( = was on my 266 HESI V1)
1. A client who underwent cardiac stent placement four days ago arrives to the
emergency department reporting a sudden onset of chest pressure and
shortness of breath. Which action should the nurse take next?
a. Listen for extra heart sounds, murmurs, and rhythm with the bell of
the stethoscope.
b. Evaluate upper and lower extremities for perfusion, pulse volume,
and pitting edema.
c. Verify troponin level assessments are scheduled every 3-6 hours
for a series of three.
d. Obtain a 12- lead electrocardiogram and begin continuous cardiac
monitoring.
3. a client with type 2 diabetes mellitus arrives to the clinic reporting episodes of
weakness and palpitations. Which finding should the nurse recognize as a
possible complication?
a. anxiety and sighing
b. myalgia in wrists and hands
c. hyperactive bowel sounds
d. dark yellow urine
4. While completing a health assessment for a client with migraine headaches,
the nurse assesses bilateral weakness in the clients hand grips. The client
reports joint pain and trouble twisting a door knob due to weaknesses. Which
action should the nurses take in response to these figures?
a. Implement fall precautions to reduce the clients risk of injury.
b. Explain that relief of the migraine pain will reduce related
symptoms.
c. Gather additional assessment data about the pain and weakness.
d. Consult with the occupational therapist for a functional assessment
Explanation: The nurse should gather additional assessment data about the pain and
weakness to better understand the client's condition and to determine if there is an
underlying issue or if the symptoms are related to the migraine headaches.
5. A client who has developed acute kidney injury (AKI) due to aminoglycoside
antibiotics has moved from the oliguric phase to the diuretic phase of AKI. Which
parameters are most important for the nurse to plan to carefully monitor?
a. Uremic irritation of mucous membranes and skin surfaces.
b. Hypovolemia and electrocardiographic (ECG) changes.
c. Side effects of total parental nutrition (TPN) and Intralipids.
d. Elevated creatinine and blood urea nitrogen (BUN).
,Explanation: During the diuretic phase of AKI, the client may experience increased urine
output, which can lead to hypovolemia and electrolyte imbalances. Monitoring for
hypovolemia and ECG changes can help detect any complications or worsening of the
client's condition.
6. The nurse is caring for a client diagnosed with psoriasis vulgaris who is
receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment
finding indicates that the client has been overexposed to the treatment?
a. Thick skin plaques topped by silvery white scales
b. Tenderness upon palpation and generalized erythema
c. Brown, rough, greasy, wart-like papules on the face
d. Requires sunglasses because sunlight hurts eyes
Explanation: Overexposure to PUVA treatment can cause skin irritation, tenderness,
and erythema. If the client exhibits these symptoms, the nurse should notify the
healthcare provider for possible treatment modifications.
7. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with
possible anastomosis leakage. The client's abdomen is tender to touch, and the
vital signs are temperature 101* F (38 3* C). heart rate 130 beats/minute,
respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg. Which
intervention is most important for the nurse to include in the client's plan of care?
a. Encourage regular turning.
b. Monitor skin for breakdown.
c. Strict IV fluid replacement.
d. Assess wound drainage daily.
Explanation: The client's vital signs indicate possible sepsis or systemic infection. Strict
IV fluid replacement is important to maintain adequate circulation, support blood
pressure, and treat potential sepsis. The other interventions are also essential but not
as critical as fluid replacement in this situation.
8. A client who was recently diagnosed with Raynaud’s disease is concerned
about pain management. Which nursing instructions should the nurse provide?
a. Painful areas should be rubbed gently until the pain subsides.
b. Return appointments will be needed for IV pain medications.
c. Enrolling in a pain clinic can provide relief alternatives.
d. Wearing gloves when handling cold items guards against painful
spasms.
Explanation: For clients with Raynaud's disease, cold temperatures can trigger painful
episodes. Instructing the client to wear gloves when handling cold items can help
protect against these episodes and manage pain.
9. A client with newly diagnosed Crohn’s disease asks the nurse about dietary
restrictions. How should the nurse respond?
, a. Explain that the need to restrict fluids is the primary limitation.
b. Advise the client to limit foods that are high in calcium and iron.
c. Instruct the client to avoid foods with gluten, such as wheat bread.
d. Describe the use of an elimination diet to find trigger foods.
Explanation: Individuals with Crohn's disease often have specific trigger foods that
exacerbate their symptoms. The nurse should describe the use of an elimination diet to
help the client identify and avoid these trigger foods to better manage their condition.
10. The nurse is obtaining a health history from a new client who has a history of
kidney stones. Which statement by the client indicates an increased risk for
renal calculi.?
a. Jogs more frequently than usual daily routine.
b. Eats a vegetarian diet with cheese 2 to 3 times a day.
c. Experiences additional stress since adopting a child.
d. Drinks several bottles of carbonated water daily.
Explanation: Diets high in animal protein, such as cheese, can increase the risk of
kidney stones. While the other options do not pose a direct risk for renal calculi, a diet
high in animal protein can contribute to the formation of stones.
11. An older male client tells the nurse that he is losing sleep because he has to
get up several times at night to go to the bathroom, that he has trouble starting
his urinary system, and that he does not feel like his bladder is ever completely
empty. Which intervention should the nurse implement?
a. Review the client’s fluid intake prior to bedtime.
b. Obtain a fingerstick blood glucose level.
c. Palpate the bladder above the symphysis pubis.
d. Collect a urine specimen for culture analysis.
Explanation: The client's symptoms suggest possible urinary retention, which is
common in older males with benign prostatic hyperplasia (BPH). Palpating the bladder
above the symphysis pubis can help the nurse assess for bladder distention and
provide information to guide further evaluation and management.
12. The nurse has conducted a cancer prevention community education
program. In evaluating the participants' understanding of the carcinogens, which
statement indicates an accurate understanding?
a. Environmental factors such as sunlight and chemicals can cause
cancer to spread.
b. Carcinogens are substances that contain cancerous cells.
c. Substances that change a cell so that it becomes cancerous are
potential sources of cancer.
d. Carcinogens are in the environment and cannot be avoided.
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