HESI###

The nurse performs a peripheral vascular assessment for a client who has swelling of the lower legs. Which finding should the nurse document that is indicative of an abnormality?

2+ palpate pedal pulse.

-The nurse observes an adult woman preform a return demonstration of diaphragmatic breathing. The client inhales while holding her abdomen, them remove her hand to allow expansion of the abdomen. Which action should the nurse take after observing the client's demonstration?

Demonstrate how to expand the abdomen while inhaling and let it sink in while exhaling

A male client presents to the clinic standing that he has a high stress job and is having difficulty falling asleep at night. He has tried over-the-counter medication, including some headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

Determine the client's sleep and activity pattern

A 24-hour urine specimen is being collected for analysis of creatine clearance. After explaining the procedure, the client tells the nurse that the first sample is in the urinal. When discarding the nurse take?

Note the beginning time of the 24 hour sample.

-The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

A client with restless leg syndrome and chronic obstructive pulmonary disease (COPD)

The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears gurgling sound every ten seconds. What action should the nurse take in response to this finding?

Observe the next bowel movement for signs of bleeding.

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What action should the nurse implement next?

Offer a pair of non-skid socks.

When assessing a client's intraocular eye movement, what tool should the nurse use?

One finger.

The nurse reorients male a client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse?

Oriented x2

The nurse measure a client a body temperature as 103 F( 38). To support and variate this finding with additional assessment data, which ....,

Palpate skin temperature Observe skin color Check for distal edema

-During assessment of client's abdomen the nurse observing the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse

Palpate the area for masses.

When assessing a male client's respiratory status. Which technique should the nurse use to assess his anterior-posterior (AP) chest diameter?

Palpation

The nurse is caring for a adult with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

Peptic ulcer disease.

It is most important .....nurse to ..... the Braden scale score for a client who has develop which problem?

Plus two ankle edema.

The nurse is using guided imaginary with a client with experiencing chronic pain. The nurse should direct the client attention on which focus

Positive external place

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

Provide a box of tissues for the client to use when coughing.

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information is regarding hospice? (Select all that apply)

Provides comfort, dignity, and emotional support. Hospice services can be initiated prior to discharge. Family members can be involved in the plan of care. Can be provided within comforts of home.

A Native American male arrives at the community clinic reporting abdominal cramping and nausea. He tells the nurse that he suffers from chronic constipation. Which information is most important?

Recent use of home remedies or herbs.

The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse note that her posture is upright, and her gait should the nurse take next?

Record the client's ability to perform ADLs safely.

In assessing an older client the nurse calculate the BMI ( body mass index) as 14kg/m2. Whar nursing problem should be included in this client plan of care.

Unbalance nutrition, less than body needs

-The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates rehydrating?

Urinary output.

An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptom important for the nurse to take?

Use personal protective equipment while assessing rash.

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which assessment by the nurse?

Uses herbal remedies.

Prior initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Vital signs

When conducting diet teaching for a client who is experiencing episodes of vomiting, the nurse recommends that the client consume only clear liquids. Which choices by the client indicate? Select all

Warn chicken broth. Carbonated ginger ale. Filtered apple juice.

A client who recently underwent a routine surgical procedure made a clinic appointment. To elicit the most information, which question best for the nurse to ask this client

What brought you to the clinic

A nurse is completing the health history for a 25-year-old male client who reports that he is allege to penicillin. Which question should the nurse ask after receiving this information?

What happens to you when you take penicillin?

-To ensure client adherence to the postoperative regimen, which content is most important for the nurse to include in the preoperative teaching?

You will feel drowsy for several hours after surgery

An older adult who has a shutting, unsteady gait want to ambulate in the hallway to a family visitation room. To reduce risk for injury. Which actions should the nurse take before the client leaves the room? Select all

Confirm that the hallway floors are clean and dry. Review the client's vital signs and activity tolerance Remove carts or other obstacles from the client's pathway

-The nurse assesses that a disoriented client drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which should the nurse monitor?

Creatinine clearance.

The nurse is performing a routine dressing change for a client on stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which ....

