WGU D439 Hesi questions WIth 100- accurate solutions

B) The client will adhere to the medication regimen after discharge.

1. The nurse is caring for a client with type 2 diabetes mellitus who had surgery for large bowel resection with a colostomy. The client has now developed hyperglycemia, which requires self-injection of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?

A) The client's breath sounds will be auscultated by the nurse every 4 hours

B) The client will adhere to the medication regimen after discharge.

C) The client attempts to self-administer insulin but is unable to perform injections

D) The client will demonstrate an ability to change the ostomy bag in two days.

C. Assist the client in walking around the room

E. Assess for sources of pain other than the surgical site

G. Consult with the surgeon about the pain level

History and Physical

The client is a 56-year-old woman who had an anteroposterior spinal fusion two days ago. She tolerated the procedure well and has been progressively increasing her walking distance.

Based on the trending heart rate and pain score, which should the nurse do? Select all that apply.

A. Give a dose of 2.5 morphine

B. Bring an opioid reversal agent to the bedside

C. Assist the client in walking around the room

D. Lead the client in guided imagery

E. Assess for sources of pain other than the surgical site

F. Refer to social work for drug-seeking behavior

G. Consult with the surgeon about the pain level

H. Change to a behavioral pain scale

B. Notify the information services department of the situation

3. The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

A. Wait for notification that the system has been rebooted.

B. Notify the information services department of the situation

C. Print the electronic medical record from the backup server

D. Identify as a late entry to the record

D. Do not allow the dropper to touch the eye

4. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in the client's teaching?

A. Squeeze your wye closed after administering the drops

B. Administer the medication directly into the coma

C. Wash your hands after each administration of eye drops

D. Do not allow the dropper to touch the eye

A. Remove the client identifying information of those who participating

5. The nurse educators on a cardiovascular unit of a health care facility are creating a social media project that addresses improving outcomes for clients with heart failure. Which action should the nurse implement to protect the client's privacy?

A. Remove the client identifying information of those who participating

B. May use information from the client's relatives instead

C. Respect all copyright laws when creating website content

D. Implement a full disclosure policy, especially when giving examples

C. Weight

6. A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to educate the client's fluid balance?

A. Blood pressure

B. Lung sounds

C. Weight

A) demonstrate proper securing of the restraints

7. The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is the most important for the nurse to implement?

A) demonstrate proper securing of the restraints

B) Initiate the facility's restraint flow sheet

C) Complete an adverse occurrence/incident report

D) Ensure that the restraints are not too tight

C) Place the wheelchair on the client's left side

8. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair.

To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

A) Have the client put both arms around the nurse's neck for support

B) Instruct the client to take slow, deep breaths while transferring

C) Place the wheelchair on the client's left side

D) Instruct the client to look at his feet

D) Assess skin folds perineal area

E) Observe skin under the breasts

9. The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment (S)should the nurse include while assisting the clients with personal care? Select all that apply

A) Monitor the color of nail beds

B) Palpate mucus membranes for cracks

C) check skin for unusual bruising

D) Assess skin folds perineal area

E) Observe skin under the breasts

A) Methods used to practice safe sex

10. An older women comes to the clinic because of vaginal bleeding. The healthcare provider finds vaginal tear. The client reports likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan?

A) Methods used to practice safe sex

B) Intercourse positions that can help prevent tears

C) Information about alternative ways to express sexuality

D) The importance of using vaginal lubricants

D) Uses sterile gloves when handling body fluids

11. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

A) Keep a pair of gloves in your uniform pocket

B) Don sterile gloves when caring for clients with HIV

C) Put on new gloves when entering the client's room

D) Uses sterile gloves when handling body fluids

Isometric exercises, quad flexing, hold for 10 sec, repeat 8-10x

12. Case Study

The client was involved in a multi-car collision six days ago. Sustained a liver laceration, right rib fracture, and right femur fracture. The liver laceration was repaired. An intermedullary rod was placed to repair the femur fracture. Client is progressing

Orders

Action to take ______ Parameters to monitor ______________

Potential condition ______________

Actions to take _______ Parameters to monitor ______________

C) Obtain a wound culture

13. A surgical incision that is healing by secondary intention develops a thick tan exudate. which action should the nurse take first?

