NUR300 HESI Fundamentals Practice Exam/ Questions & Answers/ Latest Updated

NUR300 HESI Fundamentals Practice Exam/ Questions & Answers/ Latest Updated.The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Instruct the client regarding the need for the covering. B. Observe the appearance of the skin under the ice pack. C. Ask the client how long the ice was applied to the skin. D. Reapply the covering after filling with fresh ice. (Ans - B. Observe the appearance of the skin under the ice pack. The first action by yet nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take other actions (B, C, and, D) as needed. The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gatt/ml, how many drops per minute should the client receive? (Ans - 124 gtt/min Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5mcg x 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07 ml per minute. With a drip factor of 60 gatt/ml, then 60 x 2.07 = 124.28 gatt/min OR, using dimensional analysis: gatt/min = 60 gatt/ml x 1mg/1000 mcg x 5 mcg/kg/min x 1 kg/2.2 lbs x 182 lbs. The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate with 30 Units of Piton to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. Thinners plans to set the flow rate at how many gtt/min? (Ans - 83 gtt/min gtt/min = 20 gtt/ml x 1000 ml/4 hours x 1 hr/60 min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? A. Check the remaining length of tubing to ensure that the correct length was inserted. B. Examining a chest x-ray obtained after the tubing was inserted. C. Aspiring gastric contents to assure a pH value of 4 or less. D. Hearing air pass in the stomach after injecting air into the tubing. (Ans - C. Aspiring gastric contents to assure a pH value of 4 or less. Both A and B are methods used to determine proper placement of the NG tubing. However, the best indication that the tubing is properly placed is C. D is not an indicator of proper placement. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Offer to contact a member of the local osmotic support group to help him with his concerns. B. Reassure the client that he will become accustomed to the stoma appearance in time. C. Encourage the client to handle the stoma equipment to gain confidence with the procedure. D. Instruct the client that the stoma will become smaller when the initial swelling diminishes. (Ans - D. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help the client's anxiety and promote acceptance of the colostomy. A does not provide helpful teaching or support. C is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care.