hesi 366 v1
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? - brings a heavy can close to body before lifting - locks knees while preparing food on the counter - widens stance while working near the sink - bends from the waist to pick trash off the floor - leans forward to pull a pan from a high shelf
- brings a heavy can close to body before lifting - widens stance while working near the sink
An infant who weighs 22 lb receives a prescription for amoxicillin 20 mg/kg/day PO in divided doses every 8 hours. The bottle is labeled, "amoxicillin for oral suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose?(round to the nearest tenth).
1.3 mL
15. A client who weighs 65kg receives a prescription for lorazepam 44mcg/kg IV to be administered 20 minutes before scheduled procedure. The medication is available as " lorazepam 2mg/ml vial". How many ml should the nurse administer. ( enter numerical value only. If rounding is required, round to the nearest tenth).
1.4ml
A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
2
A client is receiving "Heparin Sodium 25,000 Units in 250 mL 5% Dextrose" IV at 7 mL/hour. The healthcare provider changes the prescription to 900 units/hour. The nurse should program the infusion pump to deliver how many mL/hour? (enter numeric number only).
900 units
A client is receiving a continuous infusion of the anticoagulant, heparin, for treatment of a deep vein thrombosis of the right calf. Which goal should the nurse include in this client's plan of care? A No further thrombus will form. B The client's INR (international normalized ratio) will be 2. C The existing thrombosis will dissolve. D The circumference of the client's right calf will decrease.
A No further thrombus will form.
A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response? A) Activated partial thromboplastin time (aPTT) is 2 times the control value. B) S3 heart sounds are present with auscultation. C) Guaiac test of the stools is positive. D) Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex.
A) Activated partial thromboplastin time (aPTT) is 2 times the control value.
10. The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action Should the nurse take? Select all that apply. A. Determine if the mother has recently experienced a fall. B. Review the client's current food and medication allergies. C. Encourage increased intake of high-protein foods. D. Instruct the daughter to check her mother's temperature. E. Ask if the mother is experiencing any pain with urination.
A. Determine if the mother has recently experienced a fall. D. Instruct the daughter to check her mother's temperature. E. Ask if the mother is experiencing any pain with urination.
Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)? A. Body mass index B. Level of consciousness C. Self-description of pain D. Breath sounds
A. Body mass index
A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which results should the nurse report to the HCP? A. complete blood count B. allergy test C. skin Biopsy D. electromyography
A. Complete blood count
The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse? A. Decreased response to pain discrimination on dorsal surface of foot. B. Erythema and edema at the base of the left great toe. C. Hard, painless nodule over metatarsophalangeal joint of first toe. D. Painful corns and calluses over hammer toes on both feet.
A. Decreased response to pain discrimination on dorsal surface of foot.
When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Reference Range: Adult 4.5 to 5.6 mg/dL (1.05 to 1.3 mol/L)] Determine apical pulse rate and rhythm. A. Determine apical pulse rate and rhythm B. Observe color and amount of urine C. assess strength of deep tendon reflexes D. Compare muscle strength bilaterally
A. Determine apical pulse rate and rhythm
A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? A. Level of consciousness B. Percussion of abdomen C. Serum electrolytes D. Blood glucose
A. Level of consciousness
The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? A. apply intermittent pneumatic compression devices. B. maintain intervascular infusion rate. C. obtain frequent pain level assessments. D. progress diet slowly from ice chips to clear liquids.
A. apply intermittent pneumatic compression devices.
A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? A. defibrillate with one shock. B. prepare for external pacing C. administer atropine IV D. give a dose of amiodarone IV
A. defibrillate with one shock.
The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions ? A. events requiring steroid dose adjustments B. need to check temperature daily C. importance of recording daily weights D. adherence to a high fiber, low fat diet
A. events requiring steroid dose adjustments
The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confused to bed and being cared for by a primary caregiver. In the planning care, the nurse should determine which nurse problem is the highest priority? A. fluid volume deficit B. Bowel incontinence C. caregiver role strain D. Impaired bed motility
A. fluid volume deficit
A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A. intravenous administration of benztropine. B. oral administration of divalproex C. intravenous administration of isotonic crystalloid fluid D. oral administration of lorazepam
