Hess Practice test 1 – Flashcards
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A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma?
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Metoprolol Tartrate( Lopressor)
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A male clinic who has been taking propranolol ( inderal) for 18 months tells the nurse the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the use provide?
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Ask the health care provider about tapering the drug dose over the next week.
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A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
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How long has the client been taking the medication
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The nurse is preparing to admister atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain th reason for the prescribed medication. What response is best for the nurse to provide?
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Decrease the risk of bradycardia during surgery
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An 80 year old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urniary retention in this geriatric client. ?
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Tricyclic antidepressants
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The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter Which action should the nurse implement?
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Admister the dose as prescribed
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following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her newborn . the client asks why she should breastfeed now. Which info should the nurse provide?
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Stimulate contraction of the uterus
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The nurse identifies a clients needs and formulates th nursing problem of " Imbalancee nutrition: Less than body requirements, related to mental impairment and decreased intkae, as evidence by increasing confusion and weight loss of more than 30 pounds over the last 6 months. " which short-term goal is best for this client?
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Eat 50% od six small meals each day by the end of the week
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the nursie is caring for a client who is unable yo void. The plan of care establishes an objective for th client to ingest at least 1000 mL of fluid between 7:00 am and 3:30pm. Which client response should the nurse document that indicates a successful outcome?
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Drinks 240 mL of fluid five times during the shift.
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a client who has active tuberculosis ( TB) is admitted to the medical unit. What action is most important for the nurse to implement?
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Assign the client to a negative air-flow room
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A client is receiving atonal (tenormin) 25 mg PO after a myocardial infraction. The nurse determines the clinents apical pulse is 65 beats per minute. What action should the nurse implement next?
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Administer the medication
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A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture?
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Rhinorrhoea or otorrhoea with halo sign
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The nurse is assessing a client who complains of weight loss, racing heart rate and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retrace, and a staring expression. These findings are consistent with which disorder?
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Graves disease
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The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
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Ptosis on the left eyelid
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The nurse obtains the pluse rate of 89 beats/min for an infant before administering digoxin (Lanolin) which action should the nurse take?
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Withhold the medication and contact the healthcare provider
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The nurse is developing a teaching plan for an adolescent with a milwaukee brace. Which instruction should the nurse include?
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Wear the brace over a T-shirt 23 hours a day.
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A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse " why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?
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" To protect you because you can get an infection very easily
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A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?
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Apply a water soluble lubricant to the lips, oral mucosa and nares.
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The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clincail picture ?
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Serem potassium of 5.5 mEq and total calcium of 6 mg/dl.
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A 56 year old female client is receiving intracacitary radiation via a radium implant. Which nurse should be assigned to care for this client?
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A nurse with marfran's syndrome who is postmenopausal.
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Which info should the nurse provide a client who has undergone cryrosyrgery for stage 1A cerviacl cancer?
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Use a sanitary napkin instead of a tampon
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the nurse is preparing a client for schedules surgical procedure. What client statement should the nurse report to the healthcare provider.?
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Recalls drinking a glass of juice after midnight. Because there is a risk of aspiration while under general anesthesia
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The nurse determines that a clients body weight is 105A% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, " Imbalanced nutrition: More than body requirements ? "
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Inadequate lifesyle changes in diet and exercise
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The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
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An African-American Client may have slightly yellow sclerae.
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During the physical assessment, which finding should the nurse recognize as a normal finding?
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Regular pulsation at the epigastric area when the client is supine.
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When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
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S1 Murmur ausuclated in supine position.
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A female client reports to the nurse that her sleep was interrupted by " thoughts of anger towards my husband" What type of thoughts is the client having?
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Obsessive
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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?
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Tell the receptionist to have the healthcare provider return the phone call.
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A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perieneum and sees the umbilical cord extruding from the introits. In which position should the nurse place the client?
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Supine with he food of the bed raised
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The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes?
