Hesi #3 Struggling 101
64) The nurse is caring for a client in hypertensive crisis in an intensive care unit.The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses
D) Pupil responses
The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L
D) Serum potassium 6 mEq/L
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritationSkip
D) prevent the drug from tissue irritationSkip
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness
D) restlessness
95) To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion
A) Apply suction for no more than 10 seconds
A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness
A) Can predispose to dysrhythmias
While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? "Do you often have feeling of sadness?" "Are you having problems concentrating?" "Have you thought about taking your life?" d. "What problems are you facing right now?"
"Have you thought about taking your life?"
Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? "When I get out of bed quickly, I feel a little dizzy." "The dressing over my incision feels like it is too tight." "I'm most comfortable when the head of the bed is raised." "This IV infusion makes me urinate more often than usual."
"When I get out of bed quickly, I feel a little dizzy."
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs wereT-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88
A) FHT 168 beats/min
During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? The census report has not been completed. A client's wife has asked to speak with the charge nurse. One staff member has not reported to work. d. A bucket of water was spilled in the hallway.
A bucket of water was spilled in the hallway.
The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should thenurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube
A) Hold the tube feeding and notify the provider
87) A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered PRN medication D) Reassess the foot in fifteen minutes
A) Notify the health care provider
The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2
A) S3 ventricular gallop
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees
A) Side-lying on the left with the head elevated 10 degrees
An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation
A) Stay with client and observe for airway obstruction
96) An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip
A) administer the medication in 2 separate injections
A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.
A) until the health care provider has determined that your ejaculate does not contain sperm, continue to use another form of contraception.
an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? Add sterile water to the suction control chamber Give blood from the collection chamber as autotransfusion Manipulate blood in tubing to drain into chamber. Increase wall suction to eliminate fluctuation in water seal.
Add sterile water to the suction control chamber
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? Determine the client's level of mobility and need for assistance. Instruct the UAP that all clients deserve equal care. Advice the client to so that safety can be ensured. Assign another UAP to care for the client.
Advice the client to so that safety can be ensured.
The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? Keep the nails trimmed short. ??????????? Apply baby lotion to the skin twice daily. Bathe the child daily with bath oil. Allow the child to wear only 100% cotton clothing.
Apply baby lotion to the skin twice daily.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? Determine if the client is experiencing any anxiety. Auscultate the client's bilateral lung sounds and oxygen saturation. Notify the healthcare provider about the client's distress. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. Advise him to take his own food with him when going to fast food restaurants with his friends. Encourage him to find activities to do with his friends that do not involve eating. Assist him in fast foods that are within his meal plan for diabetes.
Assist him in fast foods that are within his meal plan for diabetes.
A client with pneumococcal pneumonia had been started on antibiotics 16hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up brown thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."
B) "I have been coughing up brown thick sputum."
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."
B) "The tube will remove excess air from your chest."
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication
B) Assess for dyspnea or stridor
Thenurseiscaringforachildimmediatelyaftersurgicalcorrectionofaventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses
B) Assess for post-operative arrhythmias
The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision
B) Assist the client to turn, deep breathe, and cough
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises
B) Deep breathing and coughing
The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles
B) Jugular vein distention
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation
B) Leukopenia
63) Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160
B) Pale mucosa of the eyelids and lips
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator
B) Perform a quick assessment of the client condition.
A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses
B) Pupils fixed and dilated
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client toreport? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion
B) Sore throat, fever
Which of these observations made by the nurse during an excretory urogram indicate a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states, "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."
B) The client's entire body turns a bright red color
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B)Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake
B)Administer acetaminophen as ordered as this is normal at this time
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? Elevate the foot of the bed. Restrict the client's fluid. Begin supplemental oxygen. d. Prepare the client for hemodialysis.
Begin supplemental oxygen.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."
C) "The medication must be continued so the fluid problem is controlled."
A 60 year-old male client had a hernia repair in a nout patient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again
C) Assist him to stand by the side of the bed to void
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms
C) Dyspnea
98) A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure
C) Improved respiratory status and increased urinary output
he nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects themucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the handsand feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of hispanic descent. D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, whichl asts 1 to2 weeks
C) Kawasaki disease occurs most often in boys, children younger than age 5, and children of Hispanic descent.
