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HESI PN Review HESI PN Diagnostic Test

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Your score: 48 out of 90 (53%) [Within Time limit] Quiz Attempts: 1

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1.

A client is being discharged and needs instructions on wound care.When planning to teach the client, the nurse should: identify the clients learning needs and learning ability. identify the clients learning needs and advise him what to do. identify the clients problems and make the appropriate referral. provide pamphlets or videotapes for ongoing learning. Feedback:Answer: a Rationale: To provide the most appropriate teaching, the nurse first needs to identify what the client needs to know and determine the clients educational level and learning ability. Comprehension Implementation Health Promotion: Preven tion and/or Early Detection of Health Problems

[3 pts.]

2.

The client tells the nurse she has been smoking one pack of cigarettes a day for the past 20 years. The nurse recognizes this is what part of the nursing process? assessment planning

[3 pts.]

implementation evaluation Feedback:Answer: a Rationale: Data collection occurs during the assessment phase; the information can be obtained during the initial assessment as well as during ongoing assessment. Knowledge Assessment Health Promotion: Prevention and/or Early Detection of Health Problems

3.

Women in the middle adult age group are at risk for cancer of the breast and reproductive organs. The nurse can suggest the following in health promotion teaching: You need to contact your physician about mammography. If there is not a history of cancer in the women of your family, you need not be concerned. An annual physical exam is important to detect early signs and symptoms of cancer. Self-breast exam monthly and an annual Pap smear are necessary for early detection of cancer. Feedback:Rationale: This option gives the most specific recommendations for tests that should be done to detect cancer. The other options provide more general information. Application Implementation Health Promotion: Prevention and/or Early Detection of Health Problems

[3 pts.]

4.

When planning care for elderly clients in long-term care facilities, the nurse gives highest priority to: ensuring that they consume at least 1,200 calories a day. providing regular periods of exercise daily. maintaining a safe environment. providing opportunities for social interactions. Incorrect answer

[3 pts.]

Feedback:Rationale: Although all the options are important, maintenance of a safe environment is always of highest priority. Application Implementation Safe, Effective Care Environment: Safety and Infection Control

5.

The nurse is planning to teach an older client how to check her blood sugar. To promote short-term memory activity, the nurse should: have the client repeat the steps of the procedure back to the nurse. ensure environment is free of distracting stimuli. review the procedure with client on several occasions. imit teaching session to 5 to 10 minutes in length. Incorrect answer Feedback:Rationale: Repetitive presentations promote short memory retention. All of the other options are helpful to the learning process, but c is the best option. Application Planning Health Promotion and Maintenance; Growth and Development

[3 pts.]

6.

An elderly client is seen in the clinic. When reviewing his health care maintenance, the nurse recommends that the client should have: a digital rectal examination for prostate enlargement every 3 months. a blood test for prostate specific antigen (PSA) yearly. a monthly screening for fecal occult blood. An eye examination every 2 years. Feedback:Rationale: A digital rectal exam and PSA blood test should be done yearly in males over 65 years of age. Screening for fecal occult blood is indicated yearly. Application Implementation Health Promotion and Maintenance: Prevention and Early Detection of Health Problems

[3 pts.]

7.

The nurse brings A.M. medications to a client who has just eaten breakfast, noticing the client has just consumed 8 ounces of milk.Which of the following medications should the nurse hold? aspirin calcium channel blocker diuretic tetracycline antibiotic Incorrect answer Feedback:Rationale: The calcium in antacids and dairy products reduces the absorption of tetracyclines. Application Implementation Physiological Integrity: Pharmacological and Parenteral Therapies

[3 pts.]

8.

A client is being discharged on warfarin (Coumadin), an anticoagulant. To avoid food drug interactions, the nurse instructs the client to [3 pts.] restrict which of the following foods? green leafy vegetables citrus foods dairy products whole grains Incorrect answer Feedback:Rationale: The vitamin K found in green leafy vegetables can interfere with the clotting cascade and prolong bleeding time, thereby enhancing the anticoagulant effect. Application Implementation Physiological Integrity: Pharmacological and Parenteral Therapies

9.

The nurse is caring for a client who has had a temperature of 38.8C for the past 24 hours.When medicating the client for pain, the nurse is aware that: elimination of the drug may be prolonged. the analgesic should be given by a parenteral route. the analgesic effect may be shortened. absorption of the drug will be reduced. Feedback:Rationale: Fever increases metabolism of drugs, resulting in a shorter duration of action and faster elimination. The analgesic does not need to be given by a parenteral route and absorption isnt affected by the fever. Analysis Planning Physiological I ntegrity: Pharmacological and Parenteral Therapies

[3 pts.]

10.

When caring for the elderly population, the nurse recognizes they are at risk for dehydration related to: decline of the thirst mechanism in the hypothalamus. altered mobility. renal failure. excessiveantidiuretichormone(ADH) released by the posterior pituitary. Feedback:Rationale: The primary regulator of water intake is thirst and this mechanism declines in the elderly. Comprehension Assessment Physiological Integrity: Reduction of Risk Potential

[3 pts.]

11.

The nurse assesses the fluid balance in a client. Which of the following findings would support a fluid volume deficit? dry skin, decreased heart rate, and increased blood pressure increased heart rate, increased blood pressure, and cold clammy skin

[3 pts.]

decreased heart rate,decreased blood pressure, and diaphoresis decreased blood pressure,increased heart rate, and dry skin Incorrect answer Feedback:Rationale: Fluid volume deficit is characterized by a decrease in extracellular fluid, which would manifest as a drop in blood pressure and dry skin. Heart rate increases to compensate for the reduction in blood volume. Analysis Assessment Physiological Integrity: Reduction of Risk Potential

12.

The nurse is caring for a client who has been experiencing nausea and vomiting for several days. The client is at risk for developing which of these imbalances? respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis Feedback:Rationale: The vomiting causes loss of acidic fluids, resulting in alkalosis. The causeismetabolic,notrespiratory,inorigin. Analysis Assessment Physiological Integrity: Reduction of Risk Potential

[3 pts.]

13.

Your client has returned from a parathyroidectomy and must be monitored for hypocalcemia. The nurse should assess for: muscle cramps,tingling,tetany. flaccid paralysis. bradycardia and weight loss. hypotension and headache. Feedback:Rationale: These symptoms result when insufficient ionized calcium causes excitability of the neuromuscular tissues.

[3 pts.]

Paralysis or muscle weakness would indicate hypercalcemia. Weight loss and headache are not necessarily seen with hypocalcemia. Analysis Assessment Physiological Integrity: Reduction of Risk Potential

14.

A client with a right lower extremity amputation complains of pain in the lost limb. The nurse plans care of the client based on the understanding that phantom limb pain should be: ignored, as it is not possible to have pain in the lost limb. referred to a grief counselor. given small doses of pain medication to prevent addiction. treated as any other client experiencing pain. Incorrect answer Feedback:Rationale: Phantom limb pain is experienced in the missing body part and is very real to the patient. Pain may be due to stimulation of severed nerves in the limb and should be treated as any other type of pain. Application Implementation Physiological Integrity: Basic Care and Comfort

[3 pts.]

15.

The nurse obtains a specimen of wound drainage ordered for a client. The specimen is sent for a culture and sensitivity test to determine the: severity of the disease. most effective antibiotic. effectiveness of the clients immune system. type of pathogen. Feedback:Rationale: The culture identifies the type of pathogen and defines which antibiotic it is sensitive and resistant to. Comprehesion Assessment Physiological Integrity: Reduction of Risk Potential

[3 pts.]

16.

An 86-year-old client asks the nurse why cancer affects mostly the elderly. An accurate response would be: The elderly have more oncogenes. It may take 10 to 20 years after damage to the DNA for the cancer to appear. The cells of the elderly are more fragile and more susceptible to cancer. The elderly have a longer time to be affected by all carcinogens. Incorrect answer Feedback:Rationale: Since the time between damage to the DNA and manifestation of a tumor may take 10 to 20 years, many cancers tend to occur in older adults. Application Implementation Physiological Integrity: Physiological Adaptation

[3 pts.]

17.

A client who has experienced a severe blood loss becomes hypotensive and loses consciousness. The nurse suspects the client is experiencing: cardiogenic shock. neurogenic shock. anaphylactic shock. hypovolemic shock. Feedback:Rationale: Hypovolemic shock is caused by a decrease in intravascular volume secondary to hemorrhage, severe dehydration, or internal fluid shifts. Cardiogenic shock occurs when damage to the heart reduces cardiac output and tissue perfusion. Neurogenic shock results from interruption to the sympathetic nervous system. Anaphylactic shock is caused by a severe allergic reaction. Comprehension Assessment Physiological Integrity: Physiological Adaptation

[3 pts.]

18.

When caring for a client in cardiogenic shock, the nurse plans to administer which of the following drugs to raise the blood pressure?

