HESIiReview 1. Following idischarge iteaching, ia imale iclientiwith iduodenal iulceritellsithe inurse ithe ihe iwill idrink iplenty iofidairy iproducts, isuch iasimilk, ito ihelp icoat iand iprotect ihisiulcer. iWhat iisithe ibest ifollow-up iaction iby ithe inurse? • Reviewiwith ithe iclientithe ineed ito iavoid ifoodsithatiare irich iin imilk iand icream 2. Aimale iclient iwith ihypertension, iwho ireceived inew iantihypertensive iprescriptionsiat ihisilast ivisit ireturnsito ithe iclinic itwo iweeksilaterito ievaluate ihis iblood ipressure i(BP). iHisiBPiisi158/106 iand ihe iadmitsithat ihe ihasinot ibeen itaking ithe iprescribed imedication ibecause ithe idrugsimake ihimi“feel ibad”. iIn iexplaining ithe ineed iforihypertension icontrol, ithe inurse ishould istressithat ian ielevated iBPiplacesithe iclient iat irisk iforiwhich ipathophysiological icondition? • Stroke isecondary ito ihemorrhage 3. The inurse iobservesian iunlicensed iassistive ipersonneli(UAP)ipositioningia inewly iadmitted iclient iwho ihasia iseizure idisorder. iThe iclientiisisupine iand ithe iUAPiisiplacing isoft ipillowsialong ithe iside irails. iWhat iaction ishould ithe inurse iimplement? • Instructithe iUAPito iobtain isoftiblanketsito isecure ito ithe iside irailsiinstead iofipillows. 4. An iadolescent iwith imajoridepressive idisorderihasibeen itaking iduloxetine i(Cymbalta)iforithe ipasti12 idays. iWhich iassessment ifinding irequires iimmediate ifollow-up? • Describesilife iwithout ipurpose 5. Ai60-year-old ifemale iclient iwith ia ipositive ifamily ihistory iofiovarian icancerihasideveloped ian iabdominal imassiand iisibeing ievaluated iforipossible iovarianicancer. iHeriPapanicolau i(Pap)ismeariresultsiare inegative. iWhat iinformation ishould ithe inurse iinclude iin ithe iclient’siteaching iplan? • Furtherievaluation iinvolving isurgery imay ibe ineeded 6. Aiclient iwho irecently iunderwearia itracheostomy iisibeing iprepared iforidischarge ito ihome. iWhich iinstructionsiisimost iimportant iforithe inurse ito iinclude iin itheidischarge iplan? • Teach itrachealisuctioningitechniques 7. In iassessing ian iadult iclient iwith ia ipartialirebreatherimask, ithe inurse inotesithat ithe ioxygen ireservoiribag idoesinot ideflate icompletely iduring iinspiration iand ithe client’sirespiratory irate iisi14 ibreathsi/iminute. iWhat iaction ishould ithe inurse iimplement? • Documentithe iassessmentidata • Rational: ireservoiribag ishould inotideflate icompletelyiduring iinspiration iand ithe iclient’sirespiratory irate iisiwithin inormalilimits. 8. During ishift ireport, ithe icentralielectrocardiogrami(EKG)imonitoring isystemialarms. iWhich iclient ialarmishould ithe inurse iinvestigate ifirs? • Respiratory iapnea iofi30 iseconds 9. Duringia ihome ivisit, ithe inurse iobserved ian ielderly iclient iwith idiabetesislip iand ifall. iWhat iaction ishould ithe inurse itake ifirst? • Check ithe iclient iforilacerationsiorifractures 10. At i0600 iwhile iadmitting ia iwoman iforia ischedule irepeat icesarean isection i(C-Section), ithe iclientitellsithe inurse ithat ishe idrank ia icup ia icoffee iat i0400 ibecause ishe wanted ito iavoid igetting ia iheadache. iWhich iaction ishould ithe inurse itake