Hesi 2

A female client reports that she drank a liter of a solution to cleanse her intestines...immediately. How many ml of fluid intake should the nurse document? Whole number

760

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

place the id bands on the infant and mother

Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

An older client post-stroke who is aphasic with right-sided hemiplegia

Which class of drugs is the only source of a cure for septic shock?

Antiinfectives

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next?

Ask for a full explanation from the interpreter of the witnessed discussion

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

Viral meningitis whose temperature changed from 101 F to 102 F.

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?

Wait 1 minute and palpate the systolic pressure before auscultating again.

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

Chest physiotherapy should be performed twice a day before a meal.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest? A.)Malignancy B.)Bacterial infection C.)Viral infection D.)Lymphangitis

A

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Bone marrow transplantation B. Blood transfusion C. Chemotherapy D. Immunosuppressive therapy

A

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? A.)Nausea and indigestion. B.)Hypersalivation C.)Eyelid and facial twitching D.)Increased appetite

A

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

1000, 1600, 2200, 0400

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

Evaluate daily blood clotting factors.

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Avoid exposure to large crowds B. Do not take any over-the-counter medications C. Call the crisis hot line if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet

A

A male client with cancer, who is receiving antineoplastic drugs, is admitted to the...what findings is most often manifest this condition? A.)Ecchymosis and hematemesis B.)Weight loss and alopecia C.)Weakness and activity intolerance D.)Sore throat and fever

A

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? A.)Hypernatremia B.)Excessive thirst C.)Elevated heart rate D.)Poor skin turgor

A

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? A.)Uncontrollable drooling B.)Inability to raise voice C.)Tingling of extremities D.)Eyelid drooling

A

A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort

C

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)

33ml

A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only) 3 ml/hour

3ml per hr

An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube. B. Placement of an endotracheal tube. C. Retraction of the nasogastric tube D. Setup of patient- controlled analgesia

A

A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take? A.)Request the mother to leave the room B.)Tell the mother to stop speaking for the client C.)Request security to remove her from the room D.)Notify the charge nurse of the situation

A

A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? A.)Allow several minutes for the client to respond B.)Ask social services to find a Korean interpreter C.)Repeat the question slowly and distinctly D.)Establish direct eye contact with the client

A

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

A

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? A.)Stop the transfusion start a saline B.)Observe for a maculopapular rash C.)Report the fever to the blood bank D.)Give a PRN dose of acetaminophen

A

The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? A.)Irregular pulse B.)Tachycardia C.)Chest pain D.)Urinary frequency

A

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? A.)Rebound tenderness in the upper quadrants B.)Hypoactive bowel sounds in the lower quadrants C.)Tympany with percussion of the abdomen D.)Light colored gastric aspirate via the nasogastric tube

A

The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... A.)Determine the availability of two units of packed cells in the blood bank for client B B.)Increase the oxygen flow rate to 4 liters/minute per face mask for client A C.)Remove any foods, such as banana or orange juice, for the breakfast tray for client C D.)Inform client D that surgery is likely to be delayed until the infection responds to antibiotics

A

The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? A.)Remind the client to hold his breath after inhaling the medication B.)Confirm that the client has correctly shaken the inhaler C.)Affirm that the client has correctly positioned the inhaler D.)Ask the client if he has a spacer to use for this medication

A

The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide? A.)Move the device one to two inches away from the mouth B.)Secure the mouthpiece under the tongue C.)Press down on the device after breathing in fully D.)Breathe out slowly and deeply while compressing the device

A

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? A.)What food does your baby usually eat in a normal day? B.)What was the baby's weight at the last well-baby clinic visit? C.)The baby is below the normal percentile for weight gain D.)Your baby is gaining weight right on schedule

A

When administering ceftriaxone sodium (Rocephin) intravenously to a client before...most immediate intervention by the nurse? A.)Stridor B.)Nausea C.)Headache D.)Pruritis

A

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? A.)Avoid exposure to respiratory infections B.)Use relaxation exercises when anxious C.)Plan short, frequent rest periods D.)Continue physical therapy at home

A

The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) A.)Monitor heart, lung, and kidney function. B.)Notify healthcare provider of serum amylase and lipase levels. C.)Review client's abdominal ultrasound findings. D.)Position client on abdomen to provide organ stability E.)Encourage an increased intake of clear oral fluids

A,B,C

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) A.)Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B.)T3 and T4 hormone levels are increased C.)Large protruding eyeballs are a sign of hyperthyroid function D.)Weight gain is a common complaint in hyperthyroidism E.)Early treatment includes levothyroxine (Synthroid).

