HESI Critical Care Exam Questions Part 3

35. Which information should the nurse give a client with chronic kidney disease (CKD)? A. Obtain monthly B12 injections. B. Restrict calcium-rich foods. C. Avoid salt substitutes. Correct D. Increase daily intake of fiber. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD. 36. A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? A. Part of a combination of chemotherapeutic agents used to treat tumors. B. An used to reduce the risk of breast cancer for all women. C. Low doses of tamoxifen prevent menopausal hot flashes. D. This anti-estrogen drug inhibits malignancy growth. Correct Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth. 37. A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? A. The nurse who is caring for another client receiving intracavitary radiation. B. A nurse with Marfan's syndrome who is postmenopausal. Correct C. A nurse with oncology experience who may be pregnant. D. The nurse who is caring for another client who has Clostridium difficile. A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D). 38. Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? A. Use condoms for sexual intercourse during the next week. B. Notify the healthcare provider if heavy vaginal discharge occurs. C. Use a sanitary napkin instead of a tampon. Correct D. Flat subclinical mucosal lesions are a common harmLess side effect. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported. 39. Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? A. Case manager. Correct B. Nurse-manager. C. Discharge manager. D. Quality manager. The role of the case manager (A) is to assist the continuum of care for the client, and coordinate the plan of care, evaluate client needs, and collaborate with the interdisciplinary healthcare team to ensure that goals are met, quality is maintained, and progress toward discharge is made. (B) focuses on staffing and assigning work on client units. (C) reviews research and assesses opportunities for process improvement, implement changes, measure outcomes, and start the improvement process. (D) is responsible for all of the discharge needs of clients at the time of discharge but would not be involved with client admission activities. 40. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? A. Expresses fear about the surgical procedure. B. Reports a history of hives after eating shellfish. C. States has a history of post-operative nausea. D. Recalls drinking a glass of juice after midnight. Correct The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications. 41. The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? A. Rebelliousness requires consequences to prevent socially deviant behavior. B. The parents should consider hospitalization to prevent self injury. C. Adolescents who demonstrate labile behaviors are at risk for self-injury. D. Early adolescence is a developmental stage of normal experimentation.Correct The nurse should support the parents by explaining that early adolescence is a developmental change spurred by hormonal increases in pubescence and teenage experimentation with values, choices, and peer acceptance (C). (A, B, and D) are not applicable in the context of this adolescent's behavior. 42. The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? A. Direct the questions to the spouse whenever possible. B. Ask another nurse to complete the interview. C. Ask the spouse to step out for a few minutes. Correct D. Repeat each question and tell the client to speak up. The nurse should ask the spouse to step out of the room (D), which maintains the client's privacy and allows the client to respond, without confronting the spouse. (A) reinforces the spouse's responses. (B) may not eliminate the spouse's responses on behalf of the client. (C) does not foster the nurse-client relationship. 43. The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" A. Markedly obese. B. Inadequate lifestyle changes in diet and exercise. Correct C. Morbidly obese. D. Increased morbidity and mortality risks. Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). (C) best identifies factors that contribute to the formulation of the nursing diagnosis. (A and B) are medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses (D), such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis. 44. The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? A. Purplish-red pinpoint lesions of the skin. Correct B. Generalized reddish discoloration of an area of skin. C. Small circumscribed elevations containing purulent fluid. D. Purple to bluish discoloration of the skin. Petechiae are described as purplish to red, non-blanchable, pinpoint lesions (A) that are tiny hemorrhages within the dermal or submucosal layers. (B) describes ecchymosis caused by trauma to the underlying blood vessels. (C) describes pustules. (D) is nonspecific and incomplete. 45. The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? A. A Hispanic client may have inward-turned eyelashes. B. A Caucasian client may have a slightly protruding eyeball. C. An African-American client may have slightly yellow sclerae. Correct D. An Asian client may have a horizontal palpebrale fissure. Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera for (C) is a normal racial variation found in the African-American population. (A, B, and D) are findings not related to one racial group. 46. During the physical assessment, which finding should the nurse recognize as a normal finding? A. Jugular venous pressure palpable with the client in an upright position. B. Point of maximal impulse at the third intercostal space in the right midclavicular line. C. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. D. Regular pulsation at the epigastric area when the client is supine.Correct Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment. 47. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? A. Loss of central reflexes. B. Unequal pupils. Incorrect C. Inability to open the eyes. D. Change in level of consciousness. Correct Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function. 48. When documenting assessment data, which statement should the nurse record in the narrative nursing notes? A. Slight tenderness in the left upper quadrant. B. Most all permanent teeth are present. C. Hair is within normal limits. D. S1 murmur auscultated in supine position. Correct Documentation of subjective and objective data obtained from the physical assessment should be communicated using precise, descriptive, clear, and accurate information, such as auscultated heart sounds while the client is in a specified position (C). (A, B, and D) are nonspecific. 49. A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? A. Obsessive. Correct B. Delusional. C. Paranoid. D. Phobic. Obsessive thoughts (A) are thoughts that the client is unable to control. (B) are irrational fears. (C) are false beliefs. (D) are suspicious thoughts. 50. The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take? A. Ask when the healthcare provider plans to return to the office and the usual office hours. B. Provide the receptionist with the client's name, age, and type of reaction. C. Ask the receptionist to notify the client's family if the healthcare provider cannot be contacted. D. Tell the receptionist to have the healthcare provider return the phone call. Correct The best nursing action is to ask for a return call from the healthcare provider (B) because the nurse must maintain the client's confidentiality. (A) is acceptable, but the best action is to leave a telephone number and request a return call. (C or D) do not promote confidentiality. 51. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? A. Right lateral side with both legs flexed. B. Left supine with thighs flexed on her abdomen. C. Semi-Fowler's with head of bed elevated 30 degrees. D. Supine with the foot of the bed elevated. Correct The supine position with the foot of the bed elevated (D) (Trendelenburg) is one position used to alleviate gravitational pressure by the fetus on the prolapsed umbilical cord, (A, B, and C) do not alleviate pressure on the umbilical cord.