ifirst? • Informithe ianesthesia icare iprovider 11. Afteriplacing ia istethoscope iasiseen iin ithe ipicture, ithe inurse iauscultatesiS1 iand iS2 iheartisounds. iTo idetermine iifian iS3 iheart isound iisipresent, iwhatiaction should ithe inurse itake ifirst? • Listen iwith ithe ibelliat ithe isame ilocation 12. Ai66-year-old iwoman iisiretiring iand iwill ino ilongerihave ia ihealth iinsurance ithrough iheriplace iofiemployment. iWhich iagency ishould ithe iclient ibe ireferred ito iby the iemployee ihealth inurse iforihealth iinsurance ineeds? • Medicare 13. Aiclient iwho iisitaking ian ioralidose iofia itetracycline icomplainsiofigastrointestinaliupset. iWhat isnack ishould ithe inurse iinstruct ithe iclientito itake iwith ithe itetracycline? • Toasted iwheatibread iand ijelly 14. Following ia ilumbaripuncture, ia iclient ivoicesiseveral icomplaints. iWhat icomplaintiindicated itoithe inurse ithat itheiclient iisiexperiencing ia icomplication? • “Iihave ia iheadache ithatigetsiworse iwheniIisitiup” • “Iiamihaving ipain iin imy iloweriback iwhen iIimove imy ilegs” • “My ithroat ihurtsiwhen iIiswallow” • “Iifeel isickitoimy istomachiandiamigoing itoithrowiup” 15. An ielderly iclientiseemsiconfused iand ireportsithe ionsetiofinausea, idysuria, iand iurgency iwith iincontinence. iWhich iaction ishould ithe inurse iimplement? • Obtain ia iclean icatch imid-streamispecimen 16. The inurse iisiassisting ithe imotheriofia ichild iwith iphenylketonuria i(PKU)itoiselect ifoodsithat iare iin ikeeping iwith ithe ichild’sidietary irestrictions. iWhich ifoods iare icontraindicated iforithisichild? • Foodsisweetened iwith iaspartame 17. Before ipreparing ia iclient iforithe ifirst isurgicalicase iofithe iday, ia ipart-time iscrub inurse iasksithe icirculating inurse iifia i3 iminute isurgicalihand iscrub iis iadequate ipreparation iforithisiclient. iWhich iresponse ishould ithe icirculating inurse iprovide? • Direct ithe inurse ito icontinue ithe isurgical ihand iscrub iforia i5 iminute iduration 18. Which ibreakfastiselection iindicatesithat ithe iclientiunderstandsithe inurse’siinstructionsiaboutithe idietaryimanagementiofiosteoporosis? • Bagel iwith ijelly iand iskimimilk 19. The icharge inurse iofia icriticalicare iunit iisiinformed iat ithe ibeginning iofithe ishift ithat ilessithan ithe ioptimalinumberiofiregistered inursesiwill ibe iworking ithat ishift. iIn iplanning iassignments, iwhich iclient ishould ireceive ithe imost icare ihoursiby ia iregistered inurse i(RN)? • An i82-year-old iclient iwithiAlzheimer’sidisease inewly-fracturesifemuriwho ihasia iFoley icatheteriand isoft iwrist irestrainsiapplied 20. Aimotheribringsiheri6-year-old ichild, iwho ihasijust istepped ion ia irusty inail, ito ithe ipediatrician’sioffice. iUpon iinspection, ithe inurse inotesithat ithe inail iwentithrough ithe ishoe iand ipierced ithe ibottomiofithe ichild’sifoot. iWhich iaction ishould ithe inurse iimplement ifirst? • Cleanse ithe ifootiwithisoap iandiwater iand iapply ianiantibiotic iointment • Provide iteaching iabout ithe ineed iforia itetanusiboosteriwithin ithe inext i72 ihours. • have ithe imothericheck ithe ichild'sitemperature iq4h iforithe inext i24 ihours • transferithe ichild ito ithe iemergencyidepartment ito ireceive iaigamma iglobulin iinjection 21. The imotheriofian iadolescent itellsithe iclinic inurse, i“My ison ihasiathlete’sifoot, iIihave ibeen iapplying itriple iantibiotic iointment iforitwo idays, ibutithere ihasibeen no iimprovement.” iWhat iinstruction ishould ithe inurse iprovide? • Stop iusing ithe iointment iand iencourage icomplete idrying iofithe ifeet iand iwearing iclean isocks. 