D439 Fundamentals (LPV3)

HESI

Questions 1–12 with correct answers highlighted

Question 1

Which assessment data reflects the need for the nurse to include the problem, “Risk for falls” in a client’s plan of care (POC)?

Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

A. Opioid analgesic received one hour ago.

B. Expressed feelings of depression.

C. Recent serum hemoglobin level of 16 g/dL (160 g/L).

D. Stooped posture with a steady gait.

Question 2

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which action should the nurse do next?

A. Attach the flowmeter to a humidification canister.

B. Adjust the flow rate to the prescribed liters per minute.

C. Release and reinsert the flowmeter in the wall outlet.

D. Assess the position of the mask on the client’s face.

Question 3 (Drag and Drop)

The client was admitted to the medical unit following a cholecystectomy. She is a 51-year-old female with a history of irritable bowel syndrome. She has had abdominal surgery in the past to remove ovarian cysts.

Nurses’ Notes (0830): The client is awake and alert with clear breath sounds bilaterally. She has absent bowel sounds. Her capillary refill is 2 seconds and radial and dorsalis pedis pulses are present bilaterally. Her surgical dressing is clean and dry. She has not urinated since her indwelling catheter was removed after surgery 3 hours ago. She tried to urinate in a bedpan but was unable to. The client’s bladder is palpable as an egg-shaped mass. States, “I have abdominal pain at 3 on the 0 to 10 scale.”

Vital Signs: Oral temperature 97°F (36.1°C); heart rate 72 beats/minute; respiratory rate 17 breaths/minute; blood pressure 129/72 mm Hg.

Orders: Admit to the surgical floor for observation; up ad lib; advance diet as tolerated; ibuprofen 800 mg PO PRN for pain greater than 4 on 0 to 10 scale.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Potential Conditions (choose 1)

•  Dehydration

•  Hemorrhage

•  Urinary tract infection

•  Urinary retention

Actions to Take (choose 2)

•  Assist the client to the commode

•  Provide pain medication

•  Provide the client a warm drink

•  Draw a complete blood count

•  Give a 1,000 mL bolus of 0.9% sodium chloride

Parameters to Monitor (choose 2)

•  Bladder distention

•  Intake and output

•  White blood cell count

•  Capillary refill

•  Blood pressure

Question 4

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client’s fluid balance?

A. Turgor.

B. Lung sounds.

C. Blood pressure.

D. Weight.

Question 5

When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care (POC). Which action should the nurse take next?

A. Review related professional standards of care.

B. Determine if the expected outcomes were realistic.

C. Modify the nursing interventions to achieve the client’s goals.

D. Obtain current client data to compare with expected outcomes.

Question 6

A client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks the nurse what can be done to decrease the swelling in his leg. Which action should the nurse implement?

A. Advise the client to dangle his feet during meals and before bedtime.

B. Instruct the client to flex both feet several times a day.

C. Explain the need to keep the head of the bed elevated.

D. Encourage the client to take short walks around the block.

Question 7

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client’s axilla. Which action should the nurse take?

A. Proceed with teaching the client how to walk with the crutches.

B. Confer with the physical therapist for correct crutch size.

C. Assess the client for signs of diminished circulation in the hands.

D. Ask the client to sit down while the crutch length is adjusted.

Question 8

The nurse is documenting wound care in a client’s electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

A. Notify information services department of the situation.

B. Print electronic medical record (EMR) from backup server.

C. Wait for notification that the system has been rebooted.

D. Identify information as late entry in the record.

Question 9

The nurse reviews a client’s vital sign measurements. To best interpret the significance of the measurements, which additional information should the nurse consider? Select all that apply.

A. Client’s baseline and pattern of vital signs.

B. Current list of the client’s medications.

C. Equipment used for vital sign measurement.

D. Designated healthcare provider for the client.

E. Normal vital sign range for the client’s age.

Question 10

A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?

A. Aggravating factors.

B. Recent life changes.

C. Onset of symptoms.

D. Methods to cope with stress.

Question 11

After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how should the nurse respond?

A. Reinforce that the pacemaker is a temporary measure.

B. Encourage discussion about the concerns and fears.

C. Use simple terms to describe how the pacemaker functions.

D. Offer reassurance that the staff will monitor the pacemaker.

Question 12

The nurse is caring for a client in the postanesthesia care unit (PACU). To assess the quality of the client’s pain, which approach should the nurse use?

A. Ask the client to describe the pain.

B. Provide a numeric pain scale.

C. Observe body language and movement.

D. Identify effective pain relief measures.

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