NURSING FUNDAMENTA NCLEX-PN Hesi Comp B
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse?
When caring for a postsurgical client who has undergone multiple blo...
the nurse is caring for a client with a cerebrovascular accident cva who is receiving enteral tube feedings which task performed by the
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NURSING FUNDAMENTA NCLEX-PN Hesi Comp B
The nurse is caring for a client with a cerebrovascular accident (CVA) who is
receiving enteral tube feedings. Which task performed by the UAP requires
immediate intervention by the nurse?
A. Suctions oral secretions from mouth
B. Positions head of bed flat when changing
sheets C.Takes temperature using the
axillary method
D.Keeps head of bed elevated at 30
degrees B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress
puts the client at risk for aspiration (B). The others are all acceptable tasks
performed by the UAP (A, C, and D).
When caring for a postsurgical client who has undergone multiple blood
transfusions, which serum laboratory finding is of most concern to the
nurse?
A.Sodium level, 137
mEq/L B.Potassium level,
5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10
mEq/L B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum
potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The
others are normal findings (A, C, and D).
Which vaccination should the nurse administer to a
newborn? A.Hepatitis B
B.Human papilloma virus
(HPV) C.Varicella
D.Meningococcal
vaccine A
Rationale:
The hepatitis B vaccination should be given to all newborns before
hospital discharge (A). HPV is not recommended until adolescence (B).
Varicella immunization begins at 12 months (C). Meningococcal vaccine is
administered beginning at 2 years (D).
The nurse is caring for a client on the medical unit. Which task can be
delegated to unlicensed assistive personnel (UAP)?
A. Assess the need to change a central line dressing.
B. Obtain a fingerstick blood glucose level.
C. Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current
medication regimen. B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an
,appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot
be delegated to UAP.
The nurse is caring for a client with an ischemic stroke who has a
prescription for tissue plasminogen activator (t-PA) IV. Which action(s)
should the nurse expect to implement? (Select all that apply.)
,A.Administer aspirin with tissue plasminogen activator (t-
PA). B.Complete the National Institute of Health Stroke
Scale (NIHSS).
C. Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E. Initiate multidisciplinary consult for potential
rehabilitation. B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client
receiving t-PA. This includes close monitoring for bleeding during and after
the infusion; if bleeding or other signs of neurologic impairment occur, the
infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA
because it increases the risk for bleeding (A).
The administration of t-PA within 6 hours of symptoms is concurrent with a
diagnosis of a myocardial infarction and within 4.5 hours of symptoms is
concurrent for a stroke (D). When caring for a client in labor, which finding is
most important to report to the primary health care provider?
A. Maternal heart rate, 90 beats/min.
B. Fetal heart rate, 100 beats/min
C. Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature,
100.0° F B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B)
because the average FHR at term is 140 beats/min and the normal range is
110 to beats/min 160. The others (A, C, and D) are normal findings for a
woman in labor.
The nurse is caring for a client with heart failure who develops respiratory
distress and coughs up pink frothy sputum. Which action should the nurse
take first?
A. Draw arterial blood gases.
B. Notify the primary health care provider.
C. Position in a high Fowler's position with the legs down.
D.Obtain a chest X-
ray. C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will
decrease further venous return to the left ventricle (C). The other actions
should be performed after the change in position (A, B, and D).
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia
develops rigidity, a shuffling gait, and tremors. Which action by the nurse is
most important?
A.Administer a dose of benztropine mesylate
(Cogentin) PRN. B.Determine if the client has
increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory
, hallucinations. A
Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is
most important for
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