Week 4 - HESI/EAQ

Question 1

the most common cause of heart failure is ________________

Answer 1

myocardial infarction

Question 2

Heart failure results in the inability of the heart to provide sufficient blood flow to meet the _____________ of the body’s tissues and organs

Answer 2

oxygen needs

Question 3

Heart failure occurs most commonly in clients over the age of ____, and occurs more commonly in _______________

Answer 3

Heart failure occurs most commonly in clients over the age of 60, and occurs more commonly in males than females.

Question 4

Which assessment finding provides the earliest indication that the client is experiencing right-sided heart failure?

Dyspnea at rest.

Sinus tachycardia.

Peripheral edema.

Lack of energy.

Answer 4

Peripheral edema.

Question 5

_________sided heart failure results in peripheral congestion due to the inability of the right ventricle to effectively pump blood out of the heart to the lungs, causing edema, JVD, an enlarged liver, abdominal ascites, and weight gain. Edema and weight gain are among the earlier signs.

Answer 5

Right-

Question 6

After the client’s cardiac rhythm is confirmed, which action should the nurse implement next?

Administer a prescribed stat dose of digoxin.

Notify the HCP of the dysrhythmia.

Transfer the client to the Medical Intensive Care Unit (MICU).

Prepare for synchronized cardioversion.

Answer 6

Administer a prescribed stat dose of digoxin.
If a dose of digoxin has already been prescribed, it should be administered before taking further action. Digoxin slows the heart rate and increases the force of the heart’s contraction, which is very useful in the treatment of the client’s type of cardiac dysrhythmia.

Question 7

Digoxin ______ the heart rate and increases the force of the heart’s contraction

Answer 7

slows

Question 8

The client is scheduled for a chest x-ray, 12 lead electrocardiograph (ECG) and an echocardiogram.

When preparing the client for the echocardiogram, which intervention should the nurse implement?

Set-up treadmill for initial test.

Instruct the client to fast for at least 6 hours before the test.

Ensure the client is wearing comfortable clothes and shoes.

Ask the client to lay on their left side during the test.

Answer 8

Ask the client to lay on their left side during the test.

The echocardiogram records direction and flow of blood through the heart and transforms it to audio and graphic data that measure valve abnormalities, congenital heart defects, wall motion, ejection fraction (EF), and heart function. The best results are obtained when the patient is in a left side lying position.

Question 9

Normal potassium is ______ mEq/L

Answer 9

3.5 - 5.0

Question 10

The client is concerned about how easily they are bruising since they started taking the warfarin. Which intervention is most important for the nurse to include in the client’s plan of care?

Monitor INR levels every 4-6 weeks.

Use soft toothbrush to minimize bleeding gums.

Use electric razors for shaving.

Avoid contact sports and hobbies.

Answer 10

Monitor INR levels every 4-6 weeks.

The target INR for warfarin is 2.4 - 3.5. INR should be monitored on a regular basis. Changes in the warfarin dosage will be adjusted to keep the INR within a safe range which will decrease the risk of a life-threatening bleed.

Question 11

[HF] The client asks the nurse why they have to be weighed every day. The nurse explains that weight gain is one of the first signs of retaining fluid. Which intervention is most important for the nurse to include in the client’s plan of care?

Weigh at the same time of day.

Keep a record of daily weights.

Report a gain of 3 pounds in one week.

Inform healthcare provider of ankle swelling.

Answer 11

Report a gain of 3 pounds in one week.

A weight gain of 3 pounds in 2 days or 3-5 pounds in a week should be reported immediately. This may indicate an exacerbation of the heart failure which requires immediate intervention.

Question 12

Carvedilol works best if you take it with ______.

Answer 12

food

Question 13

Which assessment finding provides the earliest indication that the client is experiencing digoxin toxicity?

Blood pressure 180/100.

Anorexia, nausea, and vomiting.

Pitting dependant ankle edema.

Blurred vision and halo vision.

Answer 13

Anorexia, nausea, and vomiting.

Gastrointestinal (GI) symptoms are among the earliest symptoms of digoxin toxicity, along with confusion and fatigue. Additional manifestations include headache, hypotension, and cardiac dysrhythmias.