Increase the frequency of the dressing change

An older male client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg every 12 hours. He states he took the medication only when the pain was the nurse implement?

Instruct the client to take the morphine sulfate every 12 hours as prescribed

While assessing a client the nurse noticing the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Measure the length of each leg and document the finding

An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?

Methods used to practice safe sex

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Review the priority nursing diagnoses included in the plan care.

What equipment should the nurse use to measure a 2mL dose of a viscous liquid solution most to be administered orally?

3 mL syringe.

A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? -Instruct the caregiver to offer a glass of warm prune juice at mealtimes. -Notify the health care provider and request a prescription for a large-volume enema. -Assess the client's medical record to determine the client's normal bowel pattern. -Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

-Assess the client's medical record to determine the client's normal bowel pattern. This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Options A, B, or D may then be implemented, if warranted.

A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? -Take a vitamin supplement tablet once a day -Change positions in the chair frequently -Increase daily intake of water or water or other oral fluids. -Purchase a newer model wheelchair.

-Change positions in the chair frequently The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? -Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication -Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. -Compare the current reading with the client's previously documented blood pressure readings.

-Compare the current reading with the client's previously documented blood pressure readings. Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? -Check the client's carotid pulse. -Encourage the client to get to the toilet. -In a loud voice, call for help. -Gently lower the client to the floor.

-Gently lower the client to the floor. Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

A 75-year-old client states to the nurse, "I am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the past 4 months. Which snacks will the nurse recommend to the client? (Select all that apply.) -Nuts -Milkshakes -Chocolate candy bar -Peanut butter and crackers -Glass of whole fat milk

-Nuts -Milkshakes -Peanut butter and crackers -Glass of whole fat milk The nurse must recommend high calorie/high nutrition foods for this client who is unintentionally losing weight. The candy bar is high calorie, but empty in nutritional value. The remaining selections are high calorie/high nutrition.

1-The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? -Raise the head of the bed 30 to 45 degrees. -Roll the client to her side and place a pillow behind her back. -Elevate her right arm under two pillows -Require the client to stay in bed for 72 hours post procedure. -Place a sandbag on the incision.

-Raise the head of the bed 30 to 45 degrees. -Elevate her right arm under two pillows The client must stay on her back or on the unaffected side, not on the operative side. Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm will help lymph drainage.

-When bathing an uncircumcised boy older than 3 years, which action should the nurse take -Remind the child to clean his genital area. Defer perineal care because of the child's age. -Retract the foreskin gently to cleanse the penis. -Ask the parents why the child is not circumcised

-Retract the foreskin gently to cleanse the penis. The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

-Which nonverbal action should the nurse implement to demonstrate active listening? -Sit facing the client. -Cross arms and legs. -Avoid eye contact. -Lean back in the chair.

-Sit facing the client. Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? -The client will experience increased tolerance to the drug's effects and may need a higher dose. -The onset of action of the drug will occur more rapidly, resulting in a more rapid effect -The medication will be more highly protein-bound, increasing the duration of action -The therapeutic index will be increased, placing the client at greater risk for toxicity.

-The onset of action of the drug will occur more rapidly, resulting in a more rapid effect Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the nurse? -The patient's Bill or rights protects clients from malicious intents, so the nurse could lose the case. -The lawsuit may be settled out of court; the nurse's license is likely to be revoked. -There will win be no judgment against the nurse, whose actions are protected under the Good Samaritan Act. -The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

-There will win be no judgment against the nurse, whose actions are protected under the Good Samaritan Act The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise will the nurse select to prepare the medication? -30 ml medication cup -10 ml medication spoon -3 ml needleless syringe -5 ml medicine dropper

3 ml needleless syringe Accuracy is most important when delivering small amounts of medication to a child. The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of tenths

-The healthcare provide prescribes amitriptyline 150 mg by mouth at bed time. The medication is available in 75mg tablets. How many tablets should the nurse administer?

2

The goal is for the client to take in 1500 calories/day administered through by a feeding tube. The concentration of the feeding is 1.5 calories/mL. How many mL per hour will the nurse need to set the infusion pump to deliver the feeding over 18 hours? _____ Enter a whole number.

