HESI 10
Which instruction should the nurse provide a pregnant client who is complaining of heartburn? A. Limit fluids between meals to avoid over distention of the stomach. B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Eat small meals throughout the day to avoid a full stomach.
Answer D. Eat small meals throughout the day to avoid a full stomach. Rationale Eating small frequent meals (D) throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be consumed with foods because they further distend the stomach, but fluids should not be limited between meals (A) because this puts the client at risk for dehydration. (B) is not recommended during pregnancy unless prescribed by the healthcare provider because they place the client at risk for electrolyte imbalance (sodium), constipation (aluminum), or diarrhea (magnesium). (C) Is less effective than (D) in preventing heartburn.
A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? A. Evaluate the client's upper extremity before counting the pulse rate. B. Auscultate directly below the IV site with a Doppler stethoscope. C. Turn off the intravenous fluids that are infusing while counting the pulse. D. Palpate at the radial pulse site with the pads of two or three fingers.
Answer D. Palpate at the radial pulse site with the pads of two or three fingers. Rationale The radial pulse site (D) is easily assessable and palpable unless an IV is placed at the client's wrist. (A) may make the pulse more difficult to palpate. (B) places the stethoscope over a vein rather than an artery and is unlikely to provide an accurate pulse rate. The pulse rate can be accurately counted without implementing (C).
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? A. Tell the client that the vaccine for HPV is not indicated. B. Inform the client that warts do not return following cryotherapy. C. Recommend the use of latex condoms to prevent HPV transmission D. Reinforce the importance of annual papanicolaou (Pap) smears.
Answer D. Reinforce the importance of annual papanicolaou (Pap) smears. Rationale Because the human Papilloma (HPV) is associated with cervical cancer, close follow up, including yearly Pap smears (D) should be recommended. Although the HPV Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant, does not work well for those who are exposed to the virus before receiving the vaccine, it is still recommended (A) by the CDC to prevent infection another strain. Although cryotherapy is effective in removing the presence of warts (B), relapse can occur and requires repeated treatments. Latex condoms (C) are more effective in preventing transmission via mucosal surfaces but are not as effective in preventing HPV infections transmitted by skin-to-skin contact.
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? A. Antibiotics take two weeks to become effective against infections such as athlete's foot. B. Continue using the ointment for a full week, even after the symptoms disappear. C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks.
Answer D. Stop using the ointment and encourage complete drying of the feet and wearing clean socks. Rationale Athlete's foot (tinea pedis) is a fungal infection that afflicts the feet and causes scaliness and cracking of the skin between the toes and on the soles of the feet. The feet should be well ventilated, dried well after bathing, and clean socks should be placed on the feet after bathing (D). Antifungal ointment may be prescribed but antibiotic ointments are not useful (A, B, and C).
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)
Answer 75 Rationale Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? A. Use a diluted commercial mouthwash with mouth care. B. Obtain any childhood vaccination that is not up-to-date. C. Use sunblock or protective clothing when outdoors. D. Include the child on regular outings with the family.
Answer C. Use sunblock or protective clothing when outdoors. Rationale Many CT protocol agents have an affinity for rapid proliferating cells, such as mucosal and epithelial cells, and cause oral lesions, gastrointestinal distress, myelosuppression, and photosensitivity, so the parents should ensure that the child uses sunblock or protective clothing when in sunlight (C). Diluted commercial mouthwashes (A) should be avoided because alcohol is a common ingredient that is caustic and irritating for a child with stomatitis. Vaccinations (B) and exposure to crowds (D) can produce serious side effects for a child who is immunosuppressed and should be avoided until approved by the healthcare provider.
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Answer 0.4 Rationale Using the formula, D/H xQ, 35mg/100mg x 1 = 0.35 = 0.4 ml
The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If rounding is required, round to the nearest tenth.)
Answer 2.5 Rationale To validate that the prescription is within the therapeutic range, use the clients BSA, 0.6 m2 x 5 to 15 mg/week = 3 to 9 mg/week/3 dosage Calculate each of the three doses given weekly, 7.5 mg/3 doses = 2.5 mg/dose
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? A. Add equal amounts of water and feeding to a feeding bag and infuse at 50 ml/hour. B. Continue the full strength feeding after decreasing the rate of infusion to 25 mL/hour. C. Maintain the present feeding until the diarrhea subsides and then begin the new prescription. D. Withhold any further feeding until clarifying the prescription with the healthcare provider.