Question 14

A precipitous drop in serum ___________ may occur after treatment with digoxin immune FAB .

Answer 14

potassium

Question 15

Respiratory ___________ is diagnosed with the PaCO2 is high and the pH is low.

Answer 15

acidosis

Question 16

In an effort to monitor his heart failure, what is the most important intervention that the client can perform at home?

Check radial pulse 6 times a day, upon arising, at each meal, and before bed.

Take weekly ankle measurements to monitor edema.

Weighing every day on the same scale.

Incorporate a regular exercise routine.

Answer 16

Weighing every day on the same scale.

Daily weights are the most important intervention for monitoring heart failure. Clients should be instructed to call the HCP immediately with a weight gain of 2 to 3 lbs in 24 hours.

Question 17

Which clinical manifestations further support a right-sided stroke? SATA

Visual field deficit on the left side.

Spatial-perceptual deficits.

Paresthesia of the left side.

Increased distractibility.

Global aphasia

Answer 17

Visual field deficit on the left side.

Spatial-perceptual deficits.

Paresthesia of the left side.

Increased distractibility.

Question 18

The neurologist writes a diagnosis of “suspected stroke” and prescribes a computed tomography (CT) scan without contrast STAT. Which intervention should the nurse implement when preparing client and his son for this procedure?

Determine if the client has any allergies to iodine or shellfish.

Explain that the procedure requires the client to lie completely still.

Offer client an anxiolytic prior to the procedure.

Ensure that client does not have on any material that is metal, this includes metal prosthesis.

Answer 18

Explain that the procedure requires the client to lie completely still.

Question 19

The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data warrants immediate intervention by the nurse concerning this diagnostic test?

Elevated heart rate.

Allergy to iodine.

Left hip replacement.

History of hypertension.

Answer 19

Left hip replacement.

The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure.

Question 20

With a diagnosis of a stroke, which priority interventions should the nurse include in client’s plan of care?

Monitor PTT daily.

Assess neurological status every hour.

Evaluate platelet levels daily.

Keep the head of the bed elevated.

Monitor blood glucose levels daily.

Answer 20

Monitor PTT daily.

Assess neurological status every hour.

Keep the head of the bed elevated.

Monitor blood glucose levels daily.

Question 21

Homonymous hemianopsia is loss of the visual field blindness in the ______ ______ of each visual field.

Answer 21

same half

Question 22

The student nurse rechecks the client’s blood pressure now that he has been sitting quietly for a few minutes. His blood pressure is 180/106 mmHg.

According to the assessment of this client, which recommendation is most important for the student nurse to provide?

See the HCP as soon as possible within the next week for a BP recheck.

Limit salt intake and start a weight loss program.

Attend a stress reduction seminar offered in his community.

Learn about high fiber foods and add more fiber to his diet.

Answer 22

See the HCP as soon as possible within the next week for a BP recheck.

The client’s blood pressure is significantly elevated. Since these BP readings were obtained on the same day, the client needs to see his HCP as soon as possible for another BP measurement. The HCP can then determine a diagnosis and initiate treatment.

Question 23

Often clients with hypertension have no symptoms and ____________ may occur before the client becomes symptomatic.

Answer 23

organ damage

Question 24

Most cases of hypertension are without an identified ______ and effected by multiple risk factors, so unless there is a health history indicator, the HCP does not look for one.

Answer 24

cause

Question 25

Use of _________ products is linked with increased risk for cardiovascular disease.

Answer 25

tobacco

Question 26

"Phantom limb pain is caused by the severing of _________ nerves."

Answer 26

peripheral

Question 27

The client tells the nurse that every time he walks a short distance, he gets an aching or cramping pain in his left leg. How should the nurse correctly document this data? Paresthesia. Intermittent claudication. Deep vein thrombosis (DVT). Peripheral neuropathy.

Answer 27

Intermittent claudication.

