Upgrade to remove ads
Only $35.99/year

HESI FUNDAMENTALS PRACTICE QUIZ

Terms in this set (20)

A client who has been NPO for 3 days is receiving an infusion of D5W normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 mL/hr. The client's eight hour urine output is 400 mL, BUN is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement?
Document in the medical record that these normal findings are expected outcomes.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.
(Client should be encouraged to wear a mask when working around dust or pollen; clients w/ allergies should avoid any clothing that causes itching-- washing clothes will NOT prevent an allergic reaction to some fabrics; pollen count IS related to allergens and the client should be instructed to stay indoors when the pollen count is high.)
The nurse notices that the hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?
"Hot" remedies restoration balance after surgery, which is considered a COLD condition.
Heparin 20,000 units in 500 ml D5W at 50 mL/hr has been infusing for 5.5 hrs. How much heparin has the client received?
11,000 units
An IV infusion terbutaline sulfate 5 mg in 500 mL of D5W, infusing at a rate of 30 mcg/min, is prescribed for a client in premature labor. How many mL/hr should the nurse set the infusion pump?
180
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he has a bad bout of sever coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After cleaning the tube w/ 30 mL of air, check the pH of fluid withdrawn from the tube. (Coughing, vomiting, and suctioning can precipitate displacement of the tip into the esophagus, placing the client at increased risk for aspiration)
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that is much larger than he expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in time.
B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
C. Offer to contract a member of the local ostomy support group to help him with his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
B. 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; (B) b this will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action but may be taken after the nurse provides patient teaching. The client is not yet demonstrating readiness to learn colostomy care. (D))
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?
Healthcare provider notified of client's refusal to have blood specimens collected for testing.
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.
A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client?
Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. (Customary law in some rural-sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of her husband's brother-- in those rural areas women live in a patriarchal family where decisions are made by men.
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?
Genetic and familial health disorders.
Seocarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer?oo
1.5
Which snack food is best for nurse to provide a client w/ myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding (client w/ myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia; snacks that are easy to swallow and require minimal chewing effort, and provide calories and protein
A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as possible. Which intervention is most important for the nurse to implement?
A. obtain the pre-transfusion hemoglobin level
B. prime the tubing and prepare a blood pump set-up
C. monitor vital signs q15 min for the first hour
D. ensure the accuracy of the blood type match
D. Ensure the accuracy of the blood type match.
(ALL interventions should be implemented but D has the highest priority)
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?
A. "It is important that you continue your medication while learning to meditate"
B. "Spiritual meditation requires a time commitment of 15 to 20 min daily."
C. "Obtain your HCP permission before starting meditation."
D. "Complementary therapy and western medicine can be effective for you."
"It is important that you continue your medication while learning to meditate"
(Prolonged practice of meditation may lead to a reduced need for antihypertensive meds-- meds MUST be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing med. HCP should be informed but permission not required to meditate. (C) Although it is true that complimentary therapy might be effective (D), it is essential that client continue w/ antihypertensive med until effect of med can be measured."
What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications?
Insert a Huber-point needle into the port
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
8 AM, 4 PM, midnight (Theophylline should be administered on a regular-around-the-clock schedule to provide the best bronchodilating effect and reduce potential for AE; food may alter absorption of med)
While instructing a male client's wife in the performance of passive ROM exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly. (the joint that is being exercised should be uncovered, while the rest of the body should remain covered for warmth and privacy)
The nurse is performing a nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next?
A. encourage the client to cough to help loosen secretions
B. Advise client to increase intake of oral fluids
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again.
Re-oxygenate the client before attempting to suction again. (Suctioning should NOT be continued for longer than 10-15 seconds (D) (A,B,C) may be performed after client is re-oxygenated and additional suctioning is performed.)
Other sets by this creator