Hesi 2
Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which
action should the nurse implement?
A. No action is required since postoperative bleeding can be expected
B. Lower the client's head while assessing for symptoms of shock
C. Call the health care provider and prepare to take the client back to the operating room
D. Outline the area with ink and check it every 15 minutes to see if the area has increased
D. Outline the area with ink and check it every 15 minutes to see if the area has increased
A client with acute pancreatitis is complaining of pain and nausea. Which interventions should
the nurse implement (Select all that apply)
A.)Monitor heart, lung, and kidney function.
B.)Notify healthcare provider of serum amylase and lipase levels.
C.)Review client's abdominal ultrasound findings.
D.)Position client on abdomen to provide organ stability
E.)Encourage an increased intake of clear oral fluids
A,B,C
Would need IV fluids, not oral
Placing them on their abdomen would cause more pain
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A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants
immediate intervention by the nurse?
A.)Hypernatremia
B.)Excessive thirst
C.)Elevated heart rate
D.)Poor skin turgor
A
Hypernatremia can occur due to unreplaced water that is lost from the urine in diabetes
insipidus.
In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for
the nurse to monitor which diagnostic test?
Serum creatinine
A mean old 'miacin', causes ototoxicity and nephrotoxicity
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the
baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if
the baby is gaining enough weight. What response should the nurse offer?
A.)What food does your baby usually eat in a normal day?
B.)What was the baby's weight at the last well-baby clinic visit?
C.)The baby is below the normal percentile for weight gain
D.)Your baby is gaining weight right on schedule
A
Birth weight should double by 6 months and triple by 12 months. This baby is overweight.
A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram
loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium
sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate
intervention by the nurse?
A. Blood pressure 162/94
B. Complaint of headache
, C. Urine output 20 ml/hr
D. Nausea and vomitting
Urine output 20 ml/hour
Urine output should be 30 mL/hr
Mag sulfate is used to prevent seizures
What is the nurse's priority goal when providing care for a 2-year-old child experiencing a
seizure?
A.) Stop the seizure activity
B.) Decrease the temperature
C.) Manage the airway
D.) Protect the body from injury
C
The highest priority is maintaining a patent airway
The nurse is preparing to discharge an older adult female client who is at risk for hypocalcemia.
What should the nurse include with this client's discharge teaching?
A.)Report any muscle twitching or seizures
B.)Take vitamin D with calcium daily
C.)Low fat yogurt is a good source of calcium
D.)Keep a diet record to monitor calcium intake
E.)Avoid seafood, particularly selfish
A. Report any muscle twitching or seziures
B. Take vitamin D with calcium daily
D. Low fat yogurt is a good source of calcium
E. Keep a diet record to monitor calcium intake
The husband of a client with advanced ovarian cancer wants his wife to have every treatment
available. When the husband leaves, the client tells the nurse that she has had enough
chemotherapy and wants to stop all treatments but knows her husband will sign the consent
form for more treatment. The nurse's response should include which information?
The husband cannot sign the consent for the client, her signature is required
The client's specific wishes should be discussed with her healthcare provider
The healthcare team will formulate a plan of care to keep the client comfortable
Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which
action should the nurse implement?
A. No action is required since postoperative bleeding can be expected
B. Lower the client's head while assessing for symptoms of shock
C. Call the health care provider and prepare to take the client back to the operating room
D. Outline the area with ink and check it every 15 minutes to see if the area has increased
D. Outline the area with ink and check it every 15 minutes to see if the area has increased
A client with acute pancreatitis is complaining of pain and nausea. Which interventions should
the nurse implement (Select all that apply)
A.)Monitor heart, lung, and kidney function.
B.)Notify healthcare provider of serum amylase and lipase levels.
C.)Review client's abdominal ultrasound findings.
D.)Position client on abdomen to provide organ stability
E.)Encourage an increased intake of clear oral fluids
A,B,C
Would need IV fluids, not oral
Placing them on their abdomen would cause more pain
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:00
,Full screen
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants
immediate intervention by the nurse?
A.)Hypernatremia
B.)Excessive thirst
C.)Elevated heart rate
D.)Poor skin turgor
A
Hypernatremia can occur due to unreplaced water that is lost from the urine in diabetes
insipidus.
In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for
the nurse to monitor which diagnostic test?
Serum creatinine
A mean old 'miacin', causes ototoxicity and nephrotoxicity
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the
baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if
the baby is gaining enough weight. What response should the nurse offer?
A.)What food does your baby usually eat in a normal day?
B.)What was the baby's weight at the last well-baby clinic visit?
C.)The baby is below the normal percentile for weight gain
D.)Your baby is gaining weight right on schedule
A
Birth weight should double by 6 months and triple by 12 months. This baby is overweight.
A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram
loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium
sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate
intervention by the nurse?
A. Blood pressure 162/94
B. Complaint of headache
, C. Urine output 20 ml/hr
D. Nausea and vomitting
Urine output 20 ml/hour
Urine output should be 30 mL/hr
Mag sulfate is used to prevent seizures
What is the nurse's priority goal when providing care for a 2-year-old child experiencing a
seizure?
A.) Stop the seizure activity
B.) Decrease the temperature
C.) Manage the airway
D.) Protect the body from injury
C
The highest priority is maintaining a patent airway
The nurse is preparing to discharge an older adult female client who is at risk for hypocalcemia.
What should the nurse include with this client's discharge teaching?
A.)Report any muscle twitching or seizures
B.)Take vitamin D with calcium daily
C.)Low fat yogurt is a good source of calcium
D.)Keep a diet record to monitor calcium intake
E.)Avoid seafood, particularly selfish
A. Report any muscle twitching or seziures
B. Take vitamin D with calcium daily
D. Low fat yogurt is a good source of calcium
E. Keep a diet record to monitor calcium intake
The husband of a client with advanced ovarian cancer wants his wife to have every treatment
available. When the husband leaves, the client tells the nurse that she has had enough
chemotherapy and wants to stop all treatments but knows her husband will sign the consent
form for more treatment. The nurse's response should include which information?
The husband cannot sign the consent for the client, her signature is required
The client's specific wishes should be discussed with her healthcare provider
The healthcare team will formulate a plan of care to keep the client comfortable