Question 28

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment finding would alert the nurse to the possible development of thrombocytopenia? Select all that apply. One, some, or all responses may be correct. Fever Diarrhea Melena Hematuria Ecchymosis Nausea Alopecia Mucositis

Answer 28

Melena Hematuria Ecchymosis

Question 29

The nurse reviews the medical record of a client with a grade 2 goiter. Which assessment finding is consistent with this type of goiter? It is impalpable. It is asymmetrical. It moves up when the client swallows. It is invisible when the client’s neck is in the normal position.

Answer 29

It is asymmetrical.

Question 30

Which is the purpose of encouraging active leg and foot exercises for a client who has had hip surgery? Maintain muscle strength Reduce leg discomfort Prevent clot formation Improve wound healing

Answer 30

Prevent clot formation

Question 31

Which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? Select all that apply. One, some, or all responses may be correct. Providing oxygen Assessing vital signs Obtaining a 12-lead EKG Drawing blood for cardiac enzymes Auscultating heart sounds Administering nitroglycerin

Answer 31

All of the above

Question 32

How would the nurse describe heart failure to a client? A cardiac condition caused by inadequate circulating blood volume An acute state in which the pulmonary circulation pressure decreases An inability of the heart to pump blood in proportion to metabolic needs A chronic state in which the systolic blood pressure drops below 90 mm Hg

Answer 32

An inability of the heart to pump blood in proportion to metabolic needs

Question 32

Which type of hepatitis virus spreads through contaminated food and water? Hepatitis A virus Hepatitis B virus Hepatitis C virus Hepatitis D virus

Answer 32

Hepatitis A virus

Question 33

Which assessment finding indicates that a client has had a stroke? Select all that apply. One, some, or all responses may be correct. Lopsided smile Unilateral vision Incoherent speech Unable to raise right arm Symptoms started 2 hours ago

Answer 33

All of the above

Question 34

Which statement by an older adult client about skincare to prevent pressure ulcers indicates a need for further teaching? "I should gently pat my skin." "I should use mild, heavily fatted soap." "I should wash my skin with tepid water, rather than hot water." "I should apply powders or talc on a perineum wound."

Answer 34

"I should apply powders or talc on a perineum wound."

Question 34

A client has surgery for the creation of a colostomy. Postoperatively, which color would the nurse expect a viable stoma to be? Brick red Pale pink Light gray Dark purple

Answer 34

Brick red

Question 34

Which organism would the nurse identify as causing syphilis? Treponema pallidum Campylobacter jejuni Trichomonas vaginalis Chlamydia trachomatis

Answer 34

Treponema pallidum

Question 35

After an above-the-knee amputation for bone cancer, an adolescent male is returned to his room. Which item would the nurse plan to keep at the bedside? Hemostat Vitamin K Protamine sulfate Pressure dressing

Answer 35

Pressure dressing

Question 36

Which rationale supports the need for the nurse to contact the client’s primary health care provider when a nurse observes vaginal packing protruding from the client’s vaginal vault after radium implants for cervical cancer were inserted? The radioactive packing will injure healthy tissue. Removal of the packing will prevent excessive blood loss. Radium exposure to the environment diminishes the effectiveness. Removal of the packing minimizes life-threatening contact with the radiation.

Answer 36

The radioactive packing will injure healthy tissue.

Question 37

Which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? It is a congenital abnormality. A malignancy usually results. It predisposes to hydronephrosis. Prostate-specific antigen decreases.

Answer 37

It predisposes to hydronephrosis.

Question 38

The secretion of which hormone is an example of a positive feedback mechanism? Insulin Estradiol Parathormone Catecholamines

Answer 38

?

Question 39

The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder would the nurse consider may be related to these results? Influenza virus Diphtheria bacillus Bordetella pertussis Mycobacterium tuberculosis

Answer 39

Mycobacterium tuberculosis

Question 40

A client who is receiving radiation therapy for bone cancer lives alone and works full time. Which client action would the nurse encourage? Begin to perform regularly scheduled aerobic activity daily. Take a leave of absence from work when receiving therapy. Include rest periods during the day while receiving radiation. Continue the activities usually performed before becoming ill.

Answer 40

Include rest periods during the day while receiving radiation.

