HESI Final May2018

A client with multiple sclerosis is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply)
a- Platelet count
b- White blood cell count (WBC)
c- Sodium and potassium
d- Red blood cell count (RBC)
e- Albumin and protein

2- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply)
a- Sausage patties and eggs
b- Whole wheat toast and jam
c- Bagels and cream cheese
d- Toaster pastries and milk
e- Blackberries and oatmeal

3- After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)
a- Take out dentures and place in a labeled cup
b- Apply a body shroud
c- Place a small pillow under the head
d- Remove resuscitation equipment from the room
e- Gently close the eyes

4- A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
a- Tell the client to have a complete blood count (CBC) drawn
b- Instruct the client to seek medical attention immediately
c- Encourage him to take the medication at night with a snack
d- Explain that these are common side effects of the medication

5- An older adult male is admitted with complications related to chronic obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?
a- Restrict daily fluid intake
b- Eat meals at the same time daily
c- Maintain a low protein diet
d- Limit the intake of the high calorie foods

6- A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?
a- Granulating tissue in foot ulcer
b- Full volume of pedal pulse
c- Reduced level of pain
d- Improved visual activity.

7- The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes?
a- The fating blood sugar was 120 mg/dl this morning.
b- Urine ketones have been negative for the past 6 months
c- The hemoglobin A1C was 6.5g/100 ml last week
d- No diabetic ketoacidosis has occurred in 6 months.

8- A heparin infusion is prescribed for a client who weights 220 pounds. After administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. (Enter numeric value only. If rounding to the nearest whole number.)
18

9- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?
a- Assess extremity strength and resistance
b- Report a sodium level of 132 mEq/L or mmol/L (SI units)
c- Measure and record the cardiac QRS complex
d- Check current finger stick glucose

10- The nurse assesses an older adult who is newly admitted to a long term care facility. The client has dry, flaky skin and long thickened fingernails. The clients has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)?
a- Soak and file fingernails
b- Offer fluids frequently
c- Monitor skin elasticity
d- Ambulate in the hallway

11- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/