*NURSING > EXAM > Hesi NUR 112 Exam Questions & Answers with Rationales Updated (Deeply & Well Explained Answers) (All)

Hesi NUR 112 Exam Questions & Answers with Rationales Updated (Deeply & Well Explained Answers)

Document Content and Description Below

Hesi NUR 112 Exam Questions & Answers with Rationales Updated (Deeply & Well Explained Answers)-The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. ... What findings should indicate to the nurse to withhold the next dose of the medication? A. Excessive lochia. B. Saturation of more than one pad per hour. C. Hypertension. D. Difficulty locating the uterine fundus. - Answer C. Hypertension. Rationale Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary hypertension. The nurse should withhold the medication if the client's blood pressure is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and are indications for the use of the medication. The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A. A peanut butter sandwich with soda and cookies. B. A tunafish sandwich with chips and ice cream. C. A salad with three kinds of lettuce and fruit. D. Vegetable soup, crackers, and milk. - Answer B. A tunafish sandwich with chips and ice cream. Rationale (B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serving. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be low in protein. The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse? A. Current lab report indicates an aPTT at 1.5 times the client's control. B. Several bruised areas are noted on the client's upper extremities bilaterally. C. The client states that his right calf is aching, and wants pain medication. D. The spouse is assisting the client who is shaving with an electric razor. - Answer C. The client states that his right calf is aching, and wants pain medication. Rationale A calf ache severe enough for the client to request pain medication (C) should be reported to the healthcare provider immediately so that an adjustment in the anticoagulation therapy can be made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anticoagulant heparin therapy. (A and B) are expected findings. Shaving with an electric razor is recommended to reduce the possibility of bleeding (D) and does not require intervention. While the nurse is providing morning care for a client with chronic obstructive pulmonary disease (COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement first? A. Instruct the client to perform diaphragmatic breathing. B. Use a calm voice to tell the client to breathe slowly. C. Administer two puffs of a metered-dose inhaler. D. Assist the client to an upright position. - Answer D. Assist the client to an upright position. Rationale The nurse should first assist the client to an upright position (D), which allows the lungs to expand fully. After this, the nurse can implement (A, B, and C) as needed. A female client's estranged husband arrives at the hospital and demands that his wife have no other visitors. The client becomes angry and insists that the estranged husband be barred from visiting her. Which intervention should the nurse implement? A. Obtain a prescription to allow client to dictate who can visit. B. Request a multidisciplinary care conference to discuss husband's demands. C. Have the hospital's medical-legal department meet with the client. D. Encourage the client to speak with husband regarding his disruptive behavior. - Answer B. Request a multidisciplinary care conference to discuss husband's demands. Rationale A multi-disciplinary care conference involves the healthcare team to evaluate difficult situations that conflict with client safety and autonomy. During this conference, the client's wishes regarding her health care decisions can be clarified to all team members. All other options are not indicated. The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse to first? A. Assess the level of consciousness and vital signs for both clients. B. Complete a head to toe assessment of the client with pneumonia. C. Change the surgical dressing to observe the appearance of the incision. D. Review the plan of care and the medications that are due for both clients. - Answer A. Assess the level of consciousness and vital signs for both clients. Rationale Assessing the level of consciousness and vital signs for both clients (A) provides a quick measurement of priority need. Before a complete assessment (B) is done on one client, the nurse should at least do a quick assessment of the other client. Changing the dressing and observing the incision (C) may be indicated, but only after both clients are quickly assessed. Reviewing the plan of care and medications due for administration (D) should wait until the nurse has evaluated both clients for any urgent clinical needs. A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority? A. Obtain specimens for cultures. B. Vital signs q4 hours. C. Assign private room. D. Ringers lactate IV 125 mL/8 hours. - Answer C. Assign private room. Rationale Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by fever, cough, sore throat, runny nose, body aches, headache, chills, fatigue, diarrhea, and vomiting. According to the Center for Disease Control, it is best to place a client requiring Contact or Droplet Precautions in a single client room, so to protect others, the client who is exhibiting signs of Novel H1N1 influenza should be assigned to a private room (C). (A, B, and D) do not have the right the priority of (C). A client who received partial thickness (second degree) burns over the anterior surfaces of both arms, legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a stretcher into the therapeutic bath. Which intervention should the nurse implement first? A. Obtain the hoist from the supply room. B. Explain the procedure to the client. C. Medicate the client with an analgesic. D. Remove all bandages prior to moving the client. - Answer B. Explain the procedure to the client. Rationale Before implementing any new procedure, an explanation of the procedure should be provided (B). Bringing large pieces of equipment into the client's room (A), such as a mechanical lift, may alarm the client if the procedure has not been explained. The client should be medicated (C), but first explaining what is involved in the procedure helps prepare the client for subsequent actions. Dressing bandages provide protection for the wounds and help eliminate exposure to air, which can cause pain, so removal should be done immediately prior to submersion in the bath (D). A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first and least priority last or at the bottom.) A. Stop the infusion. B. Assess vital signs. C. Contact the healthcare provider. D. Initiate adverse event report. E. Document reaction to the drug. - Answer 1. Stop the infusion. 