[3 pts.]

aminophylline dopamine lanoxin furosemide Feedback:Rationale: Dopamine is a vasopressor drug that produces vasoconstriction and raises the blood pressure. Aminophylline is a bronchodilator. Lanoxin is a cardiac glycoside and strengthens cardiac contractility and slows conduction. Furosemide is a diuretic that promotes flud loss. Application Implementation Physiological Integrity: Pharmacological and Parenteral Therapies

19.

A female member of the I Can Cope group thanked the nurse, saying that she probably would not be coming to the meetings sin ce she had to get her finances in order and planned to return to school. The nurse understands the client is in which of the following stages, of grief? denial anger depression acceptance Incorrect answer Feedback:Rationale: In the acceptance stage the individual comes to terms with loss and resumes activities and displays a positive attitude. Denial is characterized by shock and disbelief. Anger is manifested by resistance and acting out. During depressi on the person may withdraw or freely talk about the loss. Analysis Assessment Psychosocial Integrity: Coping and Adaptation

[3 pts.]

20.

In teaching a client with hypoparathyroidism about the disorder, which statement by the nurse best explains how the parathyroid hormone controls calcium levels in the blood? Parathyroid hormone blocks phosphorous excretion by the kidneys, which then decreases the blood calcium level.

[3 pts.]

When blood calcium levels fall, parathyroid hormones stimulate bone resorption and increase calcium in the blood. Parathyroid hormones promote magnesium excretion by the kidneys, which raises blood calcium levels. Parathyroid hormones stimulate cells of the gastrointestinal tract to absorb dietary calcium, raising the blood level. Feedback:Rationale: Parathyroid hormone is excreted by the parathyroid glands and regulates serum calcium and phosphorous levels; in response to low serum calcium, it stimulates resorption of calcium from the bones. It also stimulates calcium reabsorption from the kidneys and intestines, but does not regulate magnesium levels. Application Implementation Physiological Integrity: Physiological Adaptation

21.

The physician orders 10 units regular and 40 units NPH insulin subcutaneously. The nurse prepares the injection by: injecting 40 units air into the NPH, 10 units air into the regular, aspirate 10 units of regular, then aspirate 40 units NPH. injecting air into the regular, air into the NPH, aspirating the NPH, then aspirating the regular. injecting air into the regular, aspirating 10 units regular, injecting air into the NPH, then aspirating 40 units NPH. aspirating10unitsregular,then aspirating 40 units NPH. Feedback:Rationale: Option a describes the correct technique when mixing regular and NPH Insulins. The clear insulin is drawn up first to avoid accidentally contaminating the vial with NPH insulin. Application Implementation Physiological Integrity: Pharmacological and Parenteral Therapies

[3 pts.]

22.

A postpartum client who delivered an infant vaginally has an outcome written in the plan of care, To be free of perineal and uterine infection during the postpartum period. Which interven - tions should a nurse include in the clients care to promote meeting this outcome? SELECT ALL THAT APPLY. Instruct the client on wiping the anal area first after voiding and bowel movements Apply the perineal pad from front to back when changing pads

[3 pts.]

Teach the client to use a peri bottle to apply warm water over her perineum after elimination Teach the client to avoid changing the perineal pads more than once a day Prepare a Sitz bath at least once during the shift Assess the level of the fundus every shift Incorrect answer Feedback:The perineal pads should be applied from front (area under the symphysis pubis) and proceed toward the back (area around the anus) to prevent carrying contamination from the anal area to the perineum and vagina. Squirting the per- ineum with water after elimination cleanses the area and promotes comfort. Sitz baths increase circulation to tissues, which promotes healing and thus reduces the risk of infec- tion. The client should be taught to wipe the perineum after elimination from front (area under the symphysis pubis) and pro- ceed toward the back (area around the anus) to prevent carrying contamination from the anal area to the perineum and vagina. Per- ineal pads should be changed at least four times a day to decrease the risk of promoting bacteria growth in the lochia on the pad and transferring that bacteria to the perineum or vagina. Assessing the level of the fundus is not an intervention; it is an assessment.

23.

A client is admitted with a tentative diagnosis of hepatitis. A nurse determines which client statement would be consistent with the diagnosis? I have not been sleeping well because I have so much heartburn at night that it wakes me up. Whenever I eat dairy products I have diarrhea for a few days. Lately I have been short of breath during my walk from the bus stop to work. I am a smoker but lately I cant tolerate the taste of cigarettes. Incorrect answer Feedback:Anorexia can be severe in the acute phase of hepatitis. Distaste for cigarettes in smokers is characteristic of early profound anorexia. Heartburn at night is a symptom of gastroesophageal re- flux disease (GERD). Diarrhea after eating dairy products can be a symptom of lactose intolerance. Increasing shortness of breath can be related to circulatory or respiratory concerns.

