NURS 302 Hesi
Study online at https://quizlet.com/_bd0k8o
1. The nurse is assessing a client with a chest A. Emphysema indicates air is leaking
tube that is attached to suction and a closed beneath the skin
drainage system. Which finding is most impor-
tant for the nurse to further assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the wa-
ter-seal chamber.
C. Constant air bubbling in the suction-control
chamber.
D. Pain rated "8" (0-10) at the insertion site.
2. Normal urine specific gravity 1.001-1.035
3. ABX treatment after osteomyelitis Parenteral ABX for 4-8 weeks
Oral ABX for 4-8 weeks
4. A female client with hyperesthesia on the on- D.
cology unit is using a transcutaneous electrical The oncology nurse has the knowledge
nerve stimulation (TENS) unit for chronic pain. and experience with the use of a tran-
Which nursing activity should the nurse imple- scutaneous electrical nerve stimulation
ment instead of delegating to a practical nurse (TENS) unit for chronic pain relief, so
(PN)? the nurse should evaluate the client's
Determine the client's level of discomfort us- skill in effectively controlling the pain
ing a pain rating scale. by adjusting the voltage.
Ask the client about her past experience with
chronic pain.
Observe the client's facial expressions for pain
and discomfort.
Evaluate the client's ability to adjust the volt-
age to control pain.
5. B, D
, NURS 302 Hesi
Study online at https://quizlet.com/_bd0k8o
he nurse is providing postoperative instruc-
tions for a female client after a mastectomy.
Which information should the nurse include in
the teaching plan? (Select all that apply.)
Select all that apply
Empty surgical drains once a week using pro-
cedure gloves.
Report inflammation of the incision site or the
affected arm.
Wear clothing with snug sleeves over the arm
on the operative side.
Avoid lifting more than 4.5 kg (10 lb) or reach-
ing above her head.
6. In planning care for a client with an acute D.
stroke resulting in right-sided hemiplegia, After an acute stroke, a positioning and
which positioning should the nurse should use turning schedule that minimizes lying
to maintain optimal functioning? on the affected side, which can im-
Mid-Fowler's with knees supported. pair circulation and cause pain, and in-
Supine with trochanter rolls to the hips. cludes the prone position to help pre-
Sim's position alternated with right lateral po- vent flexion contractures of the hips,
sition q2 hours. prepares the client for optimal func-
Left lateral, supine, brief periods on the right tioning and ambulating.
side, and prone.
7. The nurse is assessing a middle-aged male D.
client for risk factors related to chronic illness.
Which finding should the nurse assess fur- Development of metabolic syndrome!
ther?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle
, NURS 302 Hesi
Study online at https://quizlet.com/_bd0k8o
strength.
Increase in abdominal fat deposits.
8. What is the priority nursing action while caring C.
for a client on a ventilator when an electrical
fire occurs in the intensive care unit? A client on a ventilator should have
Tell another staff member to bring extinguish- respirations maintained with a manual
ing equipment to the bedside. bag-valve-mask resuscitator while be-
Close the doors to the client's area when at- ing moved away from the oxygen wall
tempting to extinguish the fire. outlet and fire source.
Use a bag-valve-mask resuscitator while re-
moving the client from the area.
Implement an emergency protocol to remove
the client from the ventilator.
9. The nurse is caring for a client with end stage B.
liver disease who is being assessed for the
presence of asterixis. To assess the client for Asterixis (flapping tremor, liver flap)
asterixis, what position should the nurse ask is a hand-flapping tremor that is of-
the client to demonstrate? ten seen frequently in hepatic en-
Extend the left arm laterally with the left palm cephalopathy. The tremor is induced
upward. by extending the arm and dorsiflexing
Extend the arm, dorsiflex the wrist, and extend the wrist causing rapid, non-rhythmic
the fingers. extension and flexion of the wrist while
Extend the arms and hold this position for 30 attempting to hold position.
seconds.
Extend arms with both legs adducted to shoul-
der width.
10. The nurse is caring for a client with B.
non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a Platelet counts should not be less than
100,000!
Study online at https://quizlet.com/_bd0k8o
1. The nurse is assessing a client with a chest A. Emphysema indicates air is leaking
tube that is attached to suction and a closed beneath the skin
drainage system. Which finding is most impor-
tant for the nurse to further assess?