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output
C) Loss of pulse in the extremity
A client has a history of chronic obstructive pulmonary disease (COPD).Asthe nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs
C) Lower the oxygen rate
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) Minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter
C) Minimal drainage into the urinary collection bag
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate in the compressions or breathing D) Validate the client's advanced directive
C) Participate in the compressions or breathing
he nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak
C) Pulse oximetry of 88
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision
C) Reinforce the dressing and elevate the leg
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings.b. Clients reported having new confidence in making healthy food choices. Clients who incurred disease complication promptly received rehabilitation Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
Clients who incurred disease complication promptly received rehabilitation
The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? Gradual onset of continuous eye pain and blurred vision. Recent change in the ability to read and drive after dark. Gray-white circle around the iris of both eyes. Cloudy opacity of the crystalline lens.
Cloudy opacity of the crystalline lens.
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) "I knew this would happen. I've been eating too much red meat lately." B) "I really enjoyed my fishing trip yesterday. I caught 2 fish." C)"I have really been working hard practicing with the debate team at school." D) "I went to the health care provider last week for a cold and I have gotten worse."
D) "I went to the health care provider last week for a cold and I have gotten worse."
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness
D) A preschooler with intermittent episodes of alertness
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene
D) Assist with oral hygiene
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, redfluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage
D) Continue to monitor the rate of drainage
A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.
D) Fibroids that cause no problems still need to be taken out.
As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss
D) Hair loss
Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am a diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.
D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings
D) Pale, thin arms and legs, uninterested in surroundings
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? Provide information on ways to increase activity for the family Have several teachers talk about health risks associated with obesity Distribute a shopping list of suggested healthy snack items. Determine the parent's degree of concern about their children's weight.
Distribute a shopping list of suggested healthy snack items.
The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? Measure the client's body weight each morning. Establish blood pressure parameters for client monitoring Evaluate a staff member providing wound care. Evaluate client teaching through return demonstration.
Establish blood pressure parameters for client monitoring
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees celsius) C) Diffuse macular rash D) Muscle tenderness
Fever of 103 degrees Fahrenheit (39.5 degrees celsius)
After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? File a report with the specific hiring facility. Warn the colleague that their actions are unprofessional. Comment anonymously about the action of a staff discussion board. Communicate the colleague's actions to the unit charge nurse.
File a report with the specific hiring facility.
When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) Fruits without sauce Canned soup. Fresh or frozen vegetables w/o sauce. Cottage cheese. Pickled olives.
Fruits without sauce Fresh or frozen sauce.
A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? Check the protein level in urine Have the client turn to the left side Take the temperature Monitor the urine output
Have the client turn to the left side
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) Headache and tremors Irregular heart rate Skin hyperpigmentation Postural hypotension Pallor and diaphoresis
Headache and tremors Irregular heart rate Pallor and diaphoresis
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? Measure and document the client's urinary output. Request the client's reserved unit if packed red blood cells. Prepare the placement of a central venous catheter. Increase the rate of the infusion rate of lactated Ringers
Increase the rate of the infusion rate of lactated Ringers
A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) It is critical to report promptly to your health care provider any findings peptic ulcers Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the provider any findings of stomach or intestine
It is critical to report promptly to your healthcare provider any findings of peptic ulcers
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? Determine if the newborn is in the nursery. Activate the lockdown procedure. Ask the mother if any visitors were expected to arrive. d. Match ID bands of all infants and mothers on the unit.
Match ID bands of all infants and mothers on the unit.
Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? Eat a light diet for the rest of the day Rest for the next 24 hours since the preparation and the test is tiring. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? Monitor serum electrolytes daily. Provide only distilled water. Document abdominal girth. Perform range of motion exercises.
Monitor serum electrolytes daily.
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? Assess the client's oral cavity for ulcerations. Monitor the client when using a straw for liquids. Teach coughing and deep breathing exercises. Request thick nectar liquids for the client.
Monitor the client when using a straw for liquids.
A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess tomorrow morning. Nursing assess .... Client's abdominal pain has increased from 4 to 8 on a 10-point scale in the last four hours. What is priority nursing action? Notify the surgeon of pain. Administer the nest scheduled dose of antibiotic. Encourage the client to cough and deep breath. Assess for a change in the client's bowel sounds.
Notify the surgeon of pain.
The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? The client will express acceptance of their newly diagnosed health status. The nurse will encourage the client to walk thirty minutes everyday. The client's blood pressure readings will be less than 160/90 mmHg. The client's skin on the lower legs will be intact at the next clinical visit.
The client's skin on the lower legs will be intact at the next clinical visit.
A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness The flow of life is believed to flow through major pathways or nerve clusters in your body. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healingmechanisms to take over.
The flow of life is believed to flow through major pathways or nerve clusters in your body.