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate adverse event report. Rationale The client is exhibiting a drug reaction and quick action is required. When a drug reaction is suspected, first the infusion should be stopped. Then vital signs and airway compromise should be assessed and the findings reported to the healthcare provider. Documentation of the occurrence, including a description of the rash and details of the reaction should be completed after the healthcare provider is notified. Finally, and adverse drug reaction or adverse event report should be completed. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An adolescent who works part time in a paint factory. B. A 10-year-old who is an insulin-dependent diabetic (Type 1). C. An 8-year-old who lives in a housing project. D. A 2-year-old who plays on aging outdoor playground equipment. - Answer D. A 2-year-old who plays on aging outdoor playground equipment. Rationale Children who ingest dust and soil and paint from playground equipment usually practice pica—the habitual, purposeful, and compulsive ingestion of non-food products, characteristic of toddlers (D). Lead enters the system by ingestion or inhalation, usually from paint, gasoline, dust and soil, food, and water. Though (A) may present a hazard, governmental regulations decrease the risk of contracting lead poisoning by requiring use of respirators in lead paint areas. (B) is not related to lead poisoning. (C) does not practice pica the way a toddler does. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Force oral fluids. B. Request a nutrition consult. C. Administer prescribed antibiotics. D. Reapply a sterile non-adhesive dressing. - Answer C. Administer prescribed antibiotics. Rationale A client who has a postoperative dressing with a red, swollen wound, moderate amount of yellow, green drainage, foul odor, and experiencing a MRSA infection poses a risk for transmission of a healthcare-associated infection (HAI). The most important action for the nurse to take is administer prescribed antibiotics (C). (A, B, and D) are not the priority with highly resistant infections, such as MRSA. An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) A. Recommend a 24-hour caregiver on discharge to the long-term facility. B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. D. Request immediate evaluation by Rapid Response Team. E. Apply soft wrist restraints so that the operative site is protected. - Answer B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. Rationale (B and C) Are correct. The client's condition reflects mental changes that could be related to post procedure stress, sundowner's syndrome, or cerebral complications. The nurse should inform the healthcare provider of the client's change in mental status (B). For the client's safety, q2 hour reorientations and evaluations should be included in the plan of care (C). A 24-hour caregiver (A) is not indicated at this time, but the client should be reassessed for cognitive dysfunction when he is psychologically stable enough for discharge. The Rapid Response Team provides treatment for life-threatening emergencies, so (D) is not indicated at this time. Restraints may protect the client from self injury (E), but may also increase his confusion. In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the correct Apgar score for this infant? A. 7. B. 8. C. 9. D. 10. - Answer B. 8. Rationale The maximum Apgar score is 10 (2 points for 5 variables). Subtract one point for muscle tone (slight flexion with slight resistance to straightening), and subtract one point for color due to acrocyanosis (bluing of the extremities is normal at birth). A heart rate over 100 earns 2 points, respirations of 40 earns 2 points, and a loud cry in response to stimulation indicates reflex irritability and earns 2 points. The correct Apgar score for this child is, therefore, 8 (B). Three variables received a score of 2 (2x3=6) and two a score of 1 (2x1=2) for a total of 8 (6+2=8). A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply.) A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. E. Ice cream with nuts. F. Fried chicken and green salad. - Answer A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. Rationale The correct selections are (A, B, C, and D). A soft diet includes foods with a soft consistency they can be chewed easily. Nutritionally dense foods such as whole grains, nuts (E), fried meats and fresh fruits and vegetables (F) should be avoided on a soft diet. While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? A. Hemoglobin. B. Protein. C. Calcium. D. Potassium. - Answer D. Potassium. Rationale As insulin lowers the blood glucose of a client with diabetic ketoacidosis, the serum potassium level also decreases as potassium returns to the cell. This can cause potentially fatal hypokalemia, so it is essential for the nurse to monitor the clients serum potassium (D). It is less critical to monitor (A, B and C) while an intravenous insulin infusion is being administered. [Show More]

Last updated: 2 months ago

Preview 1 out of 61 pages

Add to cart

Instant download

Reviews( 0 )

$14.50

Add to cart

Instant download

Can't find what you want? Try our AI powered Search

OR

REQUEST DOCUMENT
8
0

Document information


Connected school, study & course


About the document


Uploaded On

Mar 21, 2024

Number of pages

61

Written in

Seller


seller-icon
PROF

Member since 3 years

141 Documents Sold


Additional information

This document has been written for:

Uploaded

Mar 21, 2024

Downloads

 0

Views

 8

Recommended For You

Get more on EXAM »

$14.50
What is Browsegrades

In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.

We are here to help

We're available through e-mail, Twitter, Facebook, and live chat.
 FAQ
 Questions? Leave a message!

Follow us on
 Twitter

Copyright © Browsegrades · High quality services·