HESI MEDSURG EXAM PACK 4 VERSIONS ALL
INCLUSIVE TEST BANK ACCURATELY UPDATED
2025 | VERIFIED QUESTIONS AND ANSWERS |
GUARANTEED PASS | HIGHEST LEVEL
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
hemodialysisfacility.Beforehisscheduleddialysistreatment,whichelectrolyte imbalance should the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurse anticipate?
‘ ‘
A) Hypophosphatemia.
B) Hypocalcemia.
C) Hyponatremia.
D) Hypokalemia
B.
‘
Hypocalcemia develops in CKD because of chronic hyperphosphatemia. Increased phosphate levels ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
cause the peripheral deposition of calcium and resistance to vitamin D absorption needed forcalcium
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
absorption.Priortodialysis,thenursewould expecttofindtheclienthypernatremic and hyperkalemic,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
not with C or D.
‘ ‘ ‘ ‘ ‘
The home health nurse is assessing a male client being treated for Parkinson's disease with Sinemet.The
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurseobservesthathedoesnotdemonstrateanyapparent emotionwhenspeaking and rarely blinks.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Which intervention should the nurse implement?
‘ ‘ ‘ ‘ ‘ ‘
A) Performacompletecranial nerve assessment. ‘ ‘ ‘ ‘ ‘
B) Instructtheclient that he maybe experiencingmedication toxicity. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Document the presence of theseassessment findings. ‘ ‘ ‘ ‘ ‘ ‘
D) Advisetheclienttoseekimmediatemedicalevaluation. C. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Amasklikeexpressionandinfrequentblinkingarecommonclinicalfeaturesofparkinsonism. The
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurse should document these expected findings. Signs of toxicity of Sinemet include dyskinesia,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
hallucinations, and psychosis.
‘ ‘ ‘
AclientwithCHFand Afib developsventricularectopywithapatternof8 ectopicbeats/min. Which
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
action should the nurse take based on this observation?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Assess for bilateral jugular vein distention. ‘ ‘ ‘ ‘ ‘
B) Increaseoxygen flowvia nasal cannula. ‘ ‘ ‘ ‘ ‘
C) Administer PRN Lasix. ‘ ‘
D) Auscultatefor apleural friction rub. ‘ ‘ ‘ ‘ ‘
,B.
Theclient should have theoxygen flowimmediatelyincreased to promoteoxygenation of the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
,myocardium.Ventricular ectopy,characterizedbymultiplePVCs,isoftencausedbymyocardial ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
ischemia exacerbated by hypokalemia.
‘ ‘ ‘ ‘
Duringthechangeofshift report,thechargenurse reviewstheinfusions beingreceived by clients on the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
oncology unit. The client receiving which infusion should be assessed first?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Continuous IV infusion of magnesium. ‘ ‘ ‘ ‘
B) One-timeinfusion ofalbumin. ‘ ‘ ‘
C) Continuous epidural infusion of morphine. ‘ ‘ ‘ ‘
D) IntermittentinfusionofIVvancomycin. C. ‘ ‘ ‘ ‘ ‘
All four of these clients have a potential to have significant complications. The client with the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
morphineepiduralinfusionisathighestriskforrespiratorydepressionand shouldbeassessed first.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
haveshownabasalskullfractureinthemiddlefossa.Assessmentonadmissionrevealed both halo and
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
battle signs. Which new symtom indicates that the client is likely to be experiencing a common life-
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
threatening complication associated with a basal skull fracture? ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Bilateraljugularveindistension. ‘ ‘ ‘
B) Oral tempof 102. ‘ ‘ ‘
C) Intermittent focalmotor seizures. ‘ ‘ ‘
D) Intractablepaininthecervicalregion. B. ‘ ‘ ‘ ‘ ‘ ‘
Clients withbasilarskullfracturesareathighrisk forinfectionofthebrain, asindicatedbyan increased
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
oral temp because the fracture leaves the meninges open to bacterial invasion.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Anolderclientisadmittedwithadiagnosisofbacterialpneumonia.Whichsymptomshouldthe nurse
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
report to the HCP after assessing the client?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Leukocytosisandfebrile. ‘ ‘
B) Polycythemiaand crackles. ‘ ‘
C) Pharyngitisandsputum production. ‘ ‘ ‘
D) Confusionandtachycardia. ‘ ‘
D.
‘
The onset of Pneumonia in the older client may be signaled by general deterioration, confusion,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
increasedHR,and/or increased respirations.A, B, andCare oftenabsentin theolderclientwith bacterial
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
pneumonia.
‘
The nurse is reviewing routine medications taken by a client with chronic angle closure
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
glaucoma. Which medication prescription should the nurse question?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
, A) Antianginal witha therapeutic effectof vasodilation. ‘ ‘ ‘ ‘ ‘ ‘
B) Anticholinergicwith a side effect of pupillarydilation. ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Antihistamine with aside effect of sedation. ‘ ‘ ‘ ‘ ‘ ‘
D) Corticosteroidwithasideeffectofhyperglycemia. B. ‘ ‘ ‘ ‘ ‘ ‘ ‘
Clients with angle-closure glaucoma should not take medications that dilate the pupil because theycan
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
precipitateacute andseverelyincreased IOP.A,C,andDdonot causeincreased IOP, which is the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
primary concern with angle-closure glaucoma.