22. Ai26-year-old ifemale iclient iisiadmitted ito ithe ihospital iforitreatmentiofia isimple igoiter, iand ilevothyroxine isodium i(Synthroid)iisiprescribed. iWhich isymptoms indicate ito ithe inurse ithatithe iprescribed idosage iisitoo ihigh iforithisiclient? iThe iclient iexperiences • Bradycardia iandiconstipation • Lethargyiandilack iofiappetite • Muscle icrampingiand idry, iflushed iskin • Palpitationsiandishortnessiofibreath 23. Aiclientiwith ia ihistory iofiheart ifailure ipresentsito ithe iclinic iwith ia inausea, ivomiting, iyellowivision iand ipalpitations. iWhich ifinding iisimostiimportantifor ithe inurse ito iassessito ithe iclient? • Obtain ia ilistiofimedicationsitaken iforicardiac ihistory 24. The ihealthcare iprovideriprescribesian iIVisolution iofiisoproterenol i(Isuprel)i1 img iin i250 iml iofiD5Wiat i300 imcg/hour. iThe inurse ishould iprogramithe iinfusion pump ito ideliverihowimanyiml/hour? i(Enterinumeric ivalue ionly.) • 75 • Rationale: iConvert img ito imcg iand iuse ithe iformula iD/Hix iQ. i300 imcg/houri/ i1,000 imcg ix i250 iml i=i3/1 ix i25 i=i75 iml/hour 25. The ipathophysiological imechanismiare iresponsible iforiascitesirelated ito iliverifailure? i(Select iallithatiapply) • Fluid ishiftsifromiintravascularito iinterstitialiarea idue ito idecreased iserumiprotein • Increased ihydrostatic ipressure iin iportalicirculation iincreasesifluid ishiftsiinto iabdomen • Increased icirculating ialdosterone ilevelsithatiincrease isodiumiand iwateriretention 26. The inurse iisiauscultating ia iclient’siheart isounds. iWhich idescription ishould ithe inurse iuse itoidocument ithisisound? i(Please ilisten itoithe iaudio ifirst ito iselect ithe option ithatiapplies) • Murmur • Rationale:iAimurmuriisiauscultated iasia iswishing isound ithat iisiassociated iwith ithe iblood iturbulence icreated iby ithe iheart iorivalvularidefect. 27. The ihealthcare iprovideriprescribesiceltazidime i(Fortax)i35 img ievery i8 ihoursiIMiforian iinfant. iThe i500 img ivialiisilabeled iwith ithe iinstruction ito iadd i5.3 iml idiluent ito iprovide ia iconcentration iofi100 img/ml. iHowimany iml ishould ithe inurse iadministered iforieach idose? i(Enterinumeric ivalue ionly. iIf irounding iisirequired, iround ito ithe inearest itenth) • 0.4 • rationale: i35mg/100mg ix i1 i= i0.35 i= i0.4 iml 28. The inurse inotesithat ia iclientihasibeen ireceiving ihydromorphone i(Dilaudid)ievery isix ihoursiforifouridays. iWhat iassessment iisimostiimportant iforithe inurse ito complete? • Auscultate ithe iclient'sibowel isounds • Observe iforiedema iaround ithe iankles • Measureithe iclient’sicapillaryiglucose ilevel • Count ithe iapical iand iradialipulsesisimultaneously • Rationale:ihydromorphone iisia ipotentiopioid ianalgesic ithatislowsiperistalsisiand ifrequently icausesiconstipation, iso