HESI MILESTONE 3 EXAM 160 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+ In assessing a pressure ulcer on a client's hip, which action should the nurse include? ADetermine the degree of elasticity surrounding the lesion B.) Photograph the lesion with a ruler placed next to the lesion C.)Stage the depth of the ulcer using the Braden numeric scale D.)Use a gloved finger to palpate for tunneling around the lesion - ANSWER -B A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? A.)Implements decisions about future hospices services within the next 3 months. B.)Marinating pain level below 4 when implementing outpatient pain clinic strategies. C.)Request home health care if independence become compromised for 5 days. D.)Arranges for short term counseling stressors impact work schedule for 2 weeks. - ANSWER -B A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? A.)Auscultate all quadrant of the abdomen. B.)Perform a digital rectal exam C.)Palpate the liver and spleen D.)Obtain a hemoccult of the client's stool - ANSWER -A The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating A.)A paced rhythm with 100% capture after pacemaker replacement B.)Normal sinus rhythm and complaining of chest pain C.)Atrial fibrillation with congestive heart failure and complaining of fatigue D.)Sinus tachycardia 3 days after a myocardial infarction - ANSWER -B The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? A.)Early treatment is very effective B.)I will clean my hot tub better C.)These warts are caused by a fungus D.)I need to have regular pap smears - ANSWER -D A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? A.)creatinine clearance 25 mL/ minute B.)calcium 9 mg/dl C.)hemoglobin 12 grams/dl D.)partial thromboplastin time (PTT) 30 seconds - ANSWER -A While the nurse is conducting a daily assessment of an older woman who resides in a long -term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? A.)Ask the client when a family member last visited her. B.)Determine the client's orientation to time and space C.)Review the client's record regarding social interactions D.)Reassure the client of her family's love for her - ANSWER -A The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? - ANSWER -
Observe the wound for dehiscence A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? A.)Condition of hair, nails, and skin B.)A 24 -hour diet history C.)History of a recent weight loss D.)Status of current petite - ANSWER -A The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? A.)A 10 -year -old who is receiving chemotherapy and the infusion pump is beeping B.)A young adult with Crohn's disease who reports having diarrheal stools C.)An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late
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