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HESI RN MEDICAL SURGICAL EXAM Questions Answers & Rationales The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's b...

HESI RN Med Surg II A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client: Hangs the irrigation bag on the door clothes hook during fluid insertion Following surgery, a client asks the nurse if he or she can help measure intake and output. What is the best nursing response? Assess the client's ability to measure t...

Fundamental HESI Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. C) Examining a chest x-ray obtained after the tubing was inserted B...

HESI RN Fundamentals B 1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals. C (The nursi...

HESI RN EXIT V2 1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while...

Chris jay HESI RN adaptive quiz A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin? it is a teratogen A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teachi...

HESI RN Fundamentals An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a ...

1. Which response best supports the observations that the nurse identifies in a client who is experiencing a placebo effect?  Psychological response to inert medication 2. Methylphenidate HCl (Concerta) is prescribed for daily administration to a 10-year-old child with attention deficit-hyperactivity disorder (ADHD). In preparing a teaching plan for the parents of this child newly diagnosed with ADHD, which instruction is most important for the nurse to provide to the parents?  A...

HESI Med-Surg Respiratory What is a common adverse effect of the tetracycline antibiotics? Photosensitivity Why should tetracyclines be avoided in pregnant clients and children under 8 years? It can cause yellow-brown discoloration of teeth and growth retardation Antibiotics ending in -mycin are usually? nephrotoxic and ototoxic What is the patho behind chronic bronchitis? Chronic sputum with cough production on a daily basis for a minimum of 3 months in each of 2 consecutive years ch...

HESI Med-Surg (Respiratory) List four common symptoms of pneumonia that the nurse might note on a physical examination. Fever and chills, diminished breath sounds, productive cough and tachypnea State 4 nursing interventions for assisting the client to cough productively Encourage deep breathing, staying hydrated, humidify to loosen secretions, and suction airway to stimulate coughing. What symptoms of pneumonia might the nurse expect to see in an older client? Confusion, lethargy, rapid...

Respiratory Exam Med-Surg The nurse is caring for a patient with chronic obstructive pulmonary disorder (COPD) and pneumonia who has an order for arterial blood gases to be drawn. What is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes B. 5 minutes After obtaining blood for an arterial blood gas measurement, the nurse should hold pressure on the puncture site for 5 minutes by the clock to b...

HESI MED SURG The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) A. Frequent vital signs. B. Determine if the client is allergic to aspirin. D. Offer fluids of choice. F. Monitor infusion of IV nitroglycerine. In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum...

HESI Med Surg Respiratory How does fever cause dehydration? D/t excessive fluid loss from diaphoresis. Increased temperature also increased metabolism and the demand for O2. Clients at high risk for pneumonia: ALOC, depressed or absent gag and cough reflex, susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized patients, brain injury, drug overdose, stroke victim, immunocompromised, immobile, cigarette smokers, other neuro disorders, debilitated by acc...

HESI MED STROKE The ED nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. Which additional clinical manifestations should the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. Difficulty swallowing B. Decreased bowel sounds C. A carotid bruit D. Elevated blood pressure E. Hyperreflexic deep tendon reflexes A. Difficulty swa...

HESI MATERNAL 1. When taking the health history of a child, the nurse know what which finding is an early indication of hypothyroidism in children? a. Cessation of growth in a child that had been normal a.i. Since the thyroid gland is responsible for metabolism, cessation of growth which as previously w/ in normal range, is the most common for hypothyroidism in children. The child w/ hypothyroidism is likely to be HYPOactive not (HYPERactive), although there is delay in the eruption of ...

HESI FUNDAMENTALS The nurse observes that a male client has removed the covering from an ice park applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. Observe the appearance of the skin under the ice pack (The first action taken by the nurse should be...

HESI Fundamentals Practice Exam The nurse observes that a male client has removed the covering form an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. The nurse mixes 50mg of Niproide in 250ml of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182lbs. Using a drip factor of 60gtt/ml, how many drops permin should the client receive? 124gtt/min lbs to kg 182/2.2 = 82.73k...

GASTROINTESTINAL SYSTEM practice exam - answers and rationale 1. The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms, if identified by the client, indicates an understanding of this potential complication following gastrointestinal surgery? A. Hiccups and diarrhea B. Fatigue and abdominal pain C. Constipation...

Fundamentals Practice Test B 1. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse including in the teaching? a. Assign the client to a room with a negative airflow system b. Use alcohol-based hand sanitizer when leaving the client’s room c. Clean contaminated surfaces in the client’s room with a phenol solution d. Have family members wear a gown & gloves when vis...

Fundamentals II - Evolve Hesi RN Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. ...