iit iisimostiimportant ito iAuscultate ithe iclient'sibowel isounds 29. Aifemale iclientiisiadmitted iwith iend istage ipulmonary idisease iisialert, ioriented, iand icomplaining iofishortnessiofibreath. iThe iclientitellsithe inurse ithatishe iwantsi“no iheroic imeasures” itaken iifishe istopsibreathing, iand ishe iasksithe inurse ito idocumentithisiin iherimedical irecord. iWhatiaction ishould ithe inurse iimplement? • Ask ithe iclient itoidiscussi“doinotiresuscitate” iwith iherihealthcare iprovider 30. Aiclient iisireceiving ia ifull istrength icontinuousienteralitube ifeeding iati50 iml/houriand ihasideveloped idiarrhea. iThe iclient ihasia inewiprescription ito ichange ithe feeding ito ihalfistrength. iWhat iintervention ishould ithe inurse iimplement? • Add iequaliamountsiofiwateriand ifeeding ito ia ifeeding ibag iand iinfuse iat i50ml/hour 31. Aifemale iclient ireportsithat iherihairiisibecoming icoarse iand ibreaking ioff, ithat ithe iouteripart iofiherieyebrowsihave idisappeared, iand ithat iherieyesiare iall ipuffy. Which ifollow-up iquestion iisibest iforithe inurse ito iask? • Have iyou inoticed iany ichangesiin iyourifingernails? • Rationale:iThe ipattern iofireported imanifestationsiisisuggestive iofihypothyroidism 32. Afteria ithird ihospitalization i6 imonthsiago, ia iclientiisiadmitted ito ithe ihospitaliwith iascitesiand imalnutrition. iThe iclient iisidrowsy ibut iresponding ito iverbal stimuli iand ireportsirecently ispitting iup iblood. iWhatiassessmentifinding iwarrantsiimmediate iintervention iby ithe inurse? • Capillary irefilliofi8 iseconds • bruisesion iarmsiand ilegs • round iand itight iabdomen • pitting iedema iin ilowerilegs 33. Afterithe inurse iwitnessesia ipreoperative iclient isign ithe isurgicaliconsentiform, ithe inurse isignsithe iformiasia iwitness. iWhat iare ithe ilegal iimplicationsiofithe nurse’sisignature ion ithe iclient’sisurgicaliconsent iform? i(Selectiallithatiapply) • The iclient ivoluntarily igrantsipermission iforithe iprocedure ito ibe idone • The iclient iisicompetent ito isign ithe iconsentiwithoutiimpairmentiofijudgment • The iclient iunderstandsithe irisksiand ibenefitsiassociated iwith ithe iprocedure 34. Following isurgery, ia imale iclientiwith iantisocialipersonality idisorderifrequently irequestsithat ia ispecific inurse ibe iassigned ito ihisicare iand iisibelligerentiwhen anotherinurse iisiassigned. iWhat iaction ishould ithe icharge inurse iimplement? • Advise ithe iclient ithat iassignmentsiare inot ibased ion iclientsirequests 35. Aiclient iwith icervicalicanceriisihospitalized iforiinsertion iofia isealed iinternal icervical iradiation iimplant. iWhile iproviding icare, ithe inurse ifindsithe iradiation implantiin ithe ibed. iWhatiaction ishould ithe inurse itake? • Place ithe iimplantiin ia ilead icontaineriusing ilong-handled iforceps 36. The iclient iwith iwhich itype iofiwound iisimostilikely ito ineed iimmediate iintervention iby ithe inurse? • Laceration • Abrasion • Contusion • Ulceration • Rationale: iAilaceration iisia iwound ithat iisiproduced iby ithe itearing iofisoft ibody itissue. iThisitype iofiwound iisioften iirregulariand ijagged. iA ilacerationiwound iisioften icontaminated iwith ibacteria