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Care I HESI Remediation Tutoring Flashcards | StudBud
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Care I HESI Remediation Tutoring
Care I HESI Remediation Tutoring
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1
Charge nurse is coordinating care. What should the delegate to a UAP?
Obtain vital signs on a client admitted 2 hours ago for hypertensive crisis
Turn and reposition a client with a stage three sacral pressure ulcer
Ambulate a client who is 4 hours post-op from a total hip replacement
Change the collection pouch and measure output on a pt with a new ostomy
2
A client in a long-term care facility reports to the nurse, “I have not had a bowel movement in 2 days.” First action?
Assess the client’s medical record to determine normal bowel pattern.
Notify the HCP and request a prescription for a large-volume enema.
Instruct the caregiver to increase fluids to five 8-ounce glasses per day.
Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
3
The nurse determines that a postop client’s RR has increased from 18 to 24 breaths/min. Priority nursing action?
Offer the client a high-carbohydrate snack for energy
Determine if pain is causing the client's tachypnea
Encourage the client to increase ambulation in the room
Force fluids to thin the client's pulmonary secretions
4
A visitor to a nursing home microwaves a metal container accidentally causing a fire in the living room. Nurse should...
Close doors and windows in nearby rooms
Notify the nursing staff of the electrical fire
Activate the fire alarm system and call 911
Move visitors, staff, and residents away from the room
5
A nurse is planning a heparin injection for an obese female client. What technique should be used?
25G, 1/2", do not aspirate, inject at 90 degree angle, does not massage
26G, 5/8", aspirate, inject at 45 degree angle, massages site
26G, 5/8", do not aspirate, injects at 15 degree angle, does not massage
22G, 1 1/2", aspirates, injects at 90 degrees, does not massage
6
For proper use of an MDI, which instruction should the nurse provide the client to ensure optimal benefits?
Exhale completely after compressing the inhaler and then inhale
Fill your lungs with air through your mouth and then compress the inhaler
Compress the inhaler while inhaling quickly through your nose
Compress the inhaler while slowly breathing in through your mouth
7
A terminally ill client tells the nurse, “I am so tired and in so much pain! Please help me to die.” Best response?
Administer the prescribed maximum dose of pain medication
Refer the client to the ethics committee of her local health care facility
Talk with the client about thoughts and feelings about death
Collaborate with the HCP about initiating antidepressant therapy
8
School nurse meets with 16yo. Reports exercising before and after school. BMI of 17. What question should the nurse ask?
Do you think you are overweight, underweight, or just right?
How often do you skip meals?
What type of exercise do you do everyday?
You don't think you are fat, do you?
9
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
Mode of transmission
Reservoir
Portal of exit
Portal of entry
10
A pt's K+ level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on cardiac monitoring? SATA:
Tall peaked T waves
Widened QRS complexes
ST depression
Prominent U wave
11
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Action?
Allow the client to cry alone and leave the client in the bathroom.
Sit quietly in the client’s room until the client leaves the bathroom.
Talk to the client and attempt to find out why the client is crying.
Instruct a UAP to stay and keep talking to the client.
12
The nurse notes an older pt who is incontinent of stool has an area of erythema over the sacrum. What should they do?
Measure temperature and vital signs
Gently apply pressure over the affected area
Assess for other episodes of incontinence in the EMR
Determine the client's mibility status
13
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
Put bed rails up on the side of bed opposite from the nurse.
Lower the head of the client’s bed slowly.
Correctly position and use a turn sheet.
Securely grasp the client’s arm and leg.
14
After morning report, the nurse is prioiritizing. Which should they assess first?
Client with a CVA having difficulty sitting up in bed independently
Child with otitis media complaining about yellow green fluid from the ear
Client receiving heparin infusion experiencing epistaxis after sneezing
Client w/ total knee replacement surgery reporting difficulty bending knee
15
The nurse sustains a needle stick injury when caring for a client who is HIV positive. What should they do first?