56 is the answer

The nurse is orienting a new graduate to the reporting regulations often seen in the emergency department. Which clients will the nurse need to report to the nurse manager/supervisor to alert the proper authorities? (Select all that apply.) A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are long and lonely." C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no longer welcomed there." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."

A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way." Nurses are mandatory reporters and must notify in the event of child and elder abuse, domestic violence, animal bites, gun shot and stab wounds, assault, and homicides.

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal for this client?

Absolute dullness

When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?

Acute pain

The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client's buttocks and state been incontinent with diarrhea. The UAP is wearing gloves but not a gown.

Advise the UAP to put on a gown

When entering a male client's room to assess his vital sign, the nurse finds the client crying. After allowing the client to express his feelings, which interventions should the nurse....

Allow the client to rest before taking his vital signs

When administering 0900 medications to four clients, Which prescription should the nurse administer first?

An antibiotic, to be administered every 6 hours starting at 0900.

The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.) -Apple juice -Popsicles -Vanilla pudding -Tomato soup -Gelatin -Black coffee

Apple juice -Popsicles -Gelatin -Black coffee Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla pudding are included in a full liquid diet.

After checking a client's pupillary response to light, the practical nurse (PN) tells the nurse that the client's pupil are constricted with minimal response to light. Before verifying the PN take?

Assess the client's visual fields.

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

Assess the position of the mask of the clients face

The nurse begins a client a musculoskeletal assessment. While using the technique of inspection, the nurse assessment for which ....... Findings

Atrophy Osteopenia Contracture

While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths per minute. What action should the nurse implement?

Auscultate all lobes of the client's lungs.

A nurse is teaching Unlicensed Assistive Personnel (UAP) about safety when caring for clients with limited movement. Which statement from the UAP indicates that teaching has been effective?

Avoid lifting more than 40 pounds ( 18 kg) independently.

-For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply. -Bacon, egg, and cheese biscuit -Chinese chicken and vegetables, with rice and soy sauce -Strawberry, spinach salad with yogurt-based blue cheese dressing -Chicken salad stuffed fresh tomato with a side of celery sticks -Grilled tilapia with a fresh green side salad -Grilled hot dog on a bun with ketchup and mustard

Bacon, egg, and cheese biscuit Chinese chicken and vegetables, with rice and soy sauce -Grilled hot dog on a bun with ketchup and mustard The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in sodium.

While turning a client who recently suffered a cerebrovascular accident (CVA), the nurse assesses for pressure areas and skin breakdown. The skin over the sacral area is intact with non-blanch intervention is most important for the nurse to implement for this immobile client?

Change bed pads to keep skin clean and dry.

While suctioning a client nasopharynx, the nurse observes that the client oxygen saturation remains at 94 %, which is the same reading obtained prior to starting the procedure. What .... Response to this finding?

Complete the intermittent suction of the nasopharynx.

The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

Condition of hair, nail, and skin

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D.Discuss the client another time.

D. Discuss the client another time. The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details of the client can be identified when referring to the client by gender or age, even when not using the client's name.

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Degree of neurosensory

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? -Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. -Instruct the UAP not to wake the client under any circumstances during the night. -Place a "Do not Disturb" sign on the floor and change ass assessments from every 4 to 8 hours. -Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

-The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personnel (UAP) to care and file the client's toenails? Select all

Diminished visual acuity Hand tremors Syncope when bending

An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and request that no heroic measurements are implemented if her breathing stops.

Discuss with the client her meaning of heroic measures

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client judgment?

Do you write checks if you know the bank account is overdrawn?

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Do you writes checks if you know the bank account is overdrawn?

Review the priority nursing diagnoses included in the plan care.

Emollient

The client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client's risk for infection related to the catheter?

Encourage increase intake of oral fluids

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

Ensure that the restraints are not too light.

A young adult was admitted to the postoperative unit yesterday. The grandparents request information about the client treatment plan . before answering the family members questions

Ensure that the signal release the information includes the grandparent

A client on a prescribed full liquid diet has a nursing problem of, risk for impaired skin integrity related to reduced oral intake. What snack is best to provide this .....?