A) Apply Steri Strips

B) Apply a debriding agent

C) Obtain a wound culture

D) Remove every other suture.

B) Offer to warm the prune juice

14. A client on a mechanical soft diet experiencing constipation asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

A) Advance to a regular diet

B) Offer to warm the prune juice

C) Initiate bowel training protocol

D) Restrict oral fluid intake.

D) Determine apical heart rate and rhythm

15. When assessing a client with the serum potassium level of 2.5 mEq/L 2.5 mmol/L) Which intervention is most important for the nurse to implement?

Reference range

Potassium (K+)3.5 to 5.0 MEq/L (3.5 to 5.0 Mmol/L)

A) Observe the color and amount of the urine

B) Assess strength of deep tendon reflexes

C) Compare muscle strength bilaterally

D) Determine apical heart rate and rhythm

2.5 mL

16. The healthcare provider prescribes digoxin elixir 125 mcg Po daily. The drug is available in 60 mL bottle labeled.

Digoxin elixir 0.05mg/ML , how many ML should the nurse administer? Enter the numeric value only; if rounding is required, round to the nearest tenth.

B) Inflate the blood pressure cuff to 120 mm Hg

17. The nurse is obtaining a systolic blood pressure by palpation, while inflating the cuff, the radial pulse is no longer palpable at 90 mm HG. Which action should the nurse take?

A) Document the absence of the radial pulse

B) Inflate the blood pressure cuff to 120 mm Hg

C) Release the manometer valve immediately

D) Record the palpable systolic pressure at 90 mm Hg

D) Leave the door to the client's room open slightly

18. A confused older client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A) provide a back rub at bedtime

B) Apply wrist restraints to prevent wandering

C) Administer a PRN sedative prescription

D) Leave the door to the client's room open slightly

B) Clean the urinary meatus before retracting the foreskin

19. Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

A) Advance the catheter before inflating the balloon

B) Clean the urinary meatus before retracting the foreskin

C) Use a swab to wipe the meatus in a back-and-forth motion.

D) Position the sterile field even with the nurses hips

C) Using the syringe to remove the specimen from the catheter

20. The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of the procedure should the nurse wear gloves?

A) Transporting the urine specimen to the lab

B) Clamping the urinary catheter before the collection.

C) Using the syringe to remove the specimen from the catheter

D) recording the output on the flowsheet in the client's room

C) Offer reassurance that the spouse is not alone

21. A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room, crying. and says to the nurse. I feel as if I’m already alone. Which action should the nurse take first?

A) Explain that alternative treatment options may be helpful

B) Remind the spouse that the client may still live a long time .

C) Offer reassurance that the spouse is not alone

D) Encourage the spouse to share their feelings.

Actions take ___________ Parameters taken _______________

Potential Conditions ____________

Actions to take _______________ Parameters taken______________

22. Case study

The client is a 74-year-old female with a history of type 2 diabetes mellitus. She is in the hospital recovering from pneumonia.

Actions to take -Potential Conditions -Parameters to monitor

Restrict protein-- Dysuria --Blood Glucose

Insert a catheter- -Nocturia-- Intake and output

Administer diuretic --Urinary retention-- Capillary refill

Implement fall risk-- Hematuria-- Urine pH

Review home medications-- Ketones

4

23. A client with Atrial fibrillation receives a prescription for a loading dose of digoxin 0.5 mg PO. The medication is available in 125 mcg tablets. How many tablets should the nurse administer? (Enter numerical value only )

C) Report a mismatch of prescribed and available doses

24. The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

A) withhold the medication until the exact dose is available

B) Calculate the dose on hand to match the prescribed dose

C) Report a mismatch of prescribed and available doses

D) Ask the pharmacist if another dose can be dispensed

B) While touching the client's forearm, asks, Would you like to talk about it?

25. The nurse enters a client's room for a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A) This is a bad time, I can see you are upset, I can come back later

B) While touching the client's forearm, asks, Would you like to talk about it?

C) I'm sorry to disturb you at this difficult time, this can wait until later

D) Gives the client a hug and says , it is okay to cry when your sad .

D) Change coccyx dressing, perform tracheostomy care, restart iv line.

26. A client is in contact isolation due to a stage iv coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple reentries to the client's room. In which order should the nurse perform the interventions?