Question 41

Which action transmits the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. Multiple mosquito bites Sharing syringe needles Breast-feeding a newborn Dry kissing an infected individual Anal intercourse Sharing drinking glasses

Answer 41

Sharing syringe needles Breast-feeding a newborn Anal intercourse

Question 42

The nurse is providing immediate postoperative care to a client who has undergone a total laryngectomy. It is appropriate for the plan of care to include which intervention? Instructing the client to whisper Placing the client in the orthopneic position Removing the outer tracheostomy tube as needed Suctioning the tracheostomy tube whenever necessary

Answer 42

Suctioning the tracheostomy tube whenever necessary

Question 43

Which clinical feature is indicative of hypercortisolism? Loss of weight Thickening of skin Enhanced density of bones Increased pigmentation

Answer 43

Increased pigmentation

Question 44

Which organism is a common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? Oropharyngeal candidiasis Cryptosporidiosis Toxoplasmosis encephalitis Pneumocystis jiroveci pneumonia

Answer 44

Oropharyngeal candidiasis

Question 45

Which explanation for the client’s behavior would be useful to consider in planning care for a client who has been on hemodialysis for 2 years, communicates in an angry, critical manner, and does not adhere to the prescribed medications and diet? An attempt to punish the nursing staff A constructive method of accepting reality A defense against underlying depression and fear An effort to maintain life and to live it as fully as possible

Answer 45

A defense against underlying depression and fear

Question 46

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? P wave T wave PR interval QRS interval

Answer 46

QRS interval

Question 47

Which evaluation method is the most effective way for the nurse to evaluate the teachers’ knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques? Observe the teachers lecture the children about hand hygiene. Administer an objectively written final examination to the teachers. Have the teachers share their knowledge of hand washing. Watch the teachers demonstrate infection-control techniques.

Question 48

Which action would the nurse take in caring for a client after surgical placement of an external fixator on the client’s leg? Cleanse the pin sites with alcohol several times a day. Perform a neurovascular assessment of the lower extremities. Ambulate the client with partial weight bearing on the affected leg. Maintain placement of an abduction pillow between the client’s legs.

Answer 48

Perform a neurovascular assessment of the lower extremities.

Question 49

Which information in the response of a client receiving peritoneal dialysis indicates understanding of the purpose of the procedure? Reestablishing normal kidney function Cleaning the peritoneal membrane Providing fluid for intracellular spaces Removing toxins and metabolic wastes

Answer 49

Removing toxins and metabolic wastes

Question 49

Which answer would a nurse give to a client receiving a hemodialysis treatment who asks which substances are being removed? Blood Sodium Glucose Bacteria

Answer 49

Sodium

Question 50

Which statement explains why metabolic acidosis develops with kidney failure? Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention Inability of the renal tubules to reabsorb water to dilute the acid contents of blood Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Answer 50

Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate

Question 50

Which assessment finding indicates hypersecretion of adrenocorticotrophic hormone? Moon face Lower jaw protrusion Heat intolerance Barrel-shaped chest

Answer 50

Moon face

Question 51

Which statement by a client with pruritus about personal care interventions indicates understanding of the interventions? "I will trim my fingernails regularly." "I will apply moisturizing lotion before my bath." "I will avoid filing the edges of fingernails into oval shapes." "I will use baby powder or talc in my groin areas."

Answer 51

"I will avoid filing the edges of fingernails into oval shapes."

Question 52

Which result would the nurse expect to find when reviewing the serum screening tests of a client with acquired immunodeficiency syndrome (AIDS)? A decrease in CD4 T cells An increase in thymic hormones An increase in immunoglobulin E A decrease in the serum level of glucose-6-phosphate dehydrogenase

Answer 52

A decrease in CD4 T cells

Question 53

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? "I will leave the skin markings intact." "I will protect the skin from sources of heat." "I will wear soft clothing over the upper body." "I will use an oatmeal-based lotion after each treatment."

Answer 53

"I will use an oatmeal-based lotion after each treatment."

