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