Answer A. Add equal amounts of water and feeding to a feeding bag and infuse at 50 ml/hour. Rationale Diluting the formula (A) can help alleviate the diarrhea. Diarrhea can occur as a complication of enteral tube feedings and can be due to a variety of causes including hyperosmolar formula. (B) can also help alleviate the diarrhea, but is not consistent with the new prescription. The diarrhea will continue if (C) is implemented. There is no need for further clarification of the prescription (D).
An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache rated 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply.) A. Administer a daily dose of lisinopril as scheduled. B. Assess the client for postural hypotension. C. Notify the healthcare provider immediately. D. Provide a PRN dose of acetaminophen for headache. E. Withhold the next scheduled daily dose of warfarin.
Answer A. Administer a daily dose of lisinopril as scheduled. D. Provide a PRN dose of acetaminophen for headache. Rationale (A and D) are correct. The client's routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled (A) to maintain the client's blood pressure. A PRN dose of acetaminophen (D) should be given for the client's headache. The client's blood pressure is not low and the client is not exhibiting signs of postural hypotension, such as dizziness when standing, so (B) is not necessary. The blood pressure is not sufficiently abnormal to warrant notifying the healthcare provider immediately (D), unless the client's blood pressure increases or does not respond to the maintenance dose of antihypertensive medication. There is no indication of a need to withhold a daily dose of warfarin (A), an anticoagulant.
A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? A. Ask the client about his expected goals for the hospitalization. B. Explain the palliative care measures can be provided at home. C. Notify do radiation department to withhold the treatments for now. D. Determine if the client wishes to cancel further radiation treatments.
Answer A. Ask the client about his expected goals for the hospitalization. Rationale Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client's goals for symptom control while receiving treatment in the hospital (A). Although home care (B) is available, it assumes that the client's prognosis is limited and he is eligible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and (C and D) are not appropriate unless the radiation conflicts with the client's goals.
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today? A. Assist client in identifying goals for the day. B. Encourage client to participate for one hour in a team sport. C. Schedule client for a group that focuses on self-esteem. D. Help client to develop a list of daily affirmations.
Answer A. Assist client in identifying goals for the day. Rationale Clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participate in care by identifying goals for the day (A) is the most important intervention for the client's first day at the unit. (B, C, and D) can be implemented over time, as the depression decreases.
The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply.) A. Close car windows and use air conditioner. B. Decrease the raw sugars in the diet. C. Avoid sudden changes in temperature. D. Keep away from pets with long hair. E. Stay indoors when grass is being cut.
Answer A. Close car windows and use air conditioner. C. Avoid sudden changes in temperature. D. Keep away from pets with long hair. E. Stay indoors when grass is being cut. Rationale (A, C, D, and E) are correct answers. Asthmatic triggers include air pollutants (A), sudden changes in temperature (C), and allergens such as pets (D) and grass (E). Raw sugars (B) are not related to asthma attacks.
A client is admitted with acute pancreatitis who admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? A. Confusion and tremors. B. Yellowing and itching of skin. C. Abdominal pain and vomiting. D. Anorexia and abdominal distention.
Answer A. Confusion and tremors. Rationale Daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors (A), which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. Chronic alcoholism can cause multiple comorbidities such as (B and D) that are expected findings in those with liver dysfunction, but do not require immediate action. (C) is an expected finding of pancreatitis that requires nursing action, but the priority intervention is reporting signs of DTs.
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? A. Describes life without purpose. B. Complains of nausea and loss of appetite. C. States is often fatigued and drowsy. D. Exhibits in increase in sweating.
Answer A. Describes life without purpose. Rationale Cymbalta is a selective serotonin and norepinephrine reputake inhibitor that is known to increase the risk of suicidal thinking (A) in adolescents and young adults with major depressive disorder. Although nausea, loss of appetite, fatigue, drowsiness, dizziness, and increased sweating (B, C, and D) are common side effects, the increase in hopelessness requires further assessment.
The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? A. Examine the genitalia as the last part of the total exam. B. Use soothing statements to facilitate cooperation. C. Allow the child to keep underpants on to examine genitalia. D. Work slowly and methodically so not to stress the child.