Question 54

Which sexually transmitted infection is managed with antiviral medications as the treatment of choice? Syphilis Gonorrhea Genital herpes Chlamydial infection

Answer 54

Genital herpes

Question 55

Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? Urticaria A medication reaction Atopic dermatitis Contact dermatitis

Answer 55

Contact dermatitis

Question 56

The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. Which action would the nurse take? Administer the prescribed oxygen. Administer the prescribed antianxiety medication. Notify the health care provider immediately of the findings. Record the observations and continue to observe the client.

Answer 56

Administer the prescribed oxygen.

Question 57

Which description would the nurse provide to a client scheduled for a cystoscopy who asks about the procedure? "It is a computerized scan that outlines the bladder and surrounding tissue." "It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." "It is the visualization of the bladder lining with an instrument connected to a source of light." "It is the imaging of the urinary tract through ureteral catheterization using radiopaque material."

Answer 57

"It is the visualization of the bladder lining with an instrument connected to a source of light."

Question 58

Which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours? To maintain client comfort To prevent development of pressure injuries To prevent flexion contractures of the extremities To improve venous circulation in the lower extremities

Answer 58

To prevent development of pressure injuries

Question 59

Which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation after a cerebrovascular accident (CVA)? Frontal Parietal Occipital Temporal

Answer 59

Parietal

Question 60

Which physiological activity is associated with the "proliferative phase" of normal wound healing? White blood cells migrate into the wound. Epithelial cells grow over the granulation tissue. Scar tissue gradually becomes thinner and pale. Vasodilation occurs with increased capillary permeability.

Answer 60

Epithelial cells grow over the granulation tissue.

Question 61

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? Sodium Calcium Potassium Magnesium

Answer 61

Sodium

Question 62

Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? Stabilized vital signs and complaints of pain Pale and alert; remains restless Increasing temperature and apprehension Fluctuating vital signs and drowsy, but easily roused

Answer 62

Stabilized vital signs and complaints of pain

Question 63

Which dietary instruction would be beneficial to a client who has undergone a hypophysectomy and has difficulty passing stools? "Drink plenty of water." "Eat foods rich in protein." "Drink a glass of milk daily." "Eat foods rich in carbohydrates."

Answer 63

"Drink plenty of water."

Question 64

A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do? Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client

Answer 64

Keep collection device below the level of the client's chest

Question 65

Which carcinoma is the most common type of thyroid cancer and is most often found in younger women? Papillary carcinoma Follicular carcinoma Medullary carcinoma Anaplastic carcinoma

Answer 65

Papillary carcinoma

Question 66

Which hormonal imbalance would the nurse suspect in a client who has low serum sodium levels? Epinephrine Glucagon Calcitonin Aldosterone

Answer 66

Aldosterone

Question 67

Which technology will be used for the treatment of electrical burns? Skin substitutes Electrical stimulation Topical growth factors Hyperbaric oxygen therapy

Answer 67

Hyperbaric oxygen therapy

Question 68

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery? Keep the client in a gatch bed to elevate the knees. Have the client dangle the legs off the side of the bed. Help the client use an incentive spirometer every hour. Encourage the client to ambulate multiple times daily.

Answer 68

Encourage the client to ambulate multiple times daily.

Question 69

Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? Increased blood pH Decreased hematocrit Increased blood viscosity Decreased immune response

Answer 69

Increased blood viscosity

Question 70

A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? Level of pain Quality and depth of respirations Amount of serosanguinous drainage Blood pressure and pupillary response

Answer 70

Quality and depth of respirations

Question 71

Which statement indicates that the client has a correct understanding of the condition after the nurse has finished teaching a client about sickle cell anemia? "I have abnormal platelets." "I have abnormal hemoglobin." "I have abnormal hematocrit." "I have abnormal white blood cells."

Answer 71

"I have abnormal hemoglobin."

Question 72

Which term would the nurse use to document a client experiencing urinary incontinence via involuntary loss of small amounts (25–35 mL) of urine from an overdistended bladder? Urge incontinence Stress incontinence Overflow incontinence Functional incontinence

Answer 72

Overflow incontinence

Question 73

Which electrical activity of the cardiac conduction system is reflected in the P wave? Atrial depolarization Atrial repolarization Ventricular depolarization Ventricular repolarization

Answer 73

Atrial depolarization