[3 pts.]

24.

A 5-year-old child who is brought to an emergency room is ex- periencing dyspnea and swelling of the lips and tongue. Audible wheezes, rhinitis, and stridor are also present, and the child is very anxious. Based on these assessment findings, a nurse should first: administer oxygen. assess the childs vital signs. administer subcutaneous epinephrine per physicians order. place an intravenous (IV) line to administer antianxiety and other emergency medications. Incorrect answer Feedback:Securing the airway and administering oxygen is an initial intervention. The child is most likely presenting with symp- toms directly related to anaphylactic shock, a potentially life- threatening systemic reaction to an allergen. All of the other interventions are needed to reverse anaphylaxis. The childs vital signs should be known before administering any medications, but that is not the first assessment priority because the informa- tion already suggests a life-threatening situation and an interven- tion is required. Although all of the other interventions are important, they are not the first action. Adrenalin (epinephrine) is an adrenergic (sympathomimetic) agent and cardiac stimulant used to treat anaphylactic shock. An IV line is needed for medications that can act quickly. Agitation increases oxygen demands.

[3 pts.]

25.

A client hospitalized with a history of vomiting and diarrhea for 2 days has weakness, lethargy, serum CO2 of 18 mEq/L, and abdominal cramping. The client reports an inability to eat due to nausea. Which should be the nurses priority nursing diagnosis when caring for the client? Altered nutrition less than body requirements related to diarrhea as manifested by inability to eat Deficient fluid volume related to vomiting as manifested by weakness and low serum CO2 Risk for injury related to weakness and lethargy Acute pain related to increased peristalsis as manifested by abdominal cramping Incorrect answer Feedback:The client is exhibiting signs of fluid volume deficit (dizzi- ness, weakness, and lethargy). The normal CO2 is 20 to 30 mEq/L. The decreased serum CO2 indicates metabolic acidosis, which can be caused by diarrhea. Nutrition, potential for injury, and pain are

[3 pts.]

also concerns, but not the priority, be- cause altered fluid volume can affect perfusion. Test-taking Tip: Note the key word priority. Focus on the clients symptoms and the low serum CO2 level. Use Maslows Hierarchy of Needs theo ry. Basic physiological needs have priority over safety and security needs.The ABCs (airway, breathing, circulation) can also be used because deficient fluid volume can affect circulation. Content Area: Adult Health; Category of Health Alteration: Gastrointestinal Management; Integrated Processes: Nursing Process Analysis; Client Need: Safe and Effective Care Environment/Management of Care/Establishing Priorities; Cognitive Level: Analysis

26.

In a written record of a conversation between a nurse and client, which statement by the nurse best encourages therapeutic [3 pts.] communication? Client: I just learned I might have cancer and I am having surgery tomorrow morning. 1. Nurse: I see. Why a re you afraid? Do you think surgery will reveal that you have cancer? Client: I am afraid because I dont want to have cancer. 2. Nurse: Are you afraid that it might be cancer? Client: I guess. 3. Nurse: Having a possible diagnosis of cancer is frightening. Tell me more about how you are feeling about this. Client: Im afraid I will die. My mother died of cancer when I was 10, and I have a 10 year old. 4. Nurse: This really hits close to you. Client: Yes. I dont want my 10 year old to grow up alone. response 1 response 2 response 3 response 4 Incorrect answer Feedback:The statements in option 3 use therapeutic communication techniques of sharing observations and using an open-ended statement. The statement allows the client to elaborate fur- ther about the clients feelings and fears, while building a trusting nurse client relationship. Asking the client why questions belittles the clients feelings and may cause the client to withdraw f rom the interaction. Response 2 is an example of restating and clarifying the clients response but it does not stim- ulate further conversation. Asking the client a yes/no ques- tion, as in response 2, ends the conversation and does not allow for further opportunity to build a relationship. Response 4 is an example of restatement. Although the statement allows the client to further elaborate and is therapeutic, response 3 is the best statement because it uses two therapeutic communication tech- niques, whereas response 4 uses one.

27.

