D are factors that decrease the risk for developing
osteoporosis. Vitamin D and calcium are important supplements to aid in the
decrease of bone loss. Regular sleep patterns are important to overall health but
are not identified with a decreasing risk for osteoporosis.
Which nursing action would be appropriate for a client who is newly diagnosed
with Cushing syndrome?
A.
Monitor blood glucose levels daily.
SOLUTIONS WITH RATIONALES UPDATED PRACTICE
QUESTIONS HIGH YIELD STUDY GUIDE
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
A.
The client's amylase level is three times higher than the normal level.
B.
The client has a carpal spasm when taking a blood pressure.
C.
On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7.
D.
The client states that she will continue to drink alcohol after going home. -
Answer-B
The nurse is assessing a client with acute pancreatitis. Which finding requires the
most immediate intervention by the nurse?
Rationale:A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those
with acute pancreatitis experience hypocalcemia, which can have serious,
systemic effects). A key diagnostic finding of pancreatitis is serum amylase and
lipase levels that are two to five times higher than the normal value. Severe boring
pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia
,is a priority over administering an analgesic. Long-term planning and teaching do
not have the same immediate importance as a positive Trousseau sign.
Client census is often used to determine staffing needs. Which method of
obtaining census determination for a particular unit provides the best formula for
determining long-range staffing patterns?
A.
Midnight census
B.
Oncoming shift census
C.
Average daily census
D.
Hourly census - Answer-C
Rationale:An average daily census is determined by trend data and takes into
account seasonal and daily fluctuations, so it is the best method for determining
staffing needs. Options A and B provide data at a certain point in time, and that
data could change quickly. It is unrealistic to expect to obtain an hourly census,
and such data would only provide information about a certain point in time.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should
the nurse inflate the cuff?
A.
Immediately after feeding
,B.
Just prior to tube feeding
C.
Continuous inflation is required
D.
Inflation is not required - Answer-B
Rationale:The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed
tracheostomy tube is in place. It should remain inflated throughout the feeding to
prevent aspiration of food into the respiratory system. Options A and D place the
client at risk for aspiration. Option C places the client at risk for tracheal wall
necrosis.
A client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A.
Irrigate the nasogastric tube with sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic as prescribed. - Answer-B
Rationale:The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive
, intervention, repositioning the client, should be attempted first, followed by
options A and C, unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require option D.
The nurse is conducting an osteoporosis screening clinic at a health fair. What
information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A.
Encourage alcohol and smoking cessation.
B.
Suggest supplementing diet with vitamin E.
C.
Promote regular weight-bearing exercises.
D.
Implement a home safety plan to prevent falls.
E.
Propose a regular sleep pattern of 8 hours nightly. - Answer-A, C, D
Rationale:Options A, C, and D are factors that decrease the risk for developing
osteoporosis. Vitamin D and calcium are important supplements to aid in the
decrease of bone loss. Regular sleep patterns are important to overall health but
are not identified with a decreasing risk for osteoporosis.
Which nursing action would be appropriate for a client who is newly diagnosed
with Cushing syndrome?
A.
Monitor blood glucose levels daily.