iand idebrisifromiwhateveriobject icaused ithe icut. 37. The inurse iisiplanning icare iforia iclient iadmitted iwith ia idiagnosisiofipheochromocytoma. iWhich iintervention ihasithe ihighest ipriority iforiinclusion iin ithis iclient’siplan ioficare? • Monitoriblood ipressure ifrequently • Rationale: iAipheochromocytoma iisia irare, icatecholamine-secreting itumorithat imay iprecipitate ilife-threatening ihypertension. iThe itumoriisimalignant in i10% ioficasesibut imay ibe icured icompletely iby isurgicaliremoval. iAlthough ipheochromocytoma ihasiclassically ibeen iassociated iwith i3 isyndromes —von iHippel-Lindau i(VHL)isyndrome, imultiple iendocrine ineoplasia itype i2 i(MENi2), iand ineurofibromatosisitype i1 i(NF1)—there iare inowi10 igenesithat ihave ibeen iidentified iasisitesiofimutationsileading ito ipheochromocytoma. 38. When icaring iforia iclient iwho ihasiacute irespiratory idistressisyndrome i(ARDS), ithe inurse ielevatesithe ihead iofithe ibed i30 idegrees. iWhat iisithe ireason ifor ithisiintervention? • To ireduce iabdominalipressure ionithe idiaphragm • to ipromote iretraction iofithe iintercostal iaccessoryimuscle iofirespiration • to ipromote ibronchodilation iand ieffective iairwayiclearance • to idecrease ipressure ion ithe imedullary icenteriwhich istimulatesibreathing • Rationale:ia isemi-sitting iposition iisithe ibest iposition iforimatchingiventilation iand iperfusion iand iforidecreasing iabdominalipressure ion ithe idiaphragm, iso ithat ithe iclient ican imaximize ibreathing. 39. When iassessing ia imildly iobese i35-year-old ifemale iclient, ithe inurse iisiunable ito ilocate ithe igallbladderiwhen ipalpating ibelowithe iliverimargin iat ithe ilateral iborderiofithe irectusiabdominal imuscle. iWhat iisithe imost ilikely iexplanation iforifailure ito ilocate ithe igallbladderiby ipalpation? • The iclient iisitoo iobese • Palpating iin ithe iwrong iabdominal iquadrant • Deeperipalpation itechnique iisineeded • The igallbladder iisinormal • Rationale:ia inormalihealthy igallbladderiisinotipalpable 40. Aiwoman iwith ian ianxiety idisordericallsiheriobstetrician’sioffice iand itellsithe inurse iofiincreased ianxiety isince ithe inormal ivaginal idelivery iofiherison ithreeiweeksiago. iSince ishe iisibreastfeeding, ishe istopped itaking iheriantianxiety imedications, ibut ithinksishe imay ineed ito istart itaking ithem iagain ibecause iofiheriincreased ianxiety. iWhat iresponse iisibest iforithe inurse ito iprovide ithisiwoman? • describe ithe itransmission iofidrugsito ithe iinfant ithrough ibreastimilk • encourage iherito iuse istressirelieving ialternatives, isuch iasideep ibreathing iexercises • Informiher ithatisome iantianxiety imedicationsiare isafe ito itake iwhile ibreastfeeding • Explain ithatianxiety iisia inormaliresponse iforithe imotheriofia i3-week-old. • Rationale:ithere iare iseveraliantianxiety imedicationsithatiare inoticontraindicated iforibreastfeeding imothers. 41. An iolderimale iclient iwith ia ihistory iofitype i1 idiabetesihasinotifelt iwell ithe ipast ifewidaysiand iarrivesiat ithe iclinic iwith iabdominalicramping iand ivomiting. iHe iis lethargic, imoderately, iconfused, iand icannotirememberiwhen ihe itook ihisilastidose io