A. Upper chest subcutaneous emphysema.
B. Tidaling (fluctuation) of fluid in the wa-
ter-seal chamber.
C. Constant air bubbling in the suction-control
chamber.
D. Pain rated "8" (0-10) at the insertion site.
2. Normal urine specific gravity 1.001-1.035
3. ABX treatment after osteomyelitis Parenteral ABX for 4-8 weeks
Oral ABX for 4-8 weeks
4. A female client with hyperesthesia on the on- D.
cology unit is using a transcutaneous electrical The oncology nurse has the knowledge
nerve stimulation (TENS) unit for chronic pain. and experience with the use of a tran-
Which nursing activity should the nurse imple- scutaneous electrical nerve stimulation
ment instead of delegating to a practical nurse (TENS) unit for chronic pain relief, so
(PN)? the nurse should evaluate the client's
Determine the client's level of discomfort us- skill in effectively controlling the pain
ing a pain rating scale. by adjusting the voltage.
Ask the client about her past experience with
chronic pain.
Observe the client's facial expressions for pain
and discomfort.
Evaluate the client's ability to adjust the volt-
age to control pain.
5. B, D
, NURS 302 Hesi
Study online at https://quizlet.com/_bd0k8o
he nurse is providing postoperative instruc-
tions for a female client after a mastectomy.
Which information should the nurse include in
the teaching plan? (Select all that apply.)
Select all that apply
Empty surgical drains once a week using pro-
cedure gloves.
Report inflammation of the incision site or the
affected arm.
Wear clothing with snug sleeves over the arm
on the operative side.
Avoid lifting more than 4.5 kg (10 lb) or reach-
ing above her head.
6. In planning care for a client with an acute D.
stroke resulting in right-sided hemiplegia, After an acute stroke, a positioning and
which positioning should the nurse should use turning schedule that minimizes lying
to maintain optimal functioning? on the affected side, which can im-
Mid-Fowler's with knees supported. pair circulation and cause pain, and in-
Supine with trochanter rolls to the hips. cludes the prone position to help pre-
Sim's position alternated with right lateral po- vent flexion contractures of the hips,
sition q2 hours. prepares the client for optimal func-
Left lateral, supine, brief periods on the right tioning and ambulating.
side, and prone.
7. The nurse is assessing a middle-aged male D.
client for risk factors related to chronic illness.
Which finding should the nurse assess fur- Development of metabolic syndrome!
ther?
Thinning hair and dry scalp.
Increase in appetite and taste-bud acuity.
Increase in muscle tone but decreased muscle
, NURS 302 Hesi
Study online at https://quizlet.com/_bd0k8o
strength.
Increase in abdominal fat deposits.
8. What is the priority nursing action while caring C.
for a client on a ventilator when an electrical
fire occurs in the intensive care unit? A client on a ventilator should have
Tell another staff member to bring extinguish- respirations maintained with a manual
ing equipment to the bedside. bag-valve-mask resuscitator while be-
Close the doors to the client's area when at- ing moved away from the oxygen wall
tempting to extinguish the fire. outlet and fire source.
Use a bag-valve-mask resuscitator while re-
moving the client from the area.
Implement an emergency protocol to remove
the client from the ventilator.
9. The nurse is caring for a client with end stage B.
liver disease who is being assessed for the
presence of asterixis. To assess the client for Asterixis (flapping tremor, liver flap)
asterixis, what position should the nurse ask is a hand-flapping tremor that is of-
the client to demonstrate? ten seen frequently in hepatic en-
Extend the left arm laterally with the left palm cephalopathy. The tremor is induced
upward. by extending the arm and dorsiflexing
Extend the arm, dorsiflex the wrist, and extend the wrist causing rapid, non-rhythmic
the fingers. extension and flexion of the wrist while
Extend the arms and hold this position for 30 attempting to hold position.
seconds.
Extend arms with both legs adducted to shoul-
der width.
10. The nurse is caring for a client with B.
non-Hodgkin's lymphoma who is receiving
chemotherapy. Laboratory results reveal a Platelet counts should not be less than
100,000!
