220 HESI NCLEX EXAM STUDY questions and answers well illustrated.

220 HESI NCLEX EXAM STUDY questions and answers well illustrated. The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension? A. Opague color of the sclera. B. Transparency of the cornea. C. Amount of retinal vessel damage that has occurred. D. Constriction and dilation of the pupils. - correct answers.C. Amount of retinal vessel damage that has occurred. Examination of the blood vessels of the retina reveal any damage to the retinal vessels. This is a significant indication about how much damage the client's high blood pressure has done to vessels throughout the body. Retinal damage indicates that hypertension is moderate to severe. In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.) A. Set the infusion pump to infuse the albumin within four hours. B. Compare the client's blood type within the label on the albumin. C. Assign a UAP to monitor blood pressure q15 minutes. D. Administer through a large gauge catheter. E. Monitor hemoglobin and hematocrit levels. F. Assess for increased bleeding after administration. - correct answers.A, D, E, F Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored while monitoring for bleeding because of the increased blood volume and blood pressure. A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client? A. "What dose of medication are you taking?" B. "Are you eating foods rich in potassium?" C. "Have you lost weight recently?" D. "At what time do you take your medication?" - correct answers.D. "At what time do you take your medication?" For a client taking a loop diuretic who complains of sleep issues, the nurse needs to first determine at what time of day the client takes the medication. Because of the diuretic effect of furosemide, clients should take the medication in the morning to prevent nocturia which may be the reason for the sleep difficulties. During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? A. Racing pulse with exertion. B. Clubbing of the fingers. C. An increased chest diameter. D. Productive cough with grayish-white sputum. - correct answers.D. Productive cough with grayish-white sputum. Chronic bronchitis, one of the diseases comprising the diagnosis of chronic obstructive pulmonary disease (COPD), is characterized by a productive cough with grayish-white sputum. A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? A. Osteoporosis is a progressive genetic disease with no effective treatment. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. C. Estrogen replacement therapy should be started to prevent the progression osteoporosis. D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. - correct answers.B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss. The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? A. Exercise bicycle. B. Sphygmomanometer. C. Blood glucose monitor. D. Weekly medication box. - correct answers.B. Sphygmomanometer. Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record. The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A. Limit dietary selection of cholesterol to 300 mg per day. B. Increase intake of soluble fiber to 110 to 25 grams per day. C. Decrease plant stanols and sterols to less than 2 grams/day. D. Ensure saturated fat is less than 30% of total caloric intake. - correct answers.B. Increase intake of soluble fiber to 10 to 25 grams per day. To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels. The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips. B. Bradycardia and bradypnea. C. Presence of S3 and S4 heart sounds. D. 3+ pitting edema of the lower extremities. - correct answers.A. Cyanosis of the fingertips. Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene. The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound. B. If the family would prefer a private for semi-private room. C. Prescription for removal of the drain. D. If the client's wound is infected. - correct answers.D. If the client's wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room. A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? A. Position the head of the bed (HOB) flat. B. Withhold intravenous fluids. C. Administer a bolus of IV fluids. D. Give an antihypertensive medication. - correct answers.D. Give an antihypertensive medication. Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication. A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias? A. The gram-negative infections occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. Usually occur in healthy young adults who have recently been debilitated by an upper respiratory infection. D. Gram-negative pneumonias usually affect infants and small children. - correct answers.B. Gram-negative organism are more resistant to antibiotic therapy. Gram-negative organisms are very resistant to drug therapy which makes recovery difficult. Antibiotic resistance has become a world-wide concern and the World Health Organization is keeping a very close surveillance on these occurrences. When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B. Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand on the abdomen and make both hands move outward. - correct answers.A. Place a small block or magazine on the abdomen and make it rise while inhaling deeply.