Ensure, a liquid supplement.

The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. Which action should the nurse take next?

Evaluate effectiveness of the change.

While obtaining a health history, a male client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and respiratory rate is 14 breaths/minute. What is the best nursing action?

Explain to the client the possible cause of dyspnea or shortness of breath

A client tell the nurse that he is very nervous about the surgery he is scheduled to have in the morning. Which action should the nurse implement first?

Explore the client perception of the impending surgery

A client's most recent vital signs include heart rate 90 beats/minute and blood pressure 119/70 mmHg. When the client reports dizziness after rising quickly, which finding should the nurse exp....?

Heart rate 70 beats/minute.

A 75 years old patient with a recent history of cerebrovascular accident ( CVA) presents with right hemiparesis. The nurse test the deep tendon reflexes on the right side and elicits a brisk 4+ response . which intervention this finding is accurate

Hyperactive response consistent with an upper motor neuron disorder

The nurse is caring for a client stage IV present ulcer. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Increase de daily intake the protein.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? -Assign unlicensed assistive personnel to transport the client via a wheelchair. -Remind the client to walk carefully down the stairs until reaching a lower floor. -Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. -Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Remind the client to walk carefully down the stairs until reaching a lower floor During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

The nurse determines that a client who arrive in the preoperative holding area before surgery is allergic. Which action should the nurse implement prior to taking the client .......?

Replace latex-containing device in the OR with alternative synthetic materials

A 19 years old female client comes to the clinic complaining of breast tenderness efore her menstrual period. On examination, the nurse notes generalized lumpiness of both breasts .... Discharge. Which action should the nurse takes

Request a return visit after her menstrual period for a breast's exam re-check

The nurse is interviewing a male client who is admitted for chest pain. With each question, the client answers in broken English that is mixed with French phrases and looks to his wife. Frequently and contradicts each of the client's responses. What should the nurse do?

Request an interpreter to communicate focused questions.

While engaged in a therapy conversation with an anxious client, the nurse is called to help with another client situation. What nursing action demonstrates fidelity?

Returns to the anxious client as promised after responding to the other situation.

A client with a prescription for morphine sulfate 0.2 mg intravenously every 4 hours as needed for pain report the pain is a 10 out of 10 on the numeric pain scale one hour after receiving the last administering. Which intervention should the nurse implement?

Review the medical record for additional pain medication prescriptions

The nurse is conducting an initial admission assessment for a woman who is Muslim and who is scheduled to deliver a baby by Cesarean section within the next 24 hours. What should the nurse indicate .....?

Shake client's hand and b `ow the head when first meeting to demonstrate respect.

The nurse is assessing the perianal area of a female client who states she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding healthcare provider that is most consistent with the client's complaint?

Shiny blue skin sacs around anal opening and a linear split.

The nurse finds a fire in the bathroom of an empty client room and immediately reports the location. After reporting the fire, which action should the nurse take next?

Shut the doors to be bathroom and the empty room

A male hospice client with bone cancer reports to the nurse that his bone pain is not adequately controlled with his current dose of morphine sulfate, and he is experiencing difficulties with increasing the client's dose of laxative, which pain of treatment should the nurse anticipate?

Switch from morphine to codeine.

The nurse is utilizing the situation-background, assessment - recommendations ( sbar) format to provide information to a healthcare provider about a client. Which statement by ...... situation

The client states being up about the amount of pain being experiencing

Which statement by a client indicates to the nurse that the client understands how a newly prescribed transdermal medication will be administered?

The medicine will be applied directly on my skin.

When inspecting a client's ski. Which finding requires the most immediate follow-up by the nurse

Thickened yellow nailbeds.

While interviewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?

Transient ischemic attack

The nurse is unable to palpate ..... ( point of mass of impulse) of a bedfast client who is lying in a supine position. Which action the nurse implement ?

Turn client left lateral position and reassess

11-A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? -Clamp the nasogastric tube. -Confirm placement of the tube -Use a syringe to instill the medications -Turn off the intermittent suction device .

Turn off the intermittent suction device .The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.