A,B,C

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) A.)Ease the client to the floor B.)Loosen restrictive clothing C.)Note the duration of the seizure D.)Leave the patient and check back when the seizure is over E.)Obtain a defibrillator

A,B,C

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) A.)Headache and tremors B.)Postural hypotension C.)Pallor and diaphoresis D.)Irregular heart beat E.)Plus 4 pitting edema

A,B,C,D

The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching? A.)Report any muscle twitching or seizures B.)Take vitamin D with calcium daily C.)Low fat yogurt is a good source of calcium D.)Keep a diet record to monitor calcium intake E.)Avoid seafood, particularly selfish

A,B,C,D

Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) A.)Place stethoscope in suprasternal area to auscultate from bronchial sounds B.)Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces C.)Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds D.)Document normal breath sounds and location of adventitious breath sounds

A,B,C,D

When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.) A.)Rub hands palm to palm. B.) Interlace the fingers, C.)Turn off the water faucet. D.)Dry hands with paper towel.

A,B,D,C

After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.) A.)Unrelieved back and flank pain. B.)Quarter-size red drainage at site C.)Cool and pale left leg and foot. D.)Tenderness over insertion site E.)Left groin egg-size hematoma.

A,C,E

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

A,E

After checking the fingerstick glucose at 1630, what action should the nurse implement?

Administer 8 units of insulin aspart SubQ

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Advise the client to empty her bladder fully when she first voids

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement?

Ask the client if she has had any recent thoughts of harming herself

An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse?

Ask the client to describe the changes that have occurred

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

Asses for contraindications for thrombolytic therapy

Which nursing intervention has the highest priority for a multigravida who delivered...

Assess fundal tone and lochia flow

A male client with rheumatoid arthritis is schedule for a procedure in the morning. The...unable to complete the procedure because of early morning stiffness. Which intervention...implement?

Assign a UAP to assist the client with a warm shower early in the morning

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother...During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? A.)Does your child seem mentally slower than his peers also? B.)"His smaller size is probably due to the heart disease" C.)Haven't you been feeding him according to recommended daily allowances for children? D.)You should not worry about the growth tables. They are only averages for children

B

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A.)Abnormal responses for cranial nerves I and II B.)Persistent coughing while drinking C.)Unilateral facial drooping D.)Inappropriate or exaggerated mood swings

B

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride

B

A client with hypertension receives a prescription for enalapril, an angiotensin...instruction should the nurse include in the medication teaching plan? A.)Increase intake of potassium-rich foods B.)Report increased bruising of bleeding C.)Stop medication if a cough develops D.)Limit intake of leafy green vegetables

B

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B

After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.

B

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? A. This medication will coat the lining of your esophagus B. Antacids will neutralize the acid in your stomach C. It will improve the emptying of food through your stomach D. antacids decrease the production of gastric secretions

B

An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. "Have you had a heart attack in the last 6 months" B. "Have you had any difficulty in starting your urinary stream" C. "Have you taken any antibiotics recently" D. "Have you received any blood products in the last year"

B

During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? A. I would prefer to discuss this with you privately. B. Give me specific examples to support your statements. C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind

B

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Inquire about food allergies and food likes and dislikes B. Talk directly to the adolescent while providing care C. Initiate open communication with the teen's parents D. Monitor vital signs and neuro status every 2 hours

B

The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantorn pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies.

B

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber

B

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? A. A 12-year-old with complaints of neck and lower back discomfort B. An 11-year-old with a headache, nausea, and projectile vomiting C. A 6-year-old with multiple superficial lacerations of all ectremities D. An 8-year-old with a full leg air splint for a possible broken tibia

B

The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? A.)Cognitive B.)Affective C.)Comprehension D.)Psychomotor

B

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

B

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

B

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A.)"How old do you think I am?" B.)"We need to stay focused on the topic." C.)"I think I am qualified to teach this group." D.)"Do you think you can teach it any better?"

B

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise

C,E

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.)Walk at least 2 hours a day B.)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

B,C,D,E

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply)

B,D

The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) A.)Maintain current caloric intake B.)Avoid use of alcohol as a sleep aide at bedtime C.)Reduce intake of dairy products D.)Start a weight loss program Set a goal of increasing BMI (Body Mass Index)

B,D

The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter? A.)Home hospice agency B.)Long-term care facility C.)Rehabilitation facility D.)Independent senior apartment E.)Home health agency

B,E

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

Begin manual ventilation immediately.

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Blood pressure 90/76 mm Hg

A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? A.)Measure the child's abdominal girth B.)Perform an ostoscopic examination C.)Collect a urine specimen for routine urinalysis D.)Obtain a blood specimen for serum electrolytes

C

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.)Dyspnea C.)Vomiting D.)Muscle cramps

C

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol. C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.

C

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Give the infant 5% dextrose in water orally B. Insert a nasogastric tube for feeding C. Initiate a prescribed IV for parental fluid D. Feed the infant 3 ounces of Isomil

C

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies" on preoperative checklist B. Assess client's allergies to non-drug substances C. Assess client's knowledge of an allergy response D. Flag "no known drug allergies" on the front of the chart

C

An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. "I've had dreams about Mon since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mon and would like to go see her'". D. " it's hard to concentrate on my homework"

C

An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A.)Addiction B.)Phobia C.)Compulsion D.)Obsession

C

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures

C

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level D. Administer PRN antianxiety medication.