A) Restart the iv line, perform tracheostomy care, and change the coccyx dressing.

B) Change coccyx dressing, restart the iv line, perform tracheostomy care,

C) Perform tracheostomy care, change coccyx dressing, restart iv line.

D) Change coccyx dressing, perform tracheostomy care, restart iv line.

A) over the cheeks

B) Tops of ears

D) Around the nostrils

27. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters /minute. To assess for skin damage related to the cannula. What areas should the nurse observe? Select all that apply

A) over the cheeks

B) Tops of ears

C) Across the forehead

D) Around the nostrils

E) Bridge of the nose

A) Keep mucous membranes moist

28. The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing to eat or drink. Which intervention should the nurse include in the plan of care?

A) Keep mucous membranes moist

B) Record the client's daily weight

C) Report any change in urine color

D) Maintain in the high fowler's position

B) obtain the specimen from the client's current bowel movement

29. While preparing to obtain a stool specimen for occult blood, the nurse observes the client's feces are soft, solid, and light brown. Which action should the nurse implement?

A) Contact the healthcare provider before obtaining the specimen

B) obtain the specimen from the client’s current bowel movement

C) Withhold the specimen collection until tarry black stool is observed

D) Wait to obtain the specimen until observable blood is present.

0.5

30. The healthcare provider prescribes streptomycin 200 mg intramuscularly every 12 hours. The vial is labeled “Streptomycin 1 gram/2.5 ml. How many milliliters should the nurse administer? (Enter number valve only) If rounding is required, round to the nearest tenth.)

B) Measure oxygen saturation

31. While measuring vital signs, the nurse observes that a client is using neck muscles during respirations. Which follow-up action should the nurse take first?

A) Auscultate heart sounds

B) Measure oxygen saturation

C) Determine pulse pressure

D) Check for the neck vein distention

Action taken __________ Parameter to monitor ______________

Potential Condition ________________

Action taken____________ Parameter to monitor _____________

Actions to take _____________ Potential Condition __________ Parameters to monitor ______

Case study

Blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, insulin-dependent diabetes, and mobility issues. He requires the use of a walker for mobility.

Actions to take-- Potential Conditions-- Parameters to monitor

Administering an enema,-- Pressure injury-- Family dynamics

Cleanse and dress the wound-- elder abuse-- Documentation of skin prevention measure

Offload coccyx and other bony prominences.-- Bowel obstruction-- Incontinence episodes

Immediately begin a bowel training program-- Altered Nutrition-- Vital signs

Contact adult protective services-- Wound status

B) Determine when each client last received pain medication

33. Two clients ring their call lights simultaneously, requesting pain medication. Which action should the nurse implement first?

A) Provide nonpharmacologic pain management interventions.

B) Determine when each client last received pain medication

C) Prepare both clients' medication and take it to them at once

D) Evaluate both clients' pain using a standardized pain scale.

A) Have the client demonstrate prescribed wound care.

34. A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

A) Have the client demonstrate prescribed wound care.

B) Provide written instructions in the client’s native language

C) Have an interpreter repeat the wound care instructions

D) After each instruction, ask if the client understands.

C) Use positive reinforcement to affirm that the procedure was performed correctly .

35. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A) Advise the UAP to hold the thermometer securely in place for a full three minutes.

B) Demonstrate the correct technique for pulling the client's auricle down and back.

C) Use positive reinforcement to affirm that the procedure was performed correctly .

D) Remind the UAP to lubricate the thermometer before gently inserting it into the ear.

A) Risk for infection

36. The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

A) Risk for infection

B) Self-care deficit

C) Impaired physical mobility

D) Risk for impaired skin integrity

D) Call the pharmacy to see which medications should be taken

37. A client is being discharged post-surgery. Which information provided by the client requires additional instruction by the nurse?

A) Notify the healthcare provider if a fever develops

B) Use movement techniques taught by the physical therapists

C) Verify that a follow-up appointment has been scheduled

D) Call the pharmacy to see which medications should be taken

B) call the healthcare provider to have the procedure rescheduled.

38. The nurse is preparing a client for surgery and notices that the signed consent form has an error. The form states that the client is to have a left leg amputated. However, the client's right leg is marked for the surgery. The nurse administered the preoperative opioid medication 10 minutes ago, and there are no family members present. Which action should the nurse implement?