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Participants can identify at least three coping strategies to use during labor
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Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio?
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A self evaluation that identifies how the nurse has met professional objectives and goals.
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a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map?
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Multisicipilinary group
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the scope of professional nursing practice is determined by rules promulgated by which organization.?
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States's board of nursing
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An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?
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Stage 3
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When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care?
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Coordinating and educating about multidisciplinary services
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Preoperatively, a client is to receive 75mg of meperidine (demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?
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1.5 mL
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A low potassium diet is prescribed for a client what foods should the nurse try to avodi?
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Dried prunes
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A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?
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Hypotension, rapid weak pulse, and rapid respiratory rate
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The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of th lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
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Use a soft tip rubber suction catheter and avoid deep vigorous suctioning.
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The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?
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wanting the drug is all that matter to an addict
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the nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with?
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Spinal cord injury
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Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?
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You seem to be more tense these days. Would you like to talk about the problem and how yo are dealing with it?
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The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?
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Frequent blood pressure checks, including readings taken automated machines are recommended
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A client is admitted to the hospital for alcohol decency. What is the priority nursing intervention during the first 48 hours following admission?
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Monitor for increased blood pressure and pulse
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A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet,low calorie diet. At dinner the nurse notes that he is trying to get other clients on the uni to give him part pf their meals. what intervention should the nurse implement?
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Confront the client about the consequences of the behavior.
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A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell?
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Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation.
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A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
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It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state.
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Aftr eye drops are instilled, which instruction should the nurse provide to the client?
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Close your eyelids
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the nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
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A Buretrol Attachement
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Lasix 20 mg PO is prescirbed for a client at 0600. the medication is available in a sound tablet of 40 mg. Before breaking the tablet, what action should the nurse take?
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Preform hand hygiene
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Which assessment finding should make the nurse suspect that a 21 year old male client is taking anabolic steroids
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Describes working hard to develop muscles
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Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsycotioc medication?
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Increase daily intake of raw fruits and veggies
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Prior ro the discharge of a family 4-day old newborn the nurse is collecting the blood specimens to screen for phenylketonuria(PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?
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Assess the newborns feeding patterns of formula or breast mil which has come in
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which nursing intervention is an example of a competent preformance criterion for an occupational and environmental health nurse?
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Implements health programs for construction workers
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A client is being admitted to the medical unit form the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?
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Rubber-tipped clamps
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The nurse identifies bright-red drainage about 6 cam in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next??
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Mark the drainage on the dressing and take vital signs
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The nurse is planning care for a client who is having abdominal surgery. To achieve postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such a turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?
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Administer analgesics prior to encouraging progressive activities and ambulation
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Prior to a cardiac cauterization, which activity should the nurse have the client practice?
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Valsalva's maneuver and coughing
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The nurse is caring fro a client who is one day postoperative after a left total knee arthroplasty (TKA) which intervention should the nurse include in the plan of care?
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Progressive leg exercises to obtain 90-degree flexion
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A client with osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide?
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The infection has walled off into an area of infected bone creating a barrier to antibiotics
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After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatiod arthritis returns to the clinic for a follow up visit. Which laboratory finding should the nurse review for a therapeutic response?
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Erythrocyte sedimentation rate.
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A male client who lives in an area endemic with lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?
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Look for early signs of lesion that increases in size with a red border, clear center.
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The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?
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Individual beliefs
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A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was febuary 14. the client wants to know the expected date of birth (EDB) how should the nurse respond?
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November 21 Subract 3 months and add 7 days to the first day of the last normal menstrual period.
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Two hours after vaginal devilry of a 7-pound 3 ounces infant, a clients fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?
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Palpate above the symphysis for the bladder
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The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who id in the first trimester of pregnancy . which action should the nurse prepare the client for?
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Preparing for other diagnostic testing
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Which finding should the nurse idnetify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?
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Lethargy or irritability
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Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
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Give one hour before or two hours after a meal