C

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90%

C

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? A.)Obtain a second IV access. B.)Decrease the room temperature. C.)Give the prescribed antiemetic. D.)Insert an indwelling catheter.

C

What is the nurse's priority goal when providing care for a 2-year-old child experience... A.)Stop the seizure activity B.)Decrease the temperature C.)Manage the airway D.)Protect the body from injury

C

What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure... A.)Stop the seizure activity B.)Decrease the temperature C.)Manage the airway D.)Protect the body from injury

C

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Ignore the behavior and hang the IV antibiotic B. tell the client to stop the inappropriate behavior C. Leave the room and close the door quietly D. Complete an unusual occurrence report

C

A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports...which action should the nurse implement to reduce the client's risk for falls? A.)Assign the client a wheel chair B.)The utilization of crutches C.)Schedule frequent rest periods D.)Provide assistance to bedside commode E.)Teach to patch one eye when ambulating

C,D,E

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

Chest pain and dysrhythmia

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

Cold sensitivity

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Complain of headaches and stiff neck

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

Contact the healthcare provider immediately to report the laboratory value regardless of the advice

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A. Decreased appetite B. Nausea and elevated blood pressure C. Difficulty walking D. Agitation and threats to harms staff

D

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections.

D

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

D

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? A.)Maintain adequate cardiac output B.)Promote adequate tissue perfusion C.)Promote rest and sleep D.)Reduce the risk for injury

D

In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? A.)Note the appearance and patency of the client's B.)peripheral IV site. Palpate the volume of the client's right radial pulse C.)Auscultate the client's breath sounds bilaterally. D.)Observe the amount and dose of morphine in the PCA pump syringe.

D

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.)Review the hemoglobin to determine hemorrhage C.)Increase intravenous infusion D.)Check for a distended bladder

D

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A.)Ask the mother what she usually uses on the child's lips and nose B.)Apply a petroleum jelly (Vaseline) to the child's nose and lips C.)Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips D.)Use a water soluble lubricant on affected oral and nasal mucosa

D

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and...Which nursing intervention has the highest priority?

Determine if the client has an executed living will

A client is complaining of intermittent, left, lower abdominal pain that began two days ago...implement the following interventions? (Place in order) A.)Auscultate all four abdominal quadrants B.)client supine with knees bent C.)Inspect abdominal contour D.)Determine when the client had last bowel movement

D,B,C,A

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Destruction of joint cartilage.

A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?

Determine how the client is cared for when caregiver is not present.

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide?

Dialysis would need to be resumed if chronic rejection becomes a reality

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

Document the extend of the bruising in the medical record

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing.

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

Does your pain occur when walking short distances?

A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours?

Evaluate daily serial renal laboratory studies for progressive elevations

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Evaluate the oxygen saturation

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse?

Evidence of hypoventilation

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?

Explain that memory loss and confusion are common with vitamin B12 deficiency

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take?

Explain that the hand rub can be completed in less than 2 minutes

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Explore the client's reasons for wanting to be discharged.

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

Fetal heart rate of 200 beats/minute

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

Fresh horseradish

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

Hold the thermometer in place.

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Ineffective coping related to denial

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement?

Infuse a rapid IV normal saline bolus

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

Institute coughing and deep breathing protocols

An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority?

Instruct the mother to take the teen to the emergency room

The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost...hypothyroidism, what question is most important for the nurse to ask the mother?

Is your son sleepy and difficult to feed?

A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement?

Schedule a weekly home visit to draw hCG values.

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan?

Keep room temperature 80

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Leakage around catheter insertion site

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

Lower the left arm below the level of the heart

An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client?

Magnesium hydroxide (Maalox)

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?

Maintain contact transmission precautions

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

Neurologically stable without indications of an increased ICP

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Notify the healthcare provider

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)...which breakfast selection by the client indicates effective learning?

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement?

Obtain a wound swab for culture and sensitivity

A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet?

One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Place a portable toilet next to the bed

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Place the side rails in an up position

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take?

Pull up a chair and sit beside the client's bed

The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding?

Pupils reactive to accommodation

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin...medication?

Push the undiluted Dextrose slowly through the currently infusion IV

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Recommend weigh bearing physical activity

When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

Refer child to the family healthcare provider

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?

Remain upright after taking the medication.

The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client...

Report fresh blood in the urine

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

Review the staff nurse job description to ensure that it is clear, accurate, and current

In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

Serum creatinine

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement?

Suggest the use of alternative sources of protein such as dairy products and nuts

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

Surgeon needs to see client immediately to evaluate the situation

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?

Take on an empty stomach with a full glass of water

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

Tell the client that the nurse will be back to talk to her after medications are given

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

The husband cannot sign the consent for the client, her signature is required The client's specific wishes should be discussed with her healthcare provider The healthcare team will formulate a plan of care to keep the client comfortable

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

Total calcium 5.0 mg/dl

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

Transfuse packed red blood cells

A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother

Withhold this dose