NUR 324 FUNDAMENTALS HESI (NUR 324FUNDAMENTALS HESI.)

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1. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. Feedback: INCORRECT B) 1.5 ml. Fee... dback: CORRECT C) 1.75 ml. Feedback: INCORRECT D) 2 ml. Feedback: INCORRECT Feedback: CORRECT (B) is the correct calculation: Dosage on hand/amount on hand = Dosage desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5 ml. Points Earned: 1.0/1.0 Correct Answer(s): B Correct 2. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. Feedback: INCORRECT B) exhibits expressive dysphasia. Feedback: INCORRECT C) has a diminished attention span. Feedback: INCORRECT D) is disoriented to place and time. Feedback: CORRECT Feedback: CORRECT The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C). Points Earned: 1.0/1.0 Correct Answer(s): D Correct 3. A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs? A) Autopsy of the body is prohibited. Feedback: INCORRECT B) Blood transfusions are forbidden. Feedback: CORRECT C) Alcohol use in any form is not allowed. Feedback: INCORRECT D) A vegetarian diet must be followed. Feedback: INCORRECT Feedback: CORRECT Blood transfusions are forbidden (B) in the Jehovah’s Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B). Points Earned: 1.0/1.0 Correct Answer(s): B Correct 4. Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. Feedback: INCORRECT B) Hold hands with fingers down while gloving. Feedback: INCORRECT C) Keep gloved hands above the elbows. Feedback: CORRECT D) Put the glove on the dominant hand first. Feedback: INCORRECT Feedback: CORRECT Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). Points Earned: 1.0/1.0 Correct Answer(s): C Incorrect 5. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? Feedback: INCORRECT The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Points Earned: 0.0/1.0 Correct Answer(s): 150 Correct 6. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A) Apply a condom catheter. Feedback: INCORRECT B) Apply a skin protectant. Feedback: INCORRECT C) Encourage increased fluid intake. Feedback: INCORRECT D) Assess for bladder distention. Feedback: CORRECT Feedback: CORRECT Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. Points Earned: 1.0/1.0 Correct Answer(s): D Correct 7. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A) 0.5 ml. Feedback: CORRECT B) 1 ml. Feedback: INCORRECT C) 1.5 ml. Feedback: INCORRECT D) 2 ml. Feedback: INCORRECT Feedback: CORRECT Using ratio and proportion: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Points Earned: 1.0/1.0 Correct Answer(s): A Incorrect 8. An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A) 30 Feedback: INCORRECT B) 60 Feedback: INCORRECT C) 120 Feedback: INCORRECT D) 180 Feedback: CORRECT Feedback: INCORRECT (D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Points Earned: 0.0/1.0 Correct Answer(s): D Incorrect 9. In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. Feedback: INCORRECT B) often follows relocation to new surroundings. Feedback: CORRECT C) is a result of irreversible brain pathology. Feedback: INCORRECT D) can be prevented with adequate sleep. Feedback: INCORRECT Feedback: INCORRECT Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion. Points Earned: 0.0/1.0 Correct Answer(s): B Correct 10. At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed. Feedback: CORRECT Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics. Points Earned: 1.0/1.0 Correct Answer(s): D Correct 11. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhalerdelivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. Feedback: INCORRECT B) During the inhalation. Feedback: CORRECT C) At the end of three inhalations. Feedback: INCORRECT D) Immediately after inhalation. Feedback: INCORRECT Feedback: CORRECT The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). Points Earned: 1.0/1.0 Correct Answer(s): B Correct 12. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A) Avoid any types of sprays, powders, and perfumes. Feedback: CORRECT B) Wearing a mask while cleaning will not help to avoid allergens. Feedback: INCORRECT C) Purchase any type of clothing, but be sure it is washed before wearing it. Feedback: INCORRECT D) Pollen count is related to hay fever, not to allergens. Feedback: INCORRECT Feedback: CORRECT The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes (A). The client should be encouraged to wear a mask when working around dust or pollen (B). Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics (C). Pollen count is related to allergens (D), and the client should be instructed to stay indoors when the pollen count is high. Points Earned: 1.0/1.0 Correct Answer(s): A Incorrect 13. A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. Feedback: CORRECT B) Remind the client that protein in the diet should be avoided. Feedback: INCORRECT C) Suggest that the client also select orange juice, to promote absorption. Feedback: INCORRECT D) Encourage the client to attend classes on dietary management of CRF. Feedback: INCORRECT Feedback: INCORRECT Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary. Points Earned: 0.0/1.0 Correct Answer(s): A Correct 14. The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records. Feedback: CORRECT A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client. Points Earned: 1.0/1.0 Correct Answer(s): A Incorrect 15. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A) In 8 weeks you will be able to bend at the waist to reach items on the floor. Feedback: INCORRECT B) Place a pillow between your knees while lying in bed to prevent hip dislocation. Feedback: CORRECT C) It is safe to use a walker to get out of bed, but you need assistance when walking. Feedback: INCORRECT [Show More]

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