Hesi Fundamentals Practice
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit
formation of aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
B
...
Hesi Fundamentals Practice
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit
formation of aqueous humor for a client with glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide (Humorsol)
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so
unlike me, and I don't know why this is happening." What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being experienced.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse
applies a cooling blanket and administers an antipyretic medication. The nurse explains that
the rationale for these interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with diaphoresis.
Promote integrity of intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every
12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile
water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be
added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL
1.5
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning
Impaired skin integrity, related to the effects of pressure and shearing force
1
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue
down to the underlying fascia. The nurse should document the assessment finding as which
stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the
wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no
break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving
the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or
shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous
fat. Bone, tendon, and muscle are not exposed.
A client is being admitted for a total hip replacement. When is it necessary for the nurse to
ensure that a medication reconciliation is completed? Select all that apply.
After reporting severe pain
On admission to the hospital
Upon entering the operating room
Before transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client is taking and
comparing it to the health care provider's prescriptions on admission or when there is a transfer to a
different setting or service, or discharge. A change in status does not require medication
reconciliation. A medication reconciliation should be completed long before entering the operating
room. Total hip replacement is elective surgery, and scheduling takes place before admission;
medication reconciliation takes place when the client is admitted.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for
which of the following laboratory values?
White blood cell (WBC) count of 15,000 mm3
Negative protein in the urine
Blood urea nitrogen (BUN) of 20 mg/dL
Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC count is 5000 to
10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are
normal values.
Often when a family member is dying, the client and the family are at different stages of
grieving. During which stage of a client's grieving is the family likely to require more
emotional nursing care than the client?
Anger
Denial
2
Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment and may become
indifferent to family members. In addition, the family may take longer to accept the inevitable death
than does the client. Although the family may not understand the anger, dealing with the resultant
behavior may serve as a diversion. Denial often is exhibited by the client and family members at the
same time. During depression, the family often is able to offer emotional support, which meets their
needs.
The client asks the nurse to recommend foods that might be included in a diet for diverticular
disease. Which foods would be appropriate to include in the teaching plan? Select all that
apply.
Whole grains
Cooked fruit and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore
the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs
have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and
seeds are contraindicated as they may be retained and cause inflammation and infection, which is
known as diverticulitis. The client should also decrease intake of fats and red meats.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in
the knee. What should the nurse include in the pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
Client's purposeful body movement in arranging the papers on the bedside table
Pain pattern, including precipitating and alleviating factors
Vital signs such as increased blood pressure and heart rate
The client's family statement about increases in pain with ambulation
Accurate pain assessment includes pain history with the client's identification of pain location,
intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain
includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate
and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the
pain and determine it cause. Purposeless movements such as tossing and turning or involuntary
movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated
blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a
subjective experience and therefore the nurse has to ask the client directly instead of accepting
statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
3
Immediately stop the infusion.
Lower the height of the enema bag.
Advance the enema tubing 2 to 3 inches.
Clamp the tube for 2 minutes, then restart the infusion.
Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema
solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to
the distention without causing excessive discomfort. Stopping the infusion is not necessary.
Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting
the infusion may be attempted if slowing the infusion does not relieve the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse
observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces
the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
The nurse also should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was applied
Treatment should not have been instituted until the health care provider's prescriptions were received.
According to the Nurse Practice Act, a nurse may independently treat human responses to actual or
potential health problems. An activity level is prescribed by a health care provider; this is a dependent
function of the nurse. There is not enough information to come to the conclusion that debridement
should have been done before the dressing was applied. Application of an emollient and reinforcing a
dressing are independent nursing functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a
fight and that the client is now lying unconscious on the floor. What is the most important
action the nurse needs to take?
Ask the client if he is okay.
Call security from the room.
Find out if there is anyone else in the room.
Ask security to make sure the room is safe
Safety is the first priority when responding to a presumably violent situation. The nurse needs to have
security enter the room to ensure it is safe. Then it can be determined if the client is okay and make
sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
4 to 8 hours
12 to 24 hours
24 to 48 hours
72 to 96 hours
Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96
4
hours after initiation of use in p
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