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is Differences in the intake and output Changes in the mucous membranes Skin turgor Weekly weight
Weekly weight
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter c. Widens stance while working near the sink. d. Bends from the waist to pick trash off the floor. e. Leans forward to pull a pan from a high shelf.
a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter
A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with povidone-iodine.
a. Change the dressing.
The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? a. Confirm that the client has been NPO since midnight. b. Review postoperative instructions with the client. c. Offer to assist the client to the restroom to void. d. Determine when the client last had pain medication
a. Confirm that the client has been NPO since midnight.
The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? a. Ensure adequate IV and oral fluid intake. b. Provide ice packs to major joint areas. c. Space analgesics to prevent addiction to narcotics. d. Re-enforce the importance of nutritional balance.
a. Ensure adequate IV and oral fluid intake.
The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) a. blurred vision b. Headache c. Lack of appetite. d.Urinary frequency. e. Chills and fever. f. Swollen hands.
a. blurred vision b. Headache f. Swollen hands.
A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. initiate seizure precautions Assess neurological status every 8 hours. Limit oral water intake. Administer a hypertonic IV fluids as prescribed.
a. initiate seizure precautions
A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? (Shit question) a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing. c. Instruct the nurse to remove the needle. d. Prompt the nurse to apply povidone to the site.
b. Direct the nurse to change the IV tubing.
A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? a. Were your legs ever suddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs? d. Have you experienced ankle edema and varicose veins?
b. Does the calf pain occur when walking short distances?
An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m. b. Ensure that the client is assigned to a room close to the nurses station c. Postpone administration of nighttime medications until after 2300 p.m. d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.
b. Ensure that the client is assigned to a room close to the nurse's station
An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the HP of the client wishes. c. Place a certified copy of the living will in the client's record. d. Alert the nursing staff of the client's don't resuscitate status.
b. Notify the HP of the client wishes.
An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? a. Document neurologic changes. b. Reduce environmental stimuli c. Administer prescribed neuroleptic. d. Review medications for interactions.
b. Reduce environmental stimuli
A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? a. Bring a bedside commode to the client. b. Stand on the right side as he walks. c. Walk directly behind the client to prevent a fall. d. Give the client a cane to hold in his right hand.
b. Stand on the right side as he walks.
A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? a. "When did these voices begin?" b. "Hace you taken any hallucinogens?" c. "Are you planning to obey the voices?" d. "Do you believe the voices are real?"
c. "Are you planning to obey the voices?"
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a. Diminished bowel sounds b. Loss of appetite c. A cold, pale lower leg d. Tachypnea
c. A cold, pale lower leg
A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity for the duration of treatment. d. Normal electroencephalogram after drug administration.
c. Absence of seizure activity for the duration of treatment.
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? A 16-year-old client diagnosed with major depression who refuses to participate in group. B. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client with who is being yelled at by other clients d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..
c. An 18-year-old client with who is being yelled at by other clients
A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued. b. Arrange a meeting with the family, physician, and client. c. Ask the chaplain to with the client. d. Request a consultation with the hospital social worker.
c. Ask the chaplain to with the client.
After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? a. Take prednisone doses before meals on an empty stomach. b. Wear sunglasses when exposed to bright sunlight. c. If sequential doses are missed, notify the HP d. Schedule a monthly laboratory visit for a complete blood count.
c. If sequential doses are missed, notify the HP
The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? a. The client will express acceptance of his changing health status. b. The client's family will state signs and symptoms about the disease. c. The nurse will demonstrate the procedure for accurate eye care. d.The client's daily blood pressure will be less than 140/80mm Hg this month.
c. The nurse will demonstrate the procedure for accurate eye care.
A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care? a. Attends one group activity per day. Sleeps at least 6 hours per night. Engages in one client-to-client interaction daily. d. Consumes 3 meals and 1500 mL of fluid per day.
d. Consumes 3 meals and 1500 mL of fluid per day.
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Reports left chest wall pain prior to admission. c. Verbalize a fear of being in a confined space. d. Experience facial swelling after eating crab.
d. Experience facial swelling after eating crab.
The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine.
d. Increased BUN and serum creatinine.
An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? a. History of smoking over the past 6 months. b. Sleep patterns during the previous few week. c. Activity level prior to onset of symptoms. d. Recent compliance with prescribed medications.
d. Recent compliance with prescribed medications.
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specific gravity is 1.040 b. Systolic blood pressure decreases 10 points when standing. c. The client denies being thirsty. d. Skin tenting occurs when the is pinched.
d. Skin tenting occurs when the is pinched.
Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? Bring the emergency crash cart to the bedside. Prepare a continuous heparin infusion per protocol. Provide supplemental oxygen d. Notify the healthcare provider.
provide supplemental oxygen