Answer A. Examine the genitalia as the last part of the total exam. Rationale Examination of a child's genitalia is particularly stressful to toddler's, so this assessment is best left until the end of the examination (A). Soothing statements (B) are best done by a parent, not the nurse, and often the parent's presence and comfort efforts do not gain cooperation. The genitals must be completely visualized and sometimes palpated, which requires removal of underwear for a brief period (C). When a young child is completely distraught, it is better to work quickly and precisely, not methodically and slowly (D).
A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. Explain that counseling will be provided to give her information about her cancer risk. B. Gather additional information about the client's family history for all types of cancer. C. Offer assurance that there are a variety of effective treatments for breast cancer. D. Provide information about survival rates for women who have this genetic mutation.
Answer A. Explain that counseling will be provided to give her information about her cancer risk. Rational BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A) to the client along with options for increased screening or preventative measures. (B) is completed by the genetic counselor before the client undergoes genetic testing. A positive BRACA1 test is not an indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling.
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? A. Explain that memory loss and confusion are common with vitamin B12 deficiency. B. Ask if the client is experiencing any change in bowel habits. C. Determine if the client is taking iron and folic acid supplements. D. Encourage the husband to bring the client to the clinic for a complete blood count.
Answer A. Explain that memory loss and confusion are common with vitamin B12 deficiency. Rationale Pernicious anemia is related to the absence of the intrinsic factor in gastric secretions, leading to malabsorption of vitamin B 12, and commonly causes memory loss, confusion, cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease (A). Although (B, C, and D) provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hours of B 12 injections.
A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan? A. Further evaluation involving surgery may be needed. B. A pelvic exam is also needed before cancer is ruled out. C. Pap smear evaluation should be continued every six months. D. One additional negative pap smear in six months is needed.
Answer A. Further evaluation involving surgery may be needed. Rationale An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully, including an exploratory laparotomy (A). (B, C, and D) are often negative even when ovarian cancer is present.
When implementing a disaster intervention plan, which intervention should the nurse implement first? A. Identify a command center where activities are coordinated. B. Assess community safety needs impacted by the disaster. C. Instruct all essential off-duty personnel to report to the facility. D. Initiate the discharge of stable clients from hospital units.
Answer A. Identify a command center where activities are coordinated. Rationale First, the command center should be identified (A) so activities can be coordinated. (B, C, and D) can be done after the command center is established and after the level of needs is known.
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. Information about non-pharmaceutical pain relief measures. C. Referral for social services for the child and family. D. Signs of addiction to opioid and medications.
Answer A. Instructions about how much fluid the child should drink daily. Rationale It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that a specific plan for hydration is developed (A) so that a crisis can be delayed. (B and C) should be included in the teaching plan but do not have the priority of (A). Children with SCA can have a great deal of pain during a crisis, which should be treated with opioid analgesics, but addiction (D) is usually not a risk for these children.
The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis? A. Long distance runner since high school. B. Lactose intolerant since childhood. C. Photosensitive to a drug currently taking. D. Recently treated for deep vein thrombosis.
Answer A. Long distance runner since high school. Rationale Osteoarthritis is a degenerative joint disease often caused by Trumatic injury or repetitive stress to weight-bearing joints, such as high impact sports like running (A). (B, C, and D) are unlikely to contribute to the onset of osteoarthritis, although limited calcium intake or Vitamin D deficiency related to limited exposure to sunlight may contribute to osteoporosis or osteomalacia.
An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes/daily for 50 years and is currently restless and confused. Vital signs are: temperature 96° F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 60,000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? A. Multiple organ dysfunction syndrome (MODS). B. Disseminated intravascular coagulation (DIC). C. Chronic obstructive pulmonary disease (COPD). D. Acquired immunodeficiency syndrome (AIDS).
Answer A. Multiple organ dysfunction syndrome (MODS). Rationale MODS is a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate (A). DIC (B) may develop as a result of MODS. COPD (C) is a chronic condition and if pulmonary complications develop, acute respiratory distress syndrome (ARDS) can be expected to occur. There are no known risk factors for AIDS (D) for this client.
Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply.) A. Notify the food services department of the allergy. B. Enter the allergy information in the client's record. C. Document this statement in the nurse's notes. D. Note the allergy on the diet intake flowsheet. E. Add egg allergy to the client's allergy arm band.
