The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary r...
HESI RN Exit Exam
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope correct answersB. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. correct answersA. Abdominal pain decreases when lying supine
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
A. Instructions about how much fluid the child should drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief measures
D. Referral for social services for the child and family correct answersA. Instructions about how much fluid the child should drink daily
To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot). correct answersI placed the red dot on the base of the neck on the right side After receiving report on an inpatient acute care unit, which client should the nurse assess first?
A. The client with an obstruction of the large intestine who is experiencing abdominal distention
B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity correct answersD. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis correct answersD. Respiratory alkalosis
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?
A. Supine
B. supine; feet elevated higher than head
C. supine; head elevated higher than feet
D. Fowlers correct answersFowlers
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply)
A. Frequent syncope
B. Occasional nocturia
C. Flat affect
D. Blurred vision
E. Frequent drooling correct answersA. Frequent syncope
C. Flat affect D. Blurred vision
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
A. Serum albumin
B. Culture for sensitive organisms
C. Serum blood glucose level
D. Creatinine level correct answersB. Culture for sensitive organisms
A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-
drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the
older boy becomes withdrawn when asked about what happened. Which action should the nurse take?
A. Develop a water safety teaching plan for the family
B. Ask the older brother how he felt during the incident
C. Tell the older brother that he seems depressed
D. Commend the older brother for his heroic actions correct answersB. Ask the older brother how he felt
during the incident
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?
A. Encourage the client to use cooler water and apply calamine lotion after soaking
B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
C. Suggest that the client take brief showers and apply oil-based lotion after showering
D. Explain that the symptoms are caused by liver damage and cannot be relieved correct answersA. Encourage the client to use cooler water and apply calamine lotion after soaking
An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF?
A. Increased cardiac contractility B. Reduced preload
C. Relaxed vascular tone
D. Decreased afterload correct answersB. Reduced preload
Which intervention should the nurse include in the plan of care for a child with tetanus?
A. Encourage coughing and deep breathing
B. Minimize the amount of stimuli in the room
C. Reposition from side to side every hour
D. Open window shades to provide natural light correct answersB. Minimize the amount of stimuli in the room
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin C. Had a cold and ear infection for the past two days D. Skipped eating lunch correct answersC. Had a cold and ear infection for the past two days
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status correct answersC. The client's need for pain medication should be determined
Which self care measure is most important for the nurse to include in the plan of care of a client recently
diagnosed with type 2 diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
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