A. intravenous administration of benztropine.
15. The client demonstrates effective epidural anesthesia by Vital signs, pain relief, augmentation of labor A. pain relief B. labor augmentation C. progression of labor D. stable vital signs E. good urine output F. fetal heart rate
A. pain relief B. labor augmentation D. stable vital signs
The nurse is managing the care of a client with cushing's syndrome. What interventions should the nurse delegate to the unlicensed UAP. Select all that apply A. weigh the client and report any weight gain B reporting any client complaints of pain or discomfort C. evaluate the client for sleep disturbances D. note and report the client's food and liquid intake during meals and snacks E. assess the client for weakness and fatigue
A. weigh the client and report any weight gain B reporting any client complaints of pain or discomfort D. note and report the client's food and liquid intake during meals and snacks
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide? A. discuss that partners without similar symptoms may not be infected B. answer the question directly and correct any misinformation. C. provide counseling that most contraceptives protect against infections D. notify that persons with STIs are reported to local health departments
Answer the question directly and correct any misinformation.
A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this patient's plan of care A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain clients temperature q4 hours
Assess urine and stool for occult blood.
A client is transferred from the operating room to the postanesthesia care unit (PACU) with vital signs of oral temperature 99.8 F (37.7), HR: 62 bpm, RR: 8 bpm, BP: 95/54 mmHg, O2: 94% on 2 L/min nasal cannula. Which medication should the nurse administer? Naloxone. Milrinone. Acetaminophen. Atropine.
Atropine.
The nurse is managing for clients in the ICU who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A) Diminished breath sounds in the right posterior base. B) Restrained and restless with a slow volume alarm sounding. C) High-pressure alarm sounds when client is coughing. D) An audible voice when client is trying to communicate.
B) Restrained and restless with a slow volume alarm sounding.
The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. A. explain to the UAP that changes in a client's condition should be reported immediately B. advise the UAP to stop providing care so the nurse can assess the client's condition C. ask the UAP to position the client so the oral medications can be administered. D. determine why the UAP did not notify the nurse of the change in the client's condition
B. Advise the UAP to stop providing care so the nurse can assess the client's condition
The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long-term care facility, the nurse determines that the client is in continent of urine, has dry mucous membranes, and has a large bruise on the coccyx. What interventions should the nurse include in the plan of care? (Select all that apply.) A. Thicken liquids and provide pureed foods. B. Apply a barrier cream to perianal areas. C. Report suspicion of elder abuse. D. Implement toilet training program. E. Offer beverages at frequent intervals.
B. Apply a barrier cream to perianal areas. D. Implement toilet training program. E. Offer beverages at frequent intervals.
An older client is admitted with pneumonia and the healthcare provider prescribes penicillin G potassium IV. Which assessment finding increases the risk of adverse reactions in this client? A. Previous treatment with penicillin for pneumonia. B. Daily use of spironolactone for hypertension. C. Documented allergy to sulfa drugs. D. Sputum culture results of streptococcus pneumoniae
B. Daily use of spironolactone for hypertension or document allergy to sulfa
The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority? A. Impaired bed mobility B. Fluid volume deficit C. Caregiver role strain D. Bowel Incontinence
B. Fluid volume deficit
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA . what nursing intervention(s) should the nurse include in the plan of care?(SATA). A. use standart precautions and wear a mask B. monitor the client's white blood cell count C. institute contact precautions for staff and visitors D. send wound drainage for culture and sensitivity E. explain the purpose of low-bacteria diet
B. Monitor the client's WBC C. Institute contact precautions for staff and visitors D. Send wound drainage for culture and sensitivity.