Answer A. Notify the food services department of the allergy. B. Enter the allergy information in the client's record. E. Add egg allergy to the client's allergy arm band. Rationale (A, B, and E) are correct. The dietary department (A) needs to screen menu selections for foods that are prepared with eggs. The clients chart (B) should be clearly marked but the statement does not need to be documented in the nurse's notes (C) or included on the intake record (D). Allergy identification (A) on the arm band is a universal location where allergies are noted while a client is hospitalized.
Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? (Select all that apply.) A. Prepare medication reversal agent. B. Check oxygen saturation level. C. Apply oxygen via nasal cannula. D. Initiate bag-valve-mask ventilation. E. Begin cardiopulmonary resuscitation.
Answer A. Prepare medication reversal agent. B. Check oxygen saturation level. C. Apply oxygen via nasal cannula. Rationale (A, B, and C) are correct. Sedation (A) given during the procedure may need to be reversed if the client does not easily wake up. Oxygen saturation level (B) should be assessed, and oxygen (C) applied to support respiratory effort and oxygenation. The client is still breathing so the bag-valve-mask ventilation (D) and CPR (E) are not indicated at this time.
A client with coronary artery disease who is experiencing syncopal episodes is admitted for electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Prepare skin for procedure. B. Identify client's pulse points. C. Witness consent for procedure. D. Check telemetry monitoring.
Answer A. Prepare skin for procedure. Rationale Ablation therapy uses radiofrequency, microwave, laser, or cryo-thermae to oblate areas of the cardiac system that are the source of ectopic cardiac dysrhythmias, which can cause syncope. Skin preparation (A), including hair removal can be delegated to the UAP. (B, C, and D) should be implemented by the nurse.
While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? A. Raise the client's legs and feet. B. Administer 250 mL saline bolus. C. Decrease blood flow from dialyzer. D. Stop the hemodialysis procedure.
Answer A. Raise the client's legs and feet. Rationale To raise the client's blood pressure, (A) is the most immediate and easiest intervention for the nurse to implement. (B and C) should be done as soon as possible to add volume to the vascular space by ceasing to pull fluid from the client. If the blood pressure does not increase, then the procedure may need to be stopped (D).
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? A. Reposition the infant every 2 hours. B. Perform diaper changes under the light. C. Feed the infant every 4 hours. D. Cover with a receiving blanket.
Answer A. Reposition the infant every 2 hours. Rational An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours (A). The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes (B) are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours (C) to prevent dehydration. The infant should wear only a diaper (D) so that the skin is exposed to the phototherapy.
A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? A. Sitting up and leaning forward. B. Standing with the head leaning backward. C. Side-lying with the head slightly elevated. D. Supine with the legs raised.
Answer A. Sitting up and leaning forward. Rationale A child with a nose bleed should be instructed to sit up and lean forward (A) while continuous pressure is applied to the nose with the thumb and forefinger for at least ten minutes. (B) does not give easy access to the nose and will not help stop the bleeding. (C) helps to prevent aspiration from vomiting, but this is not currently an issue with this child. (D) promotes venous return but will not help stop the nosebleed.
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? A. This hernia is a normal variation that resolves without treatment. B. Restrictive clothing will be adequate to help the hernia go away. C. An abdominal binder can be worn daily to reduce the protrusion. D. The quarter should be secured with an elastic bandage wrap.
Answer A. This hernia is a normal variation that resolves without treatment. Rationale An umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously (A) as the child learns to walk. (B, C, and D) are ineffective and unnecessary.
When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A. Massage the uterus to decrease atony. B. Check for a destined bladder. C. Increase intravenous infusion. D. Review the hemoglobin to determine hemorrhage.
Answer B. Check for a destined bladder. Rationale A great fundus that is dextroverted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention (B). The nurse should always have the client empty her bladder before the postpartum exam. This client's uterus is firm, so (A and C) are incorrect. A soft, boggy uterus indicates uterine atony. (D) should not be the nurse's first suspicion when the uterus is firm and the lochia is moderate.
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.) A. Written at a twelfth grade reading level. B. Contains a list with definitions of unfamiliar terms. C. Uses common words with few syllables. D. Printed using a 12-point type font. E. Uses pictures to help illustrate complex ideas.