A) call the nearest relative to come in and sign a new form.

B) call the healthcare provider to have the procedure rescheduled.

C) Have the client sign another form before surgery.

D) Cross out the error and initial the consent form.

D)A Braden risk assessment scale rating score of ten

39. In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

A) hypoactive bowel sounds with infrequent bowel movements

B) 4 + pitting edema of both lower extremities

C) Warm, dry skin with fever of 100.0 F (37.8 C )

D)A Braden risk assessment scale rating score of ten

C ) The healthcare provider will share this information with you

40. A 19-year-old client is admitted to the hospital with severe right quadrant abdominal pain. The father is requesting his son’s laboratory test results. Which is the best response for the nurse to provide?

A) “I'm sorry, but your son’s medical information is none of your business.”

B) I can only give medical information to your son because he is an adult

C ) The healthcare provider will share this information with you

D)I can give you those results as soon as I get them back from the lab.

B) Document the client's statement on the admission form.

E) Flag the client's record with "do not resuscitate "

41. The mother of two toddlers who was recently divorced is scheduled for breast augmentation. During the day surgery admission process, the client tells the nurse that she has not executed a living will but does not want to be resuscitated or put on any mechanical breathing machines. Which action(s) should the nurse take? Select all that apply.

A) Notify the client's next of kin before surgery

B) Document the client's statement on the admission form.

C) Explain the benefit of executing an advanced directive.

D) Encourage the client to execute a will that identifies a guardian for her children.

E) Flag the client's record with “do not resuscitate “

A) Avoid naps

C) Try to go to bed and awaken at the same time

D) Avoid alcohol in the evening

42.

Case study

A client is a 36-year-old female who is in the clinic today for insomnia, She reports that she started having trouble sleeping two years ago after her father's death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks 1 to 2 glasses of wine every evening.

Nurse notes ____

Orders ___

Have a better sleep? Select all that apply

A) Avoid naps

B) Take an analgesic before bed

C) Try to go to bed and awaken at the same time

D) Avoid alcohol in the evening

E) Watch television in bed to fall asleep

F) Eat a heavy meal before bed

G) Exercise in the evening

A) release and reinsert the flowmeter in the wall outlet

43. When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. which should the nurse do next?

A) release and reinsert the flowmeter in the wall outlet

B) Adjust the flow rate to the prescribed liters per minute?

C) Assess the position of the mask on the client’s face,

D) Attach the flowmeter to the humidification canister.

1. Wash hands

2. Put on an isolation gown

3. Apply a surgical mask

4. Don gloves

44. The Nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Put on an isolation gown

Apply a surgical mask

Wash Hands

Don gloves

D) Ensure the clients' environment is properly cleaned and disinfected.

45. While changing the dressing of an immobile client, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

A) Initiate contact precautions

B) Teach family members how to prevent transmission of infection

C) Reapply sterile non-adhesive dressing

D) Ensure the clients' environment is properly cleaned and disinfected.

C) Verify client's identification by scanning the barcode on the armband

46. When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

A) Scan the medication barcode to document administration on the eMAR?

B) Remove the medication from the unit dose package while verifying the dose.

C) Verify client's identification by scanning the barcode on the armband?

D) Reconcile the medication to be administered with the initial client prescription?

D. A private room with both contact and airborne precaution's

47. A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client.

A) A semi-private room with a roommate who has the same diagnosis and airborne precautions.

B) A private room with both standard and droplet precautions

C) A semi- private room with a roommate who has the same diagnosis and contact precautions

D. A private room with both contact and airborne precaution's

A) Determine the client's decision about homologous blood transfusion

48. The nurse is conduction an initial admission assessment for a woman who is a Jehovah Witness and is scheduled to deliver a baby by Cesarean section with the next 24 hours. Which action should the nurse take?

A) Determine the client's decision about homologous blood transfusion

B) Comment to the client for her patience after a long wait in the admissions process

C) Obtain the primary source of information from the head of the spiritual group

D) Arrange for ritual meeting together with other Jehovah's Witnesses before surgery

C) Reduce the stimuli in the area before continuing the teaching

49. While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

A) Provide the client with a step by step written instructions

B) Demonstrate the skill, speaking slowly and using simple terms

C) Reduce the stimuli in the area before continuing the teaching

D) Reassure the client that the skill is not difficult to learn.

