HESI EXIT V4 160 Questions and Answers Part 7

130. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation The correct answer is A: Auscultation of an 131. The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis? A) Observe for edema proximal to the site B) Irrigate with 5 mls of 0.9% Normal Saline C) Palpate for a thrill over the fistula D) Check color and warmth in the extremity The correct answer is C: Palpate for a thrill over the fistula 132. A 2 year-old child is being treated with Amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 30 lb. (15 kg) and the daily dose range is 2040 mg/kg of body weight, in three divided doses every 8 hours. Using principles of safe drug administration, what should the nurse do next? A) Give the medication as ordered B) Call the health care provider to clarify the dose C) Recognize that antibiotics are over-prescribed D) Hold the medication as the dosage is too low The correct answer is A: Give the medication as ordered 133. The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when A) An individual displays restlessness B) There are obvious signs of depression C) Conducting any health assessment D) The resident reports memory lapses The correct answer is C: Conducting any health assessment 134. The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization? A) Younger siblings adapt very well B) Visitation is helpful for both C) The siblings may enjoy privacy D) Those cared for at home cope better The correct answer is B: Visitation is helpful for both 135. Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school because of a rash. The child had been seen the day before by the healthcare provider and diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the nurse? A) Tell the parents to bring the child to the clinic for further evaluation B) Refer the school officials to printed materials about this viral illness C) Inform the teacher that the child is receiving antibiotics for the rash D) Explain that this rash is not contagious and does not require isolation The correct answer is D: Explain that this rash is not contagious and does not requireisolation 136. When making a home visit to a client with chronic pyelonephritis, which nursing action has the highest priority? A) Follow-up on lab values before the visit B) Observe client findings for the effectiveness of antibiotics C) Ask for a log of urinary output D) As for the log of the oral intake The correct answer is C: Ask for a log of urinary output 137. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After discussing the defect with the parents, the nurse should expect that A) Circumcision can be performed at any time B) Initial repair is delayed until ages 6-8 C) Post-operative appearance will be normal D) Surgery will be performed in stages The correct answer is D: Surgery will be performed in stages 138. The nurse is assessing a client on admission to a community mental health center. The client discloses that she has been thinking about ending her life. The nurse's best response would be A) "Do you want to discuss this with your pastor?" B) "We will help you deal with those thoughts." C) "Is your life so terrible that you want to end it?" D) "Have you thought about how you would do it?" The correct answer is D: "Have you thought about how you would do it?" 139. The nursing care plan for a client with decreased adrenal function should include A) Encouraging activity B) Placing client in reverse isolation C) Limiting visitors D) Measures to prevent constipation The correct answer is C: Limiting visitors 140. The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care? A) Cough and deep breathe every 2 hours B) Place the client in contact isolation C) Provide a diet high in protein D) Institute seizure precautions The correct answer is A: Cough and deep breathe every 2 hours 141. Which of the following conditions assessed by the nurse would contraindicate theuse of benztropine (Cogentin)? A) Neuromalignant syndrome B) Acute extrapyramidal syndrome C) Glaucoma, prostatic hypertrophy D) Parkinson's disease, atypical tremors The correct answer is C: Glaucoma, prostatic hypertrophy 142. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A) Perform defibrillation B) Administer epinephrine as ordered C) Assess for presence of pulse D) Institute CPR The correct answer is C: Assess for presence of pulse 143. During the use of an interpreter to teach a client about a procedure to do in the homethe nurse should take which approach? A) Speak directly to the interpreter while presenting information and use pauses for questions B) Talk to the interpreter in advance and leave the client and interpreter alone C) Include a family member and direct communications to that person D) Face the client while presenting the information as the interpreter talks in the native language The correct answer is D: Face the client while presenting the information as theinterpreter talks in the native language . 144. A client is in her third month of her first pregnancy. During the interview, she tellsthe nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? A) Counsel the woman to consent to HIV screening B) Perform tests for sexually transmitted diseases C) Discuss her high risk for cervical cancer D) Refer the client to a family planning clinic The correct answer is A: Counsel the woman to consent to HIV screening 145. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which ofthe following positions? A) High Fowler's B) Supine C) Left lateral D) Low Fowler's The correct answer is A: High Fowler''s 146. A nurse who is evaluating a mentally retarded 2 year-old in a clinic should stress which goal when talking to the child's mother? A) Teaching the child self care skills B) Preparing for independent toielting C) Promoting the child's optimal development D) Helping the family decide on long term care The correct answer is C: Promoting the child''s optimal development 147. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assistthe client with nutrition needs, the nurse should A) Offer small meals of high calorie soft food B) Assist the client to sit in a chair for meals C) Provide additional servings of fruits and raw vegetables D) Encourage the client to eat fish, liver and chicken The correct answer is A: Offer small meals of high calorie soft food 148. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these is most likely to be seen with this diagnosis? A) Several otitis media episodes in the last year B) Weight and height in 10th percentile since birth C) Takes frequent rest periods while playing D) Changing food preferences and dislikes The correct answer is C: Takes frequent rest periods while playing 149. The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is A) Urinary output of 30 ml per hour B) No complaints of thirst C) Increased hematocrit D) Good skin turgor around burn The correct answer is A: Urinary output of 30 ml per hour 150. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of the following conditions would most likely explain these findings? A) Ingestion of tetracycline B) Excessive fluoride intake C) Oral iron therapy D) Poor dental hygiene The correct answer is B: Excessive fluoride intake 151. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice? A) An 18 month-old who ate an undetermined amount of crystal drain cleaner B) A 14 month-old who chewed 2 leaves of a philodendron plant C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain cleaner 152. Which of these is an example of a variation in the newborn resulting from the presence of maternal hormones? A) Engorgement of the breasts B) Mongolian spots C) Edema of the scrotum D) Lanugo The correct answer is A: Engorgement of the breasts 153. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? A) Elbow B) Mummy C) Jacket D) Clove hitch The correct answer is A: Elbow 154. A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to A) Notify the health care provider immediately B) Suggest in-patient psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk The correct answer is A: Notify the health care provider immediately 155. A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A) Altered nutrition: less than body requirements B) Potential complication hemorrhage C) Ineffective individual coping D) Fluid volume excess The correct answer is B: Potential complication hemorrhage 156. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior? A) Strange bed and surroundings B) Separation from parents C) Presence of other toddlers D) Unfamiliar toys and games The correct answer is B: Separation from parents 157. Which of the following should the nurse teach the client to avoid when taking chlorpromazine HCL (Thorazine)? A) Direct sunlight B) Foods containing tyramine C) Foods fermented with yeast D) Canned citrus fruit drinks The correct answer is A: Avoid direct sunlight 158. The initial response by the nurse to a delusional client who refuses to eat because ofa belief that the food is poisoned is A) "You think that someone wants to poison you?" B) "Why do you think the food is poisoned?" C) "These feelings are a symptom of your illness." D) "You’re safe here. I won’t let anyone poison you." The correct answer is A: "You think that someone wants to poison you?" 159. The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that A) The client should remain on bed rest in a semi-Fowler's position B) The client should alternate ambulation with bed rest with legs elevated C) The client may ambulate and sit in chair as tolerated D) The client may ambulate as tolerated and remain in semi-Fowler position in bed The correct answer is B: The client should alternate ambulation with bed rest with legselevated 160. The nurse is performing physical assessments on adolescents. When would the nurse anticipate that females experience growth spurts? A) About 2 years earlier than males B) About the same time as males C) Just prior to the onset of puberty D) That increase height by 4 inches each year The correct answer is A: About 2 years earlier than males