Answer B. Contains a list with definitions of unfamiliar terms. C. Uses common words with few syllables. E. Uses pictures to help illustrate complex ideas. Rationale Correct selections are (B, C, and E). During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that a client may not know (B), and use common words that expresses information clearly and simply (C). Simple, attractive pictures help (E) hold the learner's attention. The reading level of materials should be at the 4th to 5th grade level, not (A). Materials should be printed using a large font (18-point or higher), not the standard 12-point font (D), so that materials are easy to read when visual acuity is lessened.
What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Assess the client's ability to use a numeric pain scale. B. Initiate the dosage lockout mechanism on the PCA pump. C. Instruct the client to use the medication before the pain becomes severe. D. Assess the abdomen for bowel sounds.
Answer B. Initiate the dosage lockout mechanism on the PCA pump. Rationale Morphine depresses respiration, so ensuring the client cannot overdose on the medication (B) has the highest priority. (A, C, and D) are also important nursing actions, but they do not have the priority of (B).
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? A. Ensure that the UAP has placed the pillows effectively to protect the client. B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. C. Assume responsibility for placing the pillows while the UAP completes another task. D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.
Answer B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. Rationale The nurse should instruct the UAP to pad the side rails with soft blankets (B) because the use of pillows (A) could result in suffocation and would need to be removed at the onset of a seizure. The nurse can delegate padding the side rails to the UAP (C). A side-lying position (D) may help prevent aspiration during a seizure, but turning the client is not the priority when implementing seizure precautions.
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Pain scale rating of a "9" on a 0-10 scale. B. Last menstrual period was 7 weeks ago. C. Reports white, curdy vaginal discharge. D. History of irritable bowel syndrome (IBS).
Answer B. Last menstrual period was 7 weeks ago. Rationale Acute lower abdominal pain in a young adult female can be indicative of an ectopic pregnancy, which can be life-threatening. Since the client's last menstrual period was 7 weeks ago (B) a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured fallopian tube. Although the severity of pain (A) requires treatment, the most significant finding is the client's last menstrual period. Other options are not the most important concerns. (C) is characteristic of vulvovaginal candidiasis (Monilial candidiasis), which is not related to abdominal pain. IBS (D) causes significant abdominal cramping, but does not have the priority of a possible ectopic pregnancy.
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? A. Identifies 2 treatments for constipation due to immobility. B. Names 3 home safety hazards to be resolved immediately. C. States 4 risk factors for the development of osteoporosis. D. Lists 5 calcium-rich foods to be added to her daily diet.
Answer B. Names 3 home safety hazards to be resolved immediately. Rational A major teaching goal for an elderly client with osteoporosis is maintenance of safety to prevent falls (B). Injury due to a fall, usually resulting in a hip fracture, can result in reduced mobility and associated complications. Goals related to (A, C, and D) are also important when teaching clients who have osteoporosis, but they do not have the priority of preventing falls (B), which relates to safety.
The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit. B. Obtain a detailed report from the nurse transferring the client. C. Mark the chart with the clients request for no heroic measures. D. Provide the client written information about end-of-life care.
Answer B. Obtain a detailed report from the nurse transferring the client. Rationale To maintain continuity of care, it is most important for the nurse working on the palliative care unit to obtain a detailed "situation, background, assessment, recommendation" (SBAR) report (B), which provides both clinical and non-clinical information as well as further information about what the client might need. (A, C, and D) are important interventions, but do not have the priority of (B) in facilitating continuity of care.
Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider? A. This output is not sufficient to clear nitrogenous waste. B. Oliguria signals tubular necrosis related to hypoperfusion. C. Low urine output puts the client at risk for fluid overload. D. An increased urine output is expected after splenectomy.
Answer B. Oliguria signals tubular necrosis related to hypoperfusion. Rationale Prolonged low blood pressure leads to renal ischemia, which is the common etiology of acute tubular necrosis (ATN). Decreasing urine output (B) is an early indicator of ATN. While (A and C) are pathophysiological consequences of prolonged low blood pressure, these are not the most important reasons for the client's risk for ATN. Neither oliguria nor polyuria (D) are expected findings after a splenectomy.
