HESI PN Fundamentals Exam 2023

HESI PN Fundamentals Exam

Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of

aqueous humor for a client with glaucoma?

Chlorothiazide (Diuril)

Acetazolamide (Diamox)

Bendroflumethiazide (Naturetin)

Demecarium bromide (Humorsol)

A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,

and I don't know why this is happening." What is the nurse's best response?

Tell the client it is nothing to worry about.

Talk with the client further to identify the specific cause of the problem.Instruct the

client to attempt to avoid situations that cause irritation.

Interview the client to determine whether other mood swings are being experienced.

A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me,

and I don't know why this is happening." What is the nurse's best response?

Tell the client it is nothing to worry about.

Talk with the client further to identify the specific cause of the problem.Instruct the

client to attempt to avoid situations that cause irritation.

Interview the client to determine whether other mood swings are being experienced.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a

cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for

these interventions is to:

Promote equalization of osmotic pressures.

Prevent hypoxia associated with diaphoresis.

Promote integrity of intracerebral neurons.

Reduce brain metabolism and limit hypoxia.

A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours.

The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3

mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB

bag? Record your answer using one decimal place. mL

1.5

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by

repositioning. What nursing diagnosis should be included on the client's plan of care?

Risk for pressure ulcer

Risk for impaired skin integrity

Impaired skin integrity, related to infrequent turning and repositioning Impaired skin

integrity, related to the effects of pressure and shearing force

Med C 2

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to the

underlying fascia. The nurse should document the assessment finding as whichstage of pressure ulcer?

Stage I Stage

II Stage III

Unstageable

A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before thewound can

be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A

stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the

ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer

involves full thickness tissue loss with visible subcutaneousfat. Bone, tendon, and muscle are not exposed.

A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure that a

medication reconciliation is completed? Select all that apply.

After reporting severe pain On

admission to the hospital

Upon entering the operating room Before

transfer to a rehabilitation facility

At time of scheduling for the surgical procedure

Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it

to the health care provider's prescriptions on admission or when there is a transfer to adifferent setting or

service, or discharge. A change in status does not require medication reconciliation. A medication

reconciliation should be completed long before entering the operating room. Total hip replacement is elective

surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is

admitted.

A client is taking lithium sodium (Lithium). The nurse should notify the health care provider forwhich of

the following laboratory values?

White blood cell (WBC) count of 15,000 mm3

Negative protein in the urine

Blood urea nitrogen (BUN) of 20 mg/dL

Prothrombin of 12.0 seconds

White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3

for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these arenormal values.

Often when a family member is dying, the client and the family are at different stages ofgrieving. During

which stage of a client's grieving is the family likely to require more emotional nursing care than the

client?

Anger

Denial

Med C 3

Depression

Acceptance

In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to

family members. In addition, the family may take longer to accept the inevitable death than does the client.

Although the family may not understand the anger, dealing with the resultant behavior may serve as a

diversion. Denial often is exhibited by the client and family members at thesame time. During depression, the

family often is able to offer emotional support, which meets theirneeds.

The client asks the nurse to recommend foods that might be included in a diet for diverticulardisease.

Which foods would be appropriate to include in the teaching plan? Select all that apply.

Whole grains

Cooked fruit and vegetables

Nuts and seeds

Lean red meats

Milk and eggs

With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber

should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggshave no fiber

content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated

as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client

should also decrease intake of fats and red meats.

A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe knee.

What should the nurse include in the pain assessment? Select all that apply.

Pain history, including location, intensity, and quality of pain

Client's purposeful body movement in arranging the papers on the bedside tablePain pattern,

including precipitating and alleviating factors

Vital signs such as increased blood pressure and heart rate

The client's family statement about increases in pain with ambulation

Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and

quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset,

duration, and recurrence of pain and its assessment helps the nurse anticipateand meet the needs of the client.

Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless

movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate

pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the

client with chronic pain. Pain is a

subjective experience and therefore the nurse has to ask the client directly instead of acceptingstatement of the

family members.