HESI Critical Care Exam Questions Part 4

52. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? A. Educate significant others about providing support for their partner during labor. B. Teach and practice breathing techniques to help cope with contractions during labor. C. Participants can identify at least three coping strategies to use during labor. Correct D. Introduce comfort measures that are effective techniques to use during labor and delivery. An expected outcome is a specific, measurable change in a client's status that occurs in response to nursing interventions. (B) meets the criteria for an expected outcome. (A, C, and D) are nursing interventions that should lead to the expected outcome. 53. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation? A. Health promotion. B. Primary prevention. C. Secondary prevention. Correct D. Tertiary prevention. Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence. (A) would be activities that occur before the disease process begins, such as providing community seminars on the risks, and signs and symptoms of domestic violence. (C) occurs after the disease process has started, and includes referring the client to a battered women's shelter for treatment following unabated, chronic abuse. Health promotion can be incorporated in all levels of prevention (D). 54. Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio? A. Copies of any articles the nurse has read that relate to client care on the nursing unit. B. Evaluations by past nursing faculty and employers to document ongoing competence. C. Letters of support from family members and friends who are healthcare professionals. D. A self-evaluation that identifies how the nurse has met professional objectives and goals. Correct A clinical portfolio should include pertinent information that assists in providing a comprehensive view of the employee's performance. A self-evaluation (D) provides an important assessment of the nurse's strengths, weaknesses, and progress toward the achievement of professional goals. (A) is not pertinent nor useful evaluative data regarding current performance. While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, (B) is not necessary. (C) is not a significant component of a clinical portfolio. 55. When engaging in planned change on the unit, what should the nurse-manager establish first? A. Resources needed for the change are available. B. Staff members are aware of the need for change. Correct C. Goals for achieving the change are established. D. Options for accomplishing the change are explored. Incorrect The first step in planned change involves establishing a relationship with those involved in the change process and instilling knowledge and awareness of the need for change (D). The nursemanager should next implement (C), and then (A and B). 56. A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map? A. Multidisciplinary group. Correct B. Single-discipline group. C. Nurse-manager group. D. Surgical staff group. In a multidisciplinary work group (B), a number of individuals from a variety of disciplines are involved in developing the care map, but each works independently to implement the care plan. Single-discipline work groups (C), such as (A or D), are likely to focus on the aspects of the care map related only to their specific discipline. 57. The scope of professional nursing practice is determined by rules promulgated by which organization? A. American Nurses Association (ANA). B. State's Board of Nursing. Correct C. State Nursing Associations. D. National Labor Relations Board (NLRB). The state's Board of Nursing (A) is authorized to promulgate rules and regulations that carry the weight of law. The State Legislature delegates its law-making authority to this administrative law body. (B and C) are influential in defining and describing nursing standards of care, but neither have the authority to pass laws that legally define the professional scope of nursing practice. Although (D) may rule on issues important to nursing practice, the scope of professional nursing practice is determined by the laws, rules, and regulations promulgated by state Boards of Nursing. 58. An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? A. Stage 3. Correct B. Stage 1. C. Stage 2. D. Stage 4. Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling. 59. After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? A. An anxious client who is 3 days post myocardial infarction. B. A client whose blood transfusion is near completion. C. The client with type 2 diabetes mellitus who has a call light on. D. The client who has a new onset of difficult breathing. Correct Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A). 60. When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care? A. Referring and consulting with other healthcare specialities. B. Informing about the findings that determine clinical diagnosis. C. Coordinating and educating about multidisciplinary services. Correct D. Providing information on financial assistance programs. Clinical decisions to achiev e client outcomes require collaborative efforts between the interdisciplinary team and the client-family cooperation. The nurse's role as collaborator of care is best displayed by coordinating and educating the client and family about multidisciplinary services (A). Information about financial assistance programs (B) is most often a role of social services. Although the nurse refers and consults with the healthcare team (C), client-focus care is best identified within a collaborative nurse-client-family relationship. Informing the client about a clinical diagnosis (D) is the responsibility of the healthcare provider. 61. Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer? A. 1.5 mL. Correct B. 0.5 mL. C. 2 mL. D. 1 mL. To correctly solve this problem, use the formula: Desired/On Hand, or the algebraic formula: 75: x = 50 : 1. 50x = 75. x = 75/50 or reduced to 1.5 mL (C). 62. A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? A. Mashed potatoes. B. Dried prunes. Correct C. Mustard greens. D. Cottage cheese. A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet. 63. A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? A. Headache, diaphoresis, and palpitations. B. Hypotension, rapid weak pulse, and rapid respiratory rate. Correct C. Thin, fragile skin, ecchymoses, and complaints of weakness. D. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium. The clinical manifestations of Addisonian crisis are often the manifestations of shock (C); the client is at risk for circulatory collapse and shock. (A) indicates clinical manifestations of Cushing's syndrome, (B) of pheochromocytoma (tumor of adrenal medulla), and (D) of thyroid storm (thyrotoxic crisis). 64. The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? A. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis. B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. Correct C. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long. D. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube. A soft rubber catheter with a blunt tip is preferable (B) and deep, vigorous suctioning (D) should be avoided. The client should not hold his breath (A) whether he has one or two lungs and 5 seconds of suctioning is not enough to justify the trauma caused by suctioning. Having another person available for restraint is a good idea if the client is combative or confused, but (C) is not the best answer to this question. It is important to avoid (D) in order to avoid perforating the sutures on the bronchial stump following a pneumonectomy. 65. A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? A. Rebreather mask. B. Venturi mask. C. Hand-held nebulizer. D. Nasal cannula. Correct (C) will provide oxygen without covering the client's face. (A and B) are also masks and will not alleviate the problem of feeling "smothered." (D) is used for medication administration rather than oxygen. 66. Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? A. Encourage the client to breathe slower. B. Notify the healthcare provider of the crisis blood gas values. C. Encourage the use of an incentive spirometer. Correct D. Increase the oxygen flow to 6 liters/minute. The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation (PaC02 > 45). The client needs to be encouraged in activities that increase the depth of breathing (e. g., use of the incentive spirometer) (B). (A) will only increase an already adequate Pa02. These are not crisis blood gas findings (C). (D) will only worsen the hypoventilation. 67. A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? A. Teach that anger will subside after two weeks on antidepressants. B. Ask client to describe triggers of anger. Correct C. Gather more data about social support. D. Collaborate with the treatment team about revising the goal. Depression is associated with feelings of anger, and clients are often not aware of these feelings. Awareness is the first step in dealing with anger (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings (B). Anger may persist after beginning antidepressant therapy (A), and it may not be necessary to revise the goal (D). (C) can assist the client to cope, but it's most important to ask the client to describe triggers of anger. 68. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? A. Wanting the drug is all that matters to an addict. Correct B. Addicts who use illegal drugs are trying to escape reality. C. Addiction causes people to steal and lie. D. Those who are unhappy with themselves are more likely to become addicts. The hallmark characteristic of addiction is impaired control (D): all that matters is obtaining the drug of choice. (A) may or may not be true, but is not the primary characteristic of addiction. (B) is a manifestation of impaired control. Addiction is not caused by being unhappy with one's self, but such unhappiness is usually a result of addiction (C). 69. The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with A. congestive heart failure. B. diabetes insipidus. C. spinal cord injury. Correct D. gastrointestinal hemorrhage. Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock. 70. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? A. I will be your primary resource person, and will gather the information you need to get through this situation. B. Based on past coping, I believe you will be able to deal with future problems successfully. C. I have a plan of action that I think will help you. Would you like to see if it will work for you? D. You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? Correct (D) acknowledges the stress and encourages the client to discuss options to deal with the problems. Recognizing early signs/symptoms of heightened stress can help to avert a crisis. (A and C) deny the client the opportunity to take control of the problem and use problem solving techniques to resolve the situation. (B) may be offering false reassurance. 71. A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? A. Apply warm compresses to reduce swelling. B. Take acetaminophen (Tylenol) for any eye discomfort. C. Avoid sharing towels and washcloths with siblings. Correct D. Wear sunglasses to protect eyes from sunlight. All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and washcloths (D) and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. (A, B, and C) are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention.