The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A. Suctions oral secretions from mouth
B. Positions head of bed flat when changing sheets
C. Takes temperat...
NURSING SURGICAL NCLEX-PN HESI COMP B
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving
enteral tube feedings. Which task performed by the UAP requires immediate
intervention by the nurse?
A. Suctions oral secretions from mouth
B. Positions head of bed flat when changing sheets
C. Takes temperature using the axillary method
D. Keeps head of bed elevated at 30 degrees
B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client
at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A,
C, and D).
When caring for a postsurgical client who has undergone multiple blood transfusions,
which serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level
higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C,
and D).
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge
(A). HPV is not recommended until adolescence (B). Varicella immunization begins at
12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be delegated to
unlicensed assistive personnel (UAP)?
A. Assess the need to change a central line dressing.
B. Obtain a fingerstick blood glucose level.
C. Answer a family member's questions about the client's plan of care.
D. Teach the client side effects to report related to the current medication regimen.
B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate
skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement?
(Select all that apply.)
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,NURSING SURGICAL NCLEX-PN HESI COMP B
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C. Assess the client for signs of bleeding during and after the infusion.
D. Start t-PA within 6 hours after the onset of stroke symptoms.
E. Initiate multidisciplinary consult for potential rehabilitation.
B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA.
This includes close monitoring for bleeding during and after the infusion; if bleeding or
other signs of neurologic impairment occur, the infusion should be stopped (B, C, and
E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A).
The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of
a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).
When caring for a client in labor, which finding is most important to report to the primary
health care provider?
A. Maternal heart rate, 90 beats/min.
B. Fetal heart rate, 100 beats/min
C. Maternal blood pressure, 140/86 mm Hg
D. Maternal temperature, 100.0° F
B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the
average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160.
The others (A, C, and D) are normal findings for a woman in labor.
The nurse is caring for a client with heart failure who develops respiratory distress and
coughs up pink frothy sputum. Which action should the nurse take first?
A. Draw arterial blood gases.
B. Notify the primary health care provider.
C. Position in a high Fowler's position with the legs down.
D. Obtain a chest X-ray.
C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further
venous return to the left ventricle (C). The other actions should be performed after the
change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops
rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?
A.Administer a dose of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations.
A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike
face are extrapyramidal side effects associated with Thorazine. It is most important for
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, NURSING SURGICAL NCLEX-PN HESI COMP B
the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A).
The others (B, C, D) may be appropriate interventions but are not as urgent as (A).
A nurse is interviewing a mother during a well-child visit. Which finding would alert the
nurse to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words
B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The
milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger
anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about
12 months (D).
Which intervention should be included in the plan of care for a client admitted to the
hospital with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen
the condition.
The nurse is caring for a client with deep vein thrombosis who is on a continuous IV
heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which
action should the nurse take?
A. Increase the rate of the heparin infusion using a nomogram.
B. Decrease the heparin infusion rate and give vitamin K IM.
C. Continue the heparin infusion at the current prescribed rate.
D. Stop the heparin drip and prepare to administer protamine sulfate.
D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should
be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would
increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is
the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would
increase the risk for hemorrhage (C).
While assessing a client with recurring chest pain, the unit secretary notifies the nurse
that the client's health care provider is on the telephone. What action should the nurse
instruct the unit secretary to implement?
A. Transfer the call into the room of the client.
B. Instruct the secretary to explain reason for the call.
C. Ask another nurse to take the phone call.
D. Ask the health care provider to see the client on the unit.
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