D) Opioid analgesic received one hour ago.

50. Which Assessment date reflects the need for the nurse to include the problem, Risk for falls, in a client's plan of care.

A) Stooped posture with a steady gait

B) Expressed feelings of depression

C) Recent serum hemoglobin level of 16 g/dL (160 g/L)

D) Opioid analgesic received one hour ago.

D) Perform suctioning

51. A hospitalized client who has an advance directive and healthcare power of attorney receiving enteral nutrition through a feeding tube, The client vomits and appears to be choking. Which action should the nurse take.

A) elevate the head of the bed to 45 degrees

B) review the advanced direct order

C) imitate the feeding tube with water

D) Perform suctioning

A) Double check the dosage of high-risk medications with another nurse.

C) Question unusually large or small doses

The client is a 2-year-old female with diarrhea and dehydration. She was born at 32 weeks vaginally and was in the (NICU) for several weeks before being discharged home. She is developmentally appropriate.

The nurse pulled a bottle of potassium from the automated medication administration system. They went to the medication room to pull up the medication and immediately went to the client's room to administer the dose. The nurse did not realize that they needed to calculate and pull the appropriate dose from the bottle and gave the entire volume for the total of 40 mEq,

Which medication error prevention technique would have helped to avoid this error. Select all that apply.

A) Double check the dosage of high-risk medications with another nurse.

B) Involve and educate clients in medication administration

C) Question unusually large or small doses

D) Use at least 2 client identifiers before administering a dose

D. Processed with teaching the client how to walk with the crutches.

53. A client with sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three fingers –widths between the top of the crutch and the client's axilla. Which action should the nurse take?

A) Assess the client for the signs of diminished circulation in the hands.

B) Confer with the physical therapist for a correct crutch size

C) Ask the client to sit down while the crutch length is adjusted

D. Processed with teaching the client how to walk with the crutches.

B) Blood pressure is 80/48 mm Hg

54. A nurse notifies the healthcare provider related to the client information using the situation, background, Assessment Recommendation (SBAR) technique. Which information should the nurse provide first.

A) Prescription of ceftriaxone PO every 12 hours

B) Blood pressure is 80/48 mm Hg

C) A 26 year – old client

D) Admitted after a motor vehicle collision

B) Provide a box of tissue for the client to use when coughing

55. When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

A) Teach the client to cover the mouth with hands when coughing

B) Provide a box of tissue for the client to use when coughing

C) Obtain face mask for the staff to wear upon entering the room

D) Assist the client in changing into a fresh hospital gown.

B) Apply the client's positive airway pressure device

56. The nurse assists a client who has obstructive sleep apnea (OSA) with evening care. Which intervention is the most important for the nurse to implement before leaving the client alone?

A) Elevate the head of the bed to a 45- degree angle

B) Apply the client's positive airway pressure device

C) Remove dentures or other oral appliance

D) Lift and lock the side rails in place

D) Ask the client to describe the pain

57. To assess the quality of an adult's pain, which approach should the nurse use ?

A) Provide a numeric pain scale

B) Identify effective pain relief measures

C) Observe body language and movement

D) Ask the client to describe the pain

D) Whether they contain pulp or fruit.

58. A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parents of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles.

A) If the popsicles are completely frozen

B) The color and flavor of the gelatin used.

C) How many popsicles are available

D) Whether they contain pulp or fruit.

D) Ensure bevel of the needle is pointing up

59. The nurse is administering an intradermal (ID) injection to a client. Which Action should the nurse take?

A) Hold the syringe perpendicular to the skin

B) Massage the site gently after injection

C) Select upper arm as the injection site

D) Ensure bevel of the needle is pointing up

A) 2+edema of fingers and hands

60. The nurse attaches a pulse oximeter to a client's finger and obtains an obtains an oxygen saturation reading of 91%.

Which assessment finding most likely contributes to this reading.

A) 2+edema of fingers and hands

B) Capillary refill time in 2 seconds

C) Radial pulse volume is 3 + edema

D) Blood pressure is 142/88 mm Hg