MS4 HESI Flashcards

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?

A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?

After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first?

A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide?

A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?

A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next?

A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?

A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?

An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?

A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?

The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?

Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

Which client has the highest risk for developing skin cancer?

When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)

A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem?

When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology?

A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?

While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement.

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?

The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)

A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?

A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement?

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?

Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion?

After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?

A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?

The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?

A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first?

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic?

A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?

The nurse is teaching the importance of an exercise regime that includes walking daily for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary rehabilitation clinic. Which rationale should the nurse include when motivating the clients?

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?

A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take?

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider?

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best medication that the client is adhering to the prescribed diabetic regimen?

A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?

An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse.

A female client who was involved in a motor vehicle collision with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?

A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?

The nurse is assessing a client who has tinea pedis. Which question will allow the nurse to gather further information about this condition?

A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?

A male client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should the nurse review?

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation

A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern?

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement?

A female client who received partial-thickness and full-thickness burns over 40% of her body in a house fire is admitted to the inpatient burn unit. What fluid should the nurse prepare to administer during the acute phase of the client's burn recovery?

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement?

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?

The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?

A 70-year-old male client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?

The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?

The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions?

A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client?

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse?

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first?

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which laboratory value is most important for the nurse to monitor following the procedure?

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan on care? (Select all that apply.)

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond?

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?

A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next?

The healthcare provider prescribes epoetin alfa (Procrit) 8,200 units subcutaneously for a client with chronic kidney disease (CKD). The 2 ml multidose vial is labeled, "Each 1 ml of solution contains 10,000 units of epoetin alfa." How many ml should the nurse administer?

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?

Which food is most important for the nurse to encourage a male client with osteomalacia to include in his daily diet?

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?

The healthcare provider prescribes an IV solution of regular insulin (Hummulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?

A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?

A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?

After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series?

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete?

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease?

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain?

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide?

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor?

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse?

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply)

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?

The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan?

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply)

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period?

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care?