An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? A. Obtain a urine specimen for culture and sensitivity. B. Palpate the client's suprapubic area for distention. C. Advise the client to maintain a voiding diary for one week. D. Instruct in effective technique to cleanse the glans penis.
Answer B. Palpate the client's suprapubic area for distention. Rationale The client is exhibiting classic signs of an enlarged prostate gland, which restricts urine flow and causes bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying. Assessing for bladder distention (B) should be implemented to determine the need for post void residual urine. (A, C, and D) are not warranted based on the client's symptoms.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) A. Take an additional dose for signs of hyperglycemia. B. Recognize signs and symptoms of hypoglycemia. C. Report persistent polyuria to the healthcare provider. D. Use sliding scale insulin for fingerstick glucose evaluations. E. Take Glucophage with the morning and evening meal.
Answer B. Recognize signs and symptoms of hypoglycemia. C. Report persistent polyuria to the healthcare provider. E. Take Glucophage with the morning and evening meal. Rationale (B, C, and E) are correct. Glucophage, an anti-diabetic agent, acts by inhibiting hepatic glucose production and increases peripheral tissue sensitivity to insulin. The client and family should be taught to recognize signs and symptoms of hypoglycemia (B). If the dose of Glucophage is inadequate, signs of hyperglycemia, such as polydipsia and polyuria (C), should be reported to the healthcare provider. Glucophage should be taken with meals to reduce GI upset and increase absorption (A). Prescribed dose adjustments (A) should only be made based on the healthcare provider's evaluation of the client's response to the medication regime. (D) is prescribed for type 1 DM and during illness or other stress-induced situations that impact the client's normal range of serum glucose.
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A. Replace the IV site with a smaller gauge. B. Redress the abdominal incision. C. Leave the lights on in the room at night. D. Apply soft bilateral wrist restraints.
Answer B. Redress the abdominal incision. Rationale The abdominal incision should be redressed using aseptic technique (B). The IV site (A) should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night (C) may interfere with the client's sleep and increase confusion. Restraints (D) are not indicated and should only be used as a last resort to keep client from self-harm.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Evaluate the client for sleep disturbances. B. Report any client complaint of pain or discomfort. C. Weigh the client and report any weight gain. D. Assess the client for weakness and fatigue. E. Note and report the client's food and liquid intake during meals and snacks.
Answer B. Report any client complaint of pain or discomfort. C. Weigh the client and report any weight gain. E. Note and report the client's food and liquid intake during meals and snacks. Rationale (B, C, and E) are correct. Those functions within the scope of practice for the UAP include reporting client complaints of pain (B), daily weight (C), and nutritional intake (A). (A and D) are assessments that require implementation by a licensed nurse.
A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Blood alcohol level of 0.09%. B. Serum lithium level of 1.6 mEq/L or mmol/l (SI). C. Six hours of sleep in the past three days. D. Weight loss of 10 pounds (4.5 kg) in past month.
Answer B. Serum lithium level of 1.6 mEq/L or mmol/l (SI). Rationale The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity, which is supported with the clients serum lithium level of 6 mEq/L or mmol/l (B). Although the client's blood alcohol level (A) indicates that he recently consumed alcohol (the legal intoxication level in most states is 0.10%, with some states using 0.08%), the serum lithium level is a greater priority. Sleep deprivation (C) and recent weight loss (D) should also be reported, but these findings do not have the priority of (B).
A family member of a frail elderly adult asks the nurse about eligibility requirements for Hospice care. What information should the nurse provide? (Select all that apply.) A. All family must be in agreement about the need for hospice care. B. Hospice services are covered under Medicare Part B. C. A client must be willing to accept palliative care, not curative care. D. The healthcare provider must project that the client has 6 months or less to live. E. All medications except pain treatment will be stopped during hospice care.
Answer C. A client must be willing to accept palliative care, not curative care. D. The healthcare provider must project that the client has 6 months or less to live. Rationale (C and D) are correct. The eligibility criteria for Medicare coverage requires that the client is willing to except palliative care, not curative care (C). The healthcare provider should provide an expected prognosis of 6 months or less to live (D), which can be extended by the healthcare provider. It is not necessary for all family members to agree with the need for hospice care (A). Medicare Part B is for prescription services, Hospice services are paid by Medicare Part A (B). All routine medications (A) are continued during hospice care.