‘ ‘ ‘ ‘ ‘
Thenurseiscaringfora criticallyillclientwithcirrhosis oftheliverwhohasaNGtubedraining bright red
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
additional change in laboratory data should the nurse expect?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Increasedserumalbumin level. ‘ ‘ ‘
B) Decreasedserumcreatinine. ‘ ‘
C) Decreased serum ammonia level. ‘ ‘ ‘
D) Increasedliverfunctiontestresults. C. ‘ ‘ ‘ ‘ ‘
Thebreakdownof glutamineintheintestineandtheincreasedactivityof colonicbacteriafrom the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
digestion of proteins increase ammonia levels in clients with advanced liver disease, so removalof
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood,aprotein source,fromtheintestine resultsinareducedlevelofammonia.A, B, and D will not be
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
significantly affected by the removal of blood.
‘ ‘ ‘ ‘ ‘ ‘ ‘
Aresidentinalong-termcarefacilityisdiagnosed withHepB.Whichinterventionshouldthe nurse
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
implement with the staff caring for this client?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Determineif all employees havehad theHep Bvaccine series. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
B) Explainthat thistype of hepatitis can be transmitted when feedingthe client. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Assurethe employees that theycannot contract Hep Bwhen providingdirect care.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
D) Telltheemployeesthat wearingglovesandagownarerequiredwhenprovidingcare. A.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
HepBvaccineshouldbe administeredtoall healthcareproviders.Hep A(not HepB) canbe transmitted
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
by fecal-oral contamination. There is a chance that staff could contract Hep B if exposed to the client's
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood and/or body fluids, therefore C is incorrect. There is no need to wear gloves and gowns except
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
with blood or body fluid contact.
‘ ‘ ‘ ‘ ‘ ‘
A client with HTN has been receiving ramipril (altace), 5mg, PO, daily for 2 weeks and is scheduledto
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
receive adoseat0900.At0830,theclient'sbloodpressureis120/70.Whichaction should the nurse take?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Administerthe prescribed dose at thescheduled time. ‘ ‘ ‘ ‘ ‘ ‘ ‘
B) Hold the dose and contact the HCP. ‘ ‘ ‘ ‘ ‘ ‘
INCLUSIVE TEST BANK ACCURATELY UPDATED
2025 | VERIFIED QUESTIONS AND ANSWERS |
GUARANTEED PASS | HIGHEST LEVEL
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
hemodialysisfacility.Beforehisscheduleddialysistreatment,whichelectrolyte imbalance should the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurse anticipate?
‘ ‘
A) Hypophosphatemia.
B) Hypocalcemia.
C) Hyponatremia.
D) Hypokalemia
B.
‘
Hypocalcemia develops in CKD because of chronic hyperphosphatemia. Increased phosphate levels ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
cause the peripheral deposition of calcium and resistance to vitamin D absorption needed forcalcium
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
absorption.Priortodialysis,thenursewould expecttofindtheclienthypernatremic and hyperkalemic,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
not with C or D.
‘ ‘ ‘ ‘ ‘
The home health nurse is assessing a male client being treated for Parkinson's disease with Sinemet.The
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurseobservesthathedoesnotdemonstrateanyapparent emotionwhenspeaking and rarely blinks.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Which intervention should the nurse implement?
‘ ‘ ‘ ‘ ‘ ‘
A) Performacompletecranial nerve assessment. ‘ ‘ ‘ ‘ ‘
B) Instructtheclient that he maybe experiencingmedication toxicity. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Document the presence of theseassessment findings. ‘ ‘ ‘ ‘ ‘ ‘
D) Advisetheclienttoseekimmediatemedicalevaluation. C. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Amasklikeexpressionandinfrequentblinkingarecommonclinicalfeaturesofparkinsonism. The
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
nurse should document these expected findings. Signs of toxicity of Sinemet include dyskinesia,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
hallucinations, and psychosis.
‘ ‘ ‘
AclientwithCHFand Afib developsventricularectopywithapatternof8 ectopicbeats/min. Which
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
action should the nurse take based on this observation?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Assess for bilateral jugular vein distention. ‘ ‘ ‘ ‘ ‘
B) Increaseoxygen flowvia nasal cannula. ‘ ‘ ‘ ‘ ‘
C) Administer PRN Lasix. ‘ ‘
D) Auscultatefor apleural friction rub. ‘ ‘ ‘ ‘ ‘
,B.
Theclient should have theoxygen flowimmediatelyincreased to promoteoxygenation of the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
,myocardium.Ventricular ectopy,characterizedbymultiplePVCs,isoftencausedbymyocardial ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
ischemia exacerbated by hypokalemia.