Complete risk assessment stratification protocol
Start post-exposure prophylaxis for HIV
Notify supervisor of the incident
Wash puncture site with soap and water
16
A charge nurse observes a new hire inserting an NG tube for a client diagnosed with dysphagia. What should they correct?
Schedules an x-ray to confirm placement of the NG tube
Asks the client to take a sip of water while advancing the NG tube
Applies non-sterile gloves
Positions the client in high Fowler's with the neck flexed, chin to chest
17
A pt is admitted through the ER for cramping pain of the lower abdominal quadrant. They report n/v at home. Priority?
Obtain IV access
Remove soda and snacks from the bedside
Document allergies and current medications
Administer pain medication as prescribed
18
In taking a client’s history, the nurse asks about the stool. Which description should the nurse report to the HCP ASAP?
Firm brown stool every other day
Daily dark brown stool
Daily black, sticky stool
Soft light brown stool twice a day
19
The nurse is caring for a client with a nasogastric tube that is attached to low suction. Pt is monitored for what?
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
20
ABGs
Respiratory acidosis, uncompensated
Respiratory alkalosis, compensated
Metabolic acidosis, compensated
Metabolic alkalosis, uncompensated
21
The nurse is assessing a client in skeletal traction. Which assessment requires the most immediate intervention?
Bed linens damp and wrinkled
No BM in the last 24 hours
Client reports feelings of depression and boredom
Clear liquid draining from pin site
22
The nurse is assessing a pt with a suspected dx of hypocalcemia. Which manifestation would the nurse expect to note?
Hypoactive bowel sounds
Negative Trousseau's sign
Hypoactive deep tendon reflexes
Twitching
23
Family of an elderly Japanese woman is upset b/c she has not received pain meds. Nurse says the pt never complained.
Clients from Asian cultures often believe in the power of medication
In Japanese culture people often show stoic reponse to pain, look to cues
Elderly clients often complain to children about care as a coping mechanism
The nurse was being sloppy
24
On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?
The client who requires intermittent gastrointestinal suctioning
The client with kidney disease and a 12-year history of diabetes mellitus
The client taking diuretics who has tenting of the skin
The client with an ileostomy from a recent abdominal surgery
25
The nurse plans to administer diazepam, 4 mg IV push, to a client with anxiety. How many mL should the nurse give?
0.8
1.25
5
1
26
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?
The client with hyperaldosteronism
The client with Cushing's syndrome
The client who is taking diuretics
The client who is taking corticosteroids
27
A client has an NG tube with suction. When administering medications through the tube, what should the nurse do first?
Turn off the intermittent suction device.
Clamp the nasogastric tube.
Confirm placement of the tube.
Use a syringe to instill the medications.
28
Rx reads 15u NPH and 5u regular insulin with meals + sliding scale. How much to admin at dinner if BG is 225 mg/dL?
9
25
24
19
29
Nurse is making morning rounds. Who should they see first?
Client requesting pain medication prior to breakfast
Client who needs help getting ready for physical therapy
Client with blood glucose of 55 mg/dL
Client whose IV infusion is nearly empty
30
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first?
The victim who is crying, complaining of arm pain, and no other injuries
The victim who is heavily bleeding bright red blood from a thigh wound
The victim who is bleeding out of ears, nose and mouth, with a blank stare
The victim who is not breathing and does not have a pulse
31
A client receiving CPR and defibrillation has a HR of 50 bpm and regular pulse. What should be done to support?
Asseess the client's BP and raise HOB
Continue cardiac compressions since the client is not breathing
Continue defibrillation until the HR reaches 80
Ensure the pt has adequate airway and is receiving ventilation
32
The nurse is preparing to administer a bolus tube feed. What steps must the nurse include prior to administering? SATA:
Irrigate the lumen after the contents are replaced
Assess bowel sounds
Warm the feeding to room temperature
Aspirate the stomach contents
33
Pt's chart reads "has insensible fluid loss of ~800 mL daily". Nurse notes insensible fluid loss occurs through what?
Integumentary output
Wound drainage
The gastrointestinal tract
Urinary output
34
Order: 0.5 mg/kg of dexamethasone. The child weighs 28 pounds. Dexamethasone is avail in 1mg/1mL. What device to use?