The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? A. An adult female who has been depress for the past several month and denies suicidal ideation. B. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. C. A young male with schizophrenia who said voices is telling him to kill his psychiatric. D. An elderly male who tell the staff and other client that he is superman and he can fly.
Answer C. A young male with schizophrenia who said voices is telling him to kill his psychiatric. Rationale The RN should deal with (C) because command hallucinations can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. (A, B, and D) present a low safety risk.
When should intimate partner violence (IPV) screening occur? A. As soon as the clinician suspects a problem. B. Only when a client presents with an unexplained injury. C. As a routine part of each healthcare encounter. D. Once the clinician confirms a history of abuse.
Answer C. As a routine part of each healthcare encounter. Rationale Universal screening for IPV (C) is a vital means to identify victims of abuse in relationship. The suspicions (A) of different clinicians vary greatly, so screening would not be implemented consistently. The client should be screened regardless of the presence of injury (B). Although history of abuse (D) is difficult to confirm, screening should occur regardless, and this incident may be initial case of abuse.
A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5 pound weight gain. Which intervention the nurse implement? A. Arrange transport for admission to the hospital. B. Insert saline lock for IV diuretic therapy. C. Assess compliance with routine prescriptions. D. Instruct the client to monitor daily caloric intake.
Answer C. Assess compliance with routine prescriptions. Rationale Fluid retention may be a sign that the client is not taking the medication as prescribed (C) or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%). Hospitalization (A) is not warranted. Diuretic medication (B) does not need to be given IV at this time. The weight gain is more likely due to fluid retention (D) rather than diet.
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Immunosuppressive therapy. B. Chemotherapy. C. Bone marrow transplantation. D. Blood transfusions.
Answer C. Bone marrow transplantation. Rationale Bone marrow transplantation (C) is the treatment of choice for a plastic anemia and is associated with a 60 to 80% survival rate. Because of the relatively poor prognosis when treated with drug therapy (A and B), bone marrow transplantation should be considered early in the course of the disease if a compatible donor can be found. Transplantation is more successful when performed before multiple transfusions (D) have sensitized the child to leukocyte and HLA antigens.
The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? A. Administer oxygen by face mask at 6 L/min. B. Transport the client for a cesarean delivery. C. Elevate the presenting part off the cord. D. Place the client to a knee-chest position.
Answer C. Elevate the presenting part off the cord. Rationale The nurse should immediately elevate the presenting part of the cord (C) because when the cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and reduces perfusion to the fetus. (A) can be delayed until pressure is removed from the cord. (B and D) are important but do not have the priority of (C).
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? A. Neutrophils. B. Lymphocytes. C. Eosinophils. D. Monocytes.
Answer C. Eosinophils. Rationale Eosinophils (C) are involved in allergic responses and destruction of parasitic worms. (A) serves as the body's primary defense against bacterial infection through phagocytosis. (B) is responsible for the cellular and humoral immune response. (D) are the macrophages located in the peripheral blood supply.
If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6°F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? A. The intravenous fluid replacement contains a hypertonic solution of sodium chloride, B. Urinary and gastrointestinal fluid loss reduce blood viscosity and stimulate thirst. C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. D. Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat.
Answer C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. Rationale Fever causes insensible fluid loss, which contributes to fluid volume and deficit and results in hemoconcentration of sodium (C) (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride (A). Although (B and D) are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hemoconcentration.
While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? A. Apply a pressure dressing around the chest tube insertion site. B. Assess the client for allergies to topical cleaning agents. C. Measure the area of swelling and crackling. D. Administer an oral antihistamine per PRN protocol.
Answer C. Measure the area of swelling and crackling. Rational A crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured (C) and the finding documented. (A) is not indicated for crepitus. (B and C) are not indicated.
A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? A. Determine the client's level of orientation and cognition. B. Assessed distal pulses and signs of peripheral edema. C. Obtain a list of medications taken for cardiac history. D. Ask client about exposure to environmental heat.
Answer C. Obtain a list of medications taken for cardiac history. Rationale The client is presenting with signs of digitalis toxicity. A list of medication, which is likely to include digoxin (Lanoxin) for heart failure, can direct further assessment in validating digitalis toxicity with serum levels greater than 2 ng/mL that is contributing to the client's presenting clinical picture (C). (A, B, and D) may provide information related to the client's presenting symptoms, but the first assessment should focus on digitalis toxicity.