A 2-year-old client is hospitalized with lymphoma. Which nurs- ing observation, after a parent has left the room, poses the most

[3 pts.]

immediate and serious safety threat to the child and should be removed or changed? Coloring book and crayons left in the crib Placing a doll with movable eyes in the crib Hanging a mobile over the crib Leaving the crib rail halfway down Feedback:The greatest threat to the child is a fall. Crib rails should be raised and secured unless an adult is in attendance. Although all options pose a safety threat, the most immediate and serious of these is the crib rails in a halfway position. A 2-year-old childs developmental stage focuses on mobility and exploring the environment. Crayons can pose a choking hazard if the child should chew on these. Movable eyes in a doll can pose a choking hazard if the eyes can be removed. A mobile could pose a safety risk if the child were to attempt to use this to climb out of bed. Test-taking Tip: Note the similarities in the risk posed in options 1 and 2, that option 3 may or may not pose a risk, and that option 4 presents a different risk. Often, the option that is different is the answer in a multiplechoice type question. Content Area: Child Health; Category of Health Alteration: Hematological and Oncological Management; Integrated Processes: Nursing Process Evaluation; Client Need: Safe

28.

A client is newly admitted with a diagnosis of left-sided heart failure. On assessment of the client, which findings should a nurse expect? Chest tightness and ascites Dyspnea on exertion and ascites Dyspnea on exertion and crackles Neck vein distention and crackles Feedback:Dyspnea and crackles are signs of pulmonary congestion. This occurs in left ventricular failure from back pressure into the left atrium and pulmonary venous system. Neck vein distention and ascites result from right-sided heart failure. Chest tightness could occur from either right-sided or left-sided heart failure from inadequate tissue oxygenation. Clients with left heart failure can develop right-sided failure. Test-taking Tip: This item is testing your knowledge of the difference between right and left heart failure. Duplicate information is presented in the options. If you know one of the facts, such as dyspnea on exertion, you then can eliminate the other options (1 and 4). Now, just examine options 2 and 3. Note that option 3 pertains to just the lungs, whereas option 2 pertains to two different body areas. Content Area: Adult Health; Category of Health Alteration: Cardiac Management; Integrated Processes:

[3 pts.]

Nursing Process Assessment; Client Need: Physiological Integrity/

29.

A nurse reports that a preoperative client has normal liver function. Which liver function laboratory values should the nurse note to be within the normal ranges? SELECT ALL THAT APPLY. Hemoglobin 14 g/dL Total bilirubin 1.0 mg/dL White blood cells (WBCs) 8 K/L Serum creatinine (SCr) 0.7 mg/dL Alanine aminotransferase (ALT) 18 U/L Aspartate aminotransferase (AST) 25 U/L Incorrect answer Feedback:ALT (normal = 536 U/L) and AST (normal = 740 U/L) are two enzymes found in the liver and other organs and are elevated in most liver disorders. The total bilirubin normal is 0.2 1.3 mg/dL. Bilirubin is conjugated and excreted by the liver and is used in the evaluation of liver and biliary function. Other lab values used to evaluate liver function include alka- line phosphatase (ALP, normal = 30120 U/L) and albumin (normal = 3.55.0 g/dL). Hemoglobin is the main protein in erythrocytes and is used to evaluate the ability to carry oxygen to and remove carbon dioxide from red blood cells (normal = 13.5 18 g/dL for males and 1216 g/dL for females). WBCs (normal = 411 K/L or 411 103/L) evaluate the presence of inflammation or infection. Serum creatinine (normal 0.51.5 mg/dL) evaluates kidney function.

[3 pts.]

30.

A hospitalized client diagnosed with end-stage cancer has suddenly decided to discontinue treatment. The client requests no additional treatment, such as antibi- otics, tube feedings, and mechanical ventilation. When acting as the clients advocate, which action should a nurse take? Respect the clients wishes and indicate those wishes on the plan of care Encourage the client to share the decision with the family and the clients physician

[3 pts.]

Clarify other treatments that the client wishes to withhold Wait until additional treatment is required and then decide what to do based on the clients condition Feedback:In advocating for the client, the nurse should encourage the client to share the decision with family and the physician. To advocate for someone means to speak for that person when the person is unable to speak for him- or herself. The client is still able to make his or her own decisions, which will be better supported when the client shares with the family and physician. Although the wishes should be indicated on the plan of care, this nurse action does not demonstrate advocating for the client. A physician order is required to limit treatment. Although additional treatments should be discussed, the priority at this time is the discussion with the family and physician. Test-taking Tip: Use the process of elimination. Note the key word suddenly, which indicates the decision is new. Content Area: Management of Care; Category of Health Alteration: Ethical, Legal, and Safety Issues in Nursing; Integrated Processes: Caring; Client Need: Safe and Effective Care Environment/Managemen