‘ ‘ ‘ ‘
Duringthechangeofshift report,thechargenurse reviewstheinfusions beingreceived by clients on the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
oncology unit. The client receiving which infusion should be assessed first?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Continuous IV infusion of magnesium. ‘ ‘ ‘ ‘
B) One-timeinfusion ofalbumin. ‘ ‘ ‘
C) Continuous epidural infusion of morphine. ‘ ‘ ‘ ‘
D) IntermittentinfusionofIVvancomycin. C. ‘ ‘ ‘ ‘ ‘
All four of these clients have a potential to have significant complications. The client with the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
morphineepiduralinfusionisathighestriskforrespiratorydepressionand shouldbeassessed first.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
haveshownabasalskullfractureinthemiddlefossa.Assessmentonadmissionrevealed both halo and
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
battle signs. Which new symtom indicates that the client is likely to be experiencing a common life-
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
threatening complication associated with a basal skull fracture? ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Bilateraljugularveindistension. ‘ ‘ ‘
B) Oral tempof 102. ‘ ‘ ‘
C) Intermittent focalmotor seizures. ‘ ‘ ‘
D) Intractablepaininthecervicalregion. B. ‘ ‘ ‘ ‘ ‘ ‘
Clients withbasilarskullfracturesareathighrisk forinfectionofthebrain, asindicatedbyan increased
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
oral temp because the fracture leaves the meninges open to bacterial invasion.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
Anolderclientisadmittedwithadiagnosisofbacterialpneumonia.Whichsymptomshouldthe nurse
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
report to the HCP after assessing the client?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Leukocytosisandfebrile. ‘ ‘
B) Polycythemiaand crackles. ‘ ‘
C) Pharyngitisandsputum production. ‘ ‘ ‘
D) Confusionandtachycardia. ‘ ‘
D.
‘
The onset of Pneumonia in the older client may be signaled by general deterioration, confusion,
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
increasedHR,and/or increased respirations.A, B, andCare oftenabsentin theolderclientwith bacterial
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
pneumonia.
‘
The nurse is reviewing routine medications taken by a client with chronic angle closure
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
glaucoma. Which medication prescription should the nurse question?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
, A) Antianginal witha therapeutic effectof vasodilation. ‘ ‘ ‘ ‘ ‘ ‘
B) Anticholinergicwith a side effect of pupillarydilation. ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Antihistamine with aside effect of sedation. ‘ ‘ ‘ ‘ ‘ ‘
D) Corticosteroidwithasideeffectofhyperglycemia. B. ‘ ‘ ‘ ‘ ‘ ‘ ‘
Clients with angle-closure glaucoma should not take medications that dilate the pupil because theycan
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
precipitateacute andseverelyincreased IOP.A,C,andDdonot causeincreased IOP, which is the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
primary concern with angle-closure glaucoma.
‘ ‘ ‘ ‘ ‘
Thenurseiscaringfora criticallyillclientwithcirrhosis oftheliverwhohasaNGtubedraining bright red
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
additional change in laboratory data should the nurse expect?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Increasedserumalbumin level. ‘ ‘ ‘
B) Decreasedserumcreatinine. ‘ ‘
C) Decreased serum ammonia level. ‘ ‘ ‘
D) Increasedliverfunctiontestresults. C. ‘ ‘ ‘ ‘ ‘
Thebreakdownof glutamineintheintestineandtheincreasedactivityof colonicbacteriafrom the
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
digestion of proteins increase ammonia levels in clients with advanced liver disease, so removalof
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood,aprotein source,fromtheintestine resultsinareducedlevelofammonia.A, B, and D will not be
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
significantly affected by the removal of blood.
‘ ‘ ‘ ‘ ‘ ‘ ‘
Aresidentinalong-termcarefacilityisdiagnosed withHepB.Whichinterventionshouldthe nurse
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
implement with the staff caring for this client?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Determineif all employees havehad theHep Bvaccine series. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
B) Explainthat thistype of hepatitis can be transmitted when feedingthe client. ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
C) Assurethe employees that theycannot contract Hep Bwhen providingdirect care.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
D) Telltheemployeesthat wearingglovesandagownarerequiredwhenprovidingcare. A.
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
HepBvaccineshouldbe administeredtoall healthcareproviders.Hep A(not HepB) canbe transmitted
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
by fecal-oral contamination. There is a chance that staff could contract Hep B if exposed to the client's
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
blood and/or body fluids, therefore C is incorrect. There is no need to wear gloves and gowns except
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
with blood or body fluid contact.
‘ ‘ ‘ ‘ ‘ ‘
A client with HTN has been receiving ramipril (altace), 5mg, PO, daily for 2 weeks and is scheduledto
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
receive adoseat0900.At0830,theclient'sbloodpressureis120/70.Whichaction should the nurse take?
‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
A) Administerthe prescribed dose at thescheduled time. ‘ ‘ ‘ ‘ ‘ ‘ ‘
B) Hold the dose and contact the HCP. ‘ ‘ ‘ ‘ ‘ ‘