Empty choice
Empty choice
Empty choice
Empty choice
35
Which client should a nurse see first when coming on shift?
Client needs to be turned and repositioned q2h.
Check blood glucose prior to reciving morning insulin before breakfast
Client needs morning bath prior to attending PT at 10 am
Client needs to be assisted with ambulation once per shift
36
A client diagnosed with HIV asks that their spouse not be informed. What is the best action for the nurse to take?
Convince the client that he has an ethical principle to tell his spouse
Inform the client that the local health dept. will contact his spouse
Invite the spouse to the clinic and explain that an HIV test must be done
Explain that all client information is conidential, so cannot be released
37
The nurse is concerned that a client with an ileostomy is experiencing a complication. Which should be reported to HCP?
Stoma protruding 2 cm from the abdominal wall
Pink skin around the stoma
Bulging around the stoma
Thick yellow-brown drainage in the collection device
38
Which serum lab value should the nurse monitor carefully for a client who has a NG tube to suction for the past week?
WBC
Albumin
Sodium
Calcium
39
A client who is an Orthodox Christian asks that insulin and breakfast be held until after they take communion. Action?
Notify the physician of the client's refusal to eat breakfast
Inform the client that the insulin must be given as prescribed
Document that the client refused morning medication and breakfast
Provide the insulin and breakfast after the priest provides communion
40
Which action is most important in the care for a pt at high risk for the development of postop thrombuss formation?
Instruct in the use of the incentive spirometer.
Elevate the head of the bed during all meals.
Encourage frequent ambulation in the hallway.
Use aseptic technique to change the dressing.
41
The client states to the nurse, “This medication makes my mouth so dry.” What are the nurse’s suggestions? SATA:
Infuse your water with fresh citrus fruits to quench your thirst
Keep a few pieces of hard candy with you to suck on
Freeze strawberries and water together in popsicle mold
Drink 2, 8 ounce glasses of lemon-lime soda daily
42
Shortly after insertion of an indwelling catheter, a client complains of pain. What should the nurse do?
Obtain an order for medication to treat a possible infection
Explain that a little discomfort is to be expected and reassure the client
Deflate the balloon, remove the catheter, replace with a new one
Obtain a urine sample for testing
43
The nurse is at a teen event. Which teen’s statement would cause the nurse to input some safety tips? SATA:
I hang around with my friends after the games, like football and baseball
I work until 10:00 at a local fast-food restaurant
I never use my seatbelt when I am driving, I hate the way it feels
My boyfriend and I fool around on occasion, but he never comes inside me
44
The nurse is concerned about nosocomial infection for an incontinent pt. Best action to take when providing care?
Maintain standard precautions
Insert an indwelling urinary catheter
Initiate contact isolation procedure
Instruct client in the use of adult diapers
45
The nurse is about to give a 14yo pt a prescribed antipsychotic and sees that consent has not been obtained. Action?
Review the chart for a signed consent for hospitalization
Complete an incident report and notify parents
Get the HCP's permission to give the medication
Do not give the medication and document the reason
46
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?
The client who has been overusing laxatives
The client with Cushing's syndrome
The client who has sustained a traumatic burn
The client with colitis
47
Question in picture
Muscle twitches
Hyperactive bowel sounds
Increased specific gravity of urine
Decreased urinary output
48
The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?
Private room or cohort client
Mask worn by staff when the client needs to leave the room
Private room with negative airflow pressure
Personal respiratory protection device
49
A nurse is assigned to care for a close friend. Which action should the nurse take first when given the assignment?
Explain the relationship to the charge nurse and ask for reassignment
Approach the client to ask if the assignment is uncomfortable
Notify the friend that all medical information will be kept confidential
Accept the assignment but protect the client's confidentiality
50
The nurse is reviewing a client’s lab results. The sodium level is 128 mEq/L. The nurse should be alert for what? SATA:
+1 reflexes to the patella
Weakness in the hands and feet
Muscle twitching
Headache
