HESI EXIT V4 160 Questions and Answers Part 6

108. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find anyair leaks in the system. The next best action for the nurse is to A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage The correct answer is A: Check for subcutaneous emphysema in the upper torso 109. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers The correct answer is D: SA node, AV node, Bundle of His, Purkinje fibers 110. When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations The correct answer is D: 4. Continue to monitor respirations 111. A new nurse on the unit notes that the nurse manager seems to be highly respectedby the nursing staff. The new nurse is surprised when one of the nurses states: "The manager makes all decisions and rarely asks for our input." The best description of the nurse manager's management styleis A) Participative or democratic B) Ultraliberal or communicative C) Autocratic or authoritarian D) Laissez faire or permissive The correct answer is C: Autocratic or authoritarian 112. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response? A) "You’ve made some decisions." B) "Are you thinking about killing yourself?" C) "I’m so glad to hear that you’ve made some decisions." D) "You need to discuss your decisions with your therapist." The correct answer is B: "Are you thinking about killing yourself?" 113. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, what must the nurse understand about adolescents with hemophilia? A) Must have structured activities B) Often take part in active sports C) Explain limitations to peer groups D) Avoid risks after bleeding episodes The correct answer is B: Often take part in active sports 114. When an autistic client begins to eat with her hands, the nurse can best handle the problem by A) Placing the spoon in the client’s hand and stating, "Use the spoon to eat your food." B) Commenting "I believe you know better than to eat with your hand." C) Jokingly stating, "Well I guess fingers sometimes work better than spoons." D) Removing the food and stating "You can’t have anymore food until you use the spoon." The correct answer is A: Placing the spoon in the client’s hand and stating "Use the spoonto eat your food." 115. In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing? A) White patches B) Green drainage C) Reddened tissue D) Eschar development The correct answer is C: Reddened tissue 116. Which therapeutic communication skill is most likely to encourage a depressed client to vent feelings? A) Direct confrontation B) Reality orientation C) Projective identification D) Active listening The correct answer is D: Active listening 117. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize A) Learning relaxation techniques B) Limiting alcohol use C) Eating smaller meals D) Avoiding passive smoke The correct answer is A: Learning relaxation techniques 118. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? A) Arterial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect The correct answer is D: Ventricular septal defect 119. Clients with mitral stenosis would likely manifest findings associated with congestion in the A) Pulmonary circulation B) Descending aorta C) Superior vena cava D) Bundle of His The correct answer is A: Pulmonary circulation 120. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control The correct answer is B: There is a relationship between smoking and low birth weight 121. What is the best way for the nurse to accomplish a health history on a 14 year-old client? A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group The correct answer is B: Allow an opportunity for the teen to express feelings 122. What principle of HIV disease should the nurse keep in mind when planning care fora newborn who was infected in utero? A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated The correct answer is B: The infant is very susceptible to infections 123. While planning care for a preschool aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom The correct answer is B: Expressing shame 124. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? A) Maintain a low sodium diet B) Take a diuretic with lithium C) Come in for evaluation of serum lithium levels every 1-3 months D) Have blood lithium levels drawn during the summer months The correct answer is D: Have blood lithium levels drawn during the summer months 125. While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? A) Immediately B) Several days C) 2 weeks D) 1 month The correct answer is C: 2 weeks 126. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include A) Pointing out inconsistencies in speech patterns to correct thought disorders B) Accepting client and the client's behavior unconditionally C) Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day Review Information: The correct answer is D: Consistent limit-setting enforced 24 hoursper day 127. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A) Craving B) Crashing C) Outward bound D) Nodding out The correct answer is B: Crashing 128. The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states "I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? A) Denial B) Projection C) Intellectualization D) Rationalization The correct answer is D: Rationalization 129. One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships The correct answer is B: There is typically a series of minor, vague complaints