HESI Critical Care Comprehensive Exam1 with correct answers

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HESI Critical Care Comprehensive Exam1 Critical Care Comprehensive Exam 1 1. A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription shoul... d the nurse anticipate the client to receive that is least likely to exacerbate asthma? 2. A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide? 3. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? 4. The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide? . 5.ID: 6974876286 An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? 6.ID: 6974873559 A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? 7.ID: 6974876262 A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? 8.ID: 6974875110 The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement? . 9.ID: 6974873583 A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? . 10.ID: 6974877914 Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? 11.ID: 6974875104 Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? 12.ID: 6974873535 A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent? 13.ID: 6974876258 During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? 14.ID: 6974875112 The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client? 15.ID: 6974873569 A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond? 16.ID: 6974877906 The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment? 17.ID: 6974876220 What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? 18.ID: 6974876280 Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict? 19.ID: 6974873531 The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome? 20.ID: 6974873553 The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? 21.ID: 6974875106 A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? 22.ID: 6974873585 A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? 23.ID: 6974875175 The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? 24.ID: 6974876270 A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? 25.ID: 6974873555 The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? 26.ID: 6974875146 The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? . 27.ID: 6974875126 The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take? 28.ID: 6974876202 A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 29.ID: 6974877920 The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? 30.ID: 6974873567 The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include? 31.ID: 6974873594 A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? 32.ID: 6974876230 The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? 33.ID: 6974876242 A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? 34.ID: 6974877904 The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture? 35.ID: 6974875190 Which information should the nurse give a client with chronic kidney disease (CKD)? 36.ID: 6974877916 A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? 37.ID: 6974875118 A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? 38.ID: 6974873561 Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? 39.ID: 6974873525 Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? 40.ID: 6974875196 The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? 41.ID: 6974873596 The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? 42.ID: 6974877902 The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? . 43.ID: 6974875184 The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" 44.ID: 6974876234 The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? . 45.ID: 6974876214 The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? 46.ID: 6974875194 During the physical assessment, which finding should the nurse recognize as a normal finding? 47.ID: 6974876238 The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? 48.ID: 6974876274 When documenting assessment data, which statement should the nurse record in the narrative nursing notes? 49.ID: 6974876272 A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? 50.ID: 6974873565 The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take? 51.ID: 6974876232 A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? 52.ID: 6974876250 The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? 53.ID: 6974875132 A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation? 54. Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio? 55.ID: 6974873563 When engaging in planned change on the unit, what should the nurse-manager establish first? 56.ID: 6974876260 A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map? 57.ID: 6974873557 The scope of professional nursing practice is determined by rules promulgated by which organization? 58.ID: 6974875102 An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? 59.ID: 6974873551 After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? 60. When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care? 61.ID: 6974876278 Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer? 62.ID: 6974877918 A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? 63.ID: 6974873571 A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? 64.ID: 6974877900 The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? 65.ID: 6974873537 A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? 66.ID: 6974873581 Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? 67.ID: 6974875154 A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? 68.ID: 6974876228 The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? 69.ID: 6974875108 The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with 70.ID: 6974876296 Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? 71.ID: 6974875188 A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? 72.ID: 6974876240 The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis? 73.ID: 6974876206 The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? 74.ID: 6974875180 The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? 75.ID: 6974876226 A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? 76, The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.) Correct Correct Responses 1. 3 20 grams is equivalent to 20,000 mg. 20,000 mg/100 mL = 200 mg/1 mL. Using Desired/Have X Volume: 600 mg/200 mg X 1 mL = 3 mL. 77.ID: 6974877908 A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement? …………………………………………………continued……………………………… [Show More]

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