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Practice HESI BSN266 #2

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Question
Answer
show An image that describes metastatic sites of cancer.  
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The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?   show
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Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?   show
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show Perform weight resistance exercises.  
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A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider?   show
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The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)?   show
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show Assess for signs of bleeding and hypovolemia.  
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show Compress the flank and upper buttocks.  
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show Risk for infection.  
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show  
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show Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.  
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show  
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show An electrical stimulus is discharged when no ventricular response is sensed.  
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show Prevent the formation of effusion fluid.  
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The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?   show
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show Gastrointestinal disturbance.  
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show Use a bag-valve-mask resuscitator while removing the client from the area.  
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The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client?   show
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A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse?   show
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A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis?   show
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The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)?   show
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A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide?   show
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Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire?   show
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show "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection."  
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show  
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show Assist the client to ambulate in the hall.  
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A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect?   show
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show Evaluate the effectiveness of narcotic analgesics.  
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show Bluish periumbilical skin discoloration.  
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show Provide cheese and bread to eat.  
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show Flushed skin and headache.  
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Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)?   show
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show Have intercourse or masturbate at least twice a week.  
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The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate?   show
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show Low impact exercise, walking, swimming and water aerobics.  
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show Heart palpitations.  
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In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning?   show
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A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care?   show
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show Promotion of comfort.  
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show "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle."  
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A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement?   show
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show Low risk for prostate cancer.  
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show Avoid allergy medications that contain pseudoephedrine or phenylephrine.  
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show Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head  
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The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care?   show
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show Give IV fluids with electrolytes.  
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show  
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The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client?   show
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Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer?   show
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show  
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show Notify the healthcare provider.  
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The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.)   show
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The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan?   show
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A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement?   show
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The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement?   show
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The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment?   show
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show Discuss retesting to verify the results, which will ensure continuing contact.  
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The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique?   show
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What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home?   show
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show A 55-year-old newly admitted client complaining of jaw pain and indigestion.  
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show A 29-year-old woman whose uterus ruptured after giving birth to her first child.  
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The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT).   show
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Which explanation best describes how they are different?   show
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The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately?   show
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show  
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show Exposure to cold environmental temperatures.  
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Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome?   show
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What is the primary nursing problem for a client with asymptomatic primary syphilis?   show
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The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy?   show
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show  
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show Document the finding as the only action.  
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show Notify the client's healthcare provider.  
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When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.)   show
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During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client’s stoma is dry and dark red in color. What action should the nurse implement?   show
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A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)?   show
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The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client?   show
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show Anticoagulation therapy.  
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show Increase in abdominal fat deposits.  
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show Instill the first dose of nystatin (Mycostatin) vaginally per applicator.  
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The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP?   show
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A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client?   show
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The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess?   show
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The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement?   show
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A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate?   show
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An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete?   show
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show Give a sublingual nitroglycerin tablet.  
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show Irrigate the catheter.  
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An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client?   show
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show Dry, itchy skin changes may occur.  
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The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?   show
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show Allow the client nothing by mouth until the gag reflex returns.  
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show The client should not be catheterized through the stent for at least three months.  
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When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority?   show
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A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.)   show
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A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed?   show
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show pH 6. Specific gravity 1.015.  
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show Wash hands after caring for the client.  
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The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement?   show
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A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?   show
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The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.)   show
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show The cell count of the tumor reduces by half with each dose.  
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show Document the temperature reading on the vital sign graphic sheet.  
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A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings?   show
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A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.)   show
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The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately?   show
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Which method elicits the most accurate information during a physical assessment of an older client?   show
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show Wheezing becomes louder.  
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show Obtain a prescription for an adjusted dose of insulin.  
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