HESI Comprehensive Exam (B) Correct 100%

if bleeding or other signs of neurologic impairment occur, the infusion should be stopped The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.) - ANSWER An Rh-negative woman who has had a miscarriage at 24 weeks, An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs test, & An Rh-negative mother with a negative antibody titer at 28 weeks (RhoGAM should never be given to an infant or father!) A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? - ANSWER Chills, fever, and sore throat--Cyclophosphamide is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? - ANSWER place infant in prone position--alleviates pressure on the surgical site, which is in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiber diet should be implemented to prevent constipation. A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? - ANSWER Maternal temperature-- this should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.) - ANSWER Umbilical cord contains one vein and two arteries & Slightly edematous labia in the female newborn A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? - ANSWER access client's vital signs The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is 2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? - ANSWER Planning--allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) - ANSWER Inhalation of powder form, Handling of infected animals, Eating undercooked meat from infected animals & Direct cutaneous contact with the powder The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? - ANSWER 10:30 AM (Regular insulin is short-acting and peaks between 2 and 3 hours after administration. The client is most at risk for a hypoglycemic reaction during the peak times) The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? - ANSWER O2 Saturation of 89% A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? - ANSWER Assign the client to a semiprivate room.--It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? - ANSWER Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? - ANSWER A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.) - ANSWER Quiet environment, Deep tendon reflex assessments, Neurologic checks & Daily weights A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement? - ANSWER answer all questions regarding the procedure--This action assists the couple in coping with the situation The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? - ANSWER Usual prepregnant weight A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? - ANSWER Agoraphobia--fear of crowds 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? - ANSWER Position in a high Fowler position with the legs down.--Positioning the client in a high Fowler position with dangling feet will decrease further venous return to the left ventricle. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? - ANSWER There will continue to be a risk of alcohol and drug interaction--Alcohol enhances the side effects of fluphenazine HCl. The half-