NURS 2520 Hesi exit Exam

⦁ Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? ⦁ Remind the client that it is also important to switch to decaffeinated coffee and tea. ⦁ c. ⦁ Suggest that the client also plan to eat frequent small meals to reduce discomfort d. Reinforce this teaching by asking the client to list a dairy food that he might select. ⦁ A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed med- ication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? ⦁ Blindness secondary to cataracts ⦁ Acute kidney injury due to glomerular damage ⦁ Stroke secondary to hemorrhage ⦁ Heart block due to myocardial damage ⦁ The nurse observes an unlicensed assistive personnel (UAP) posi- tioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? ⦁ Ensure that the UAP has placed the pillows effectively to protect the client. ⦁ Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. ⦁ Assume responsibility for placing the pillows while the UAP completes another task. ⦁ Ask the UAP to use some of the pillows to prop the client in a side lying position. ⦁ An adolescent with major depressive disorder has been taking du- loxetine (Cymbalta) for the past 12 days. Which assessment find- ing requires immediate follow-up? ⦁ Describes life without purpose ⦁ Complains of nausea and loss of appetite ⦁ States is often fatigued and drowsy ⦁ Exhibits an increase in sweating. Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder. B, C and D are side effects ⦁ A 60-year-old female client with a positive family history of ovar- ian cancer has developed an abdominal mass and is being evaluat- ed for possible ovarian cancer. Her Papanicolau (Pap) smear re- sults are negative. What information should the nurse include in the client’s teaching plan? ⦁ Further evaluation involving surgery may be needed ⦁ A pelvic exam is also needed before cancer is ruled out ⦁ Pap smear evaluation should be continued every six month ⦁ One additional negative pap smear in six months is needed. Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully ⦁ A client who recently underwear a tracheostomy is being pre- pared for discharge to home. Which instructions is most impor- tant for the nurse to include in the discharge plan? ⦁ Explain how to use communication tools. ⦁ Teach tracheal suctioning techniques ⦁ c- Encourage self-care and independence. d- Demonstrate how to clean tracheostomy site. ⦁ In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely dur- ing inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? ⦁ Encourage the client to take deep breaths ⦁ Remove the mask to deflate the bag ⦁ Increase the liter flow of oxygen ⦁ Document the assessment data ⦁ During a home visit, the nurse observed an elderly client with di- abetes slip and fall. What action should the nurse take first? ⦁ Give the client 4 ounces of orange juice ⦁ Call 911 to summon emergency assistance ⦁ Check the client for lacerations or fractures ⦁ Asses clients blood sugar level ⦁ At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? ⦁ Ensure preoperative lab results are available ⦁ Start prescribed IV with lactated Ringer’s ⦁ Inform the anesthesia care provider ⦁ d- Contact the client’s obstetrician. ⦁ After placing a stethoscope as seen in the picture, the nurse auscul- tates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? ⦁ Side the stethoscope across the sternum. ⦁ Listen with the bell at the same location ⦁ Move the stethoscope to the mitral site c. ⦁ Observe the cardiac telemetry monitor 11.A 66-year-old woman is retiring and will no longer have a health in- surance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? ⦁ Woman, Infant, and Children program ⦁ Medicaid ⦁ Medicare ⦁ Consolidated Omnibus Budget Reconciliation Act provision. Rationale: Title XVII of the social security Act of 1965 created ⦁ client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?