The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? A. Empty the urinary drainage bag. B. Feed the client a snack. C. Offer the client oral fluids. D. Assess the breath sounds.
Answer C. Offer the client oral fluids. Rationale Increasing oral fluid intake reduces the risk of problems associated with immobility, so the UAP should be instructed to offer the client oral fluids every two hours (C), or whenever turning he client. It is not necessary to empty the urinary bag (C) or feed the client (B) every two hours. Assessment is a nursing function, and UAPs do not have the expertise to perform assessment of breath sounds (D).
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler's position with his arms at his side. What action should the nurse implement? A. Reposition the client in a side-lying position and support his abdomen with pillows. B. Elevate the client's feet on a pillow while keeping the head of the bed elevated. C. Raise the head of the bed to a Fowler's position and support his arms with a pillow. D. Place the client in a shock position and monitor his vital signs at frequent intervals.
Answer C. Raise the head of the bed to a Fowler's position and support his arms with a pillow. Rationale Ascites is the accumulation of fluid in the peritoneal or abdominal cavity, and this fluid pushes on the diaphragm, limiting the client's lung expansion and causing dyspnea. To relieve this pressure, the head of the bed should be elevated (C) with the arms supported for comfort. (A, B, and D) may further decrease lung expansion and increased venous return, thereby worsening the client's dyspnea.
When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? A. The client is too obese. B. Palpating in the wrong abdominal quadrant. C. The gallbladder is normal. D. Deeper palpation technique is needed.
Answer C. The gallbladder is normal. Rationale A normal healthy gallbladder (C) is not palpable. (A) should not interfere with abdominal palpation. The examiner is palpating the correct site (B). (D) is not necessary to locate an enlarged gallbladder.
A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? A. Tachycarcia. B. Muscle cramps. C. Vomiting. D. Dyspnea.
Answer C. Vomiting. Rationale Vomiting (C) is a common sign of digitalis toxicity in children. (A and D) are associated with heart failure, and if these signs increase, it could be an indication that the child's condition is worsening. Muscle cramps may be associated with diuretic therapy (B).
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Express feelings of sadness and loneliness. B. Neglects personal hygiene and has no appetite. C. Lacks interest in the activities of family and friends. D. Begin to show signs of improvement in affect.
Answer D. Begin to show signs of improvement in affect. Rationale When a depressed client begins to show signs of improvement (D), it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appears suddenly happy, begin to give away possessions, or becomes more relaxed and talkative. (A, B, and C) are signs and symptoms of persisting anhedonia (lack of pleasure) associated with depression.
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? A. Bruises on arms and legs. B. Round and tight abdomen. C. Pitting edema in lower legs. D. Capillary refill of 8 seconds.
Answer D. Capillary refill of 8 seconds. Rationale The client is bleeding and hypovolemia is likely. Capillary refill that is greater than 3 to 5 seconds indicates poor perfusion and requires immediate attention (D). Bruises (A), a tight and round abdomen (B), and pitting edema (C) are normal findings for a client with liver disease.
A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12 hours. When the client request an afternoon snack, which dietary choice should the nurse provide? A. Vanilla-flavored yogurt. B. Low fat chocolate milk. C. Calcium fortified juice. D. Cinnamon applesauce.
Answer D. Cinnamon applesauce. Rationale Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce (D) contains no calcium, so this is the best snack selection. Since (A, B, and C) contain calcium, these snacks should be avoided by a client who is taking ciprofloxacin.
The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first? A. Flush the vein with 3 ml of sterile normal saline. B. Assess the IV catheter insertion site for infiltration. C. Verify the threading of the tubing through the IV pump. D. Determine if the clamp on the IV tubing is released.
Answer D. Determine if the clamp on the IV tubing is released. Rational When the pump immediately beeps, it is often because the IV tubing clamp is occluding the flow, so the clamp should be checked first to ensure that it is open (D). If the alarm is not eliminated after the tubing clamp is released, flushing the IV site with saline (A) is a common practice to clean the needle or to identify resistance due to another source. Local signs of infiltration (C) may indicate the need to select another vein, but the pump's beeping this early in the procedure is likely due to a mechanical problem. If beeping continues after verifying that the clamp is released the placement or threading of the tubing through the pump should be verified (D).