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). A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips
B. Plain, air-popped popcorn. D. Natural whole almonds.
A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options? A. repeat information to the client B. Write information on a whiteboard. C. talk loudly into the affected ear D. speak directly facing the client
B. Write information on a whiteboard.
A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review? A. liver enzymes B. complete blood cell count. C. serum electrolytes D. platelet count
B. complete blood cell count.
While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? A. tell me about the activities that cause your pain B. does your pain occur when walking short distances C. when did your first notice the pain in your chest D. how do you feel when the pain becomes noticeable
B. does your pain occur when walking short distances
While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? A. tell me about the activities that cause your pain B. does your pain occur when walking short distances? C. when did you first notice the pain in your chest D. how did you feel when the pain becomes noticeable
B. does your pain occur when walking short distances?
A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a peripheral line. The UAP reports to the nurse that the client's HR is 90 BPM, and BP is 110/50. Which intervention should the nurse implement? A. tell the UAP to turn off the amiodarone B. evaluate the rhythm of the heart rate C. determine the regularity of peripheral pulses D. restart the iv infusion in another site
B. evaluate the rhythm of the heart rate
The nurse implements a secondary prevention program for sexually transmitted infections in a local health centerWhich outcome indicates that the program was effective? A. condoms were provided in all health clinics in the community colleges B. more than 50% of at risk clients were diagnosed early in their disease process. C. healthcare providers prescribed 40% more HPV vaccines D. average client scores improved on specific risk factor knowledge tests
B. more than 50% of at risk clients were diagnosed early in their disease process.
A client who has been taking allopurinol prophylactically comes into the clinic with reoccuring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching? A. eat high protein foods to achieve ideal body weight B. report experiencing right upper quadrant discomfort. C. use electric heating pad when pain is at its worse D. replace dietary table salt with salt substitutes
B. report experiencing right upper quadrant discomfort.
A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is distended, blood pressure is elevated, and 6500 mL were infused while 5,500 mL were drained. In response to this finding, what action should the nurse take? A. Instruct the client to cough B. turn the client from side to side C. irrigate the drainage tube with normal Saline D.lower the head of the bed
B.turn the client from side to side
An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods? A Provide handouts written at a 12th grade reading level. B Use background music to promote relaxation. C Turn on overhead lights while giving instructions. D Stand behind the client to avoid intimidation.
C Turn on overhead lights while giving instructions.
A new nurse preparing to irrigate an intravenous cath is attaching a 24-gauge action should the charge nurse implement A. Suggest the nurse use a 20-gauge B. Direct the nurse to change IV tubing C. Instruct the nurse to remove the needle D. Prompt the nurse to apply pressure to the site
C-Instruct the nurse to remove the needle
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 17 year old client diagnosed with bipolar disorder who is pacing around the lobby C. an 18 year old client with antisocial behaviour who is being yelled at by the other clients D. a 14 year old client with anorexia nervosa who is refusing to eat the evening snack.
C. an 18 year old client with antisocial behaviour who is being yelled at by the other clients
The nurse is developing the plan of care for a client with pneumonia and includes the nursing problem of Ineffective airway clearance related to thick pulmonary secretions. Which intervention is most important for the nurse to include in the client's plan of care? A. Provide frequent rest periods. B. Administer at minute per nasal cannula. C. Increase fluid intake to 3,000 mL/ daily. D. Maintain the client in a semi-Fowler's position.
C. Increase fluid intake to 3,000 mL/ daily.
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. What action should the nurse take? A. Instruct the UAP to return to the client's room to perform handwashing B. Supervise the UAP in the next client's room to evaluate hand hygiene C. Remind the UAP to continue rubbing the hands together until they are dry D. Advice the UAP to wear gloves when obtaining vital signs for all clients
C. Remind the UAP to continue rubbing the hands together until they are dry
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status
C. The client's need for pain medication should be determined
A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A. Lorazepam (Ativan). B. Famotidine (Pepcid). C. Thiamine (Vitamin B1). D. Atenolol (Tenormin).
C. Thiamine (Vitamin B1).
Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach
C. Use cold and allergy medications only as directed by a health care provider
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which infomation is most for the nurse to note before administering the initial dose? A. conversion of the client's PPD test from negative to positive B. history of intravenous drug abuse C. current diagnosis of hepatitis B D. length of time of the exposure to tuberculosis
C. current diagnosis of hepatitis B
A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility? A. normalized electrolytes B. decreased nausea C. passing of flatus D. return appetite
C. passing of flatus
An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the health care provider? A. blood alcohol level of 0.09( B. 6 hours of sleep in the past 3 days C. serum lithium level of 1.6 mEq/ L D. weight loss of 10 pounds in past month
C. serum lithium level of 1.6 mEq/ L
The nurse is performing a routine assessment of an IV site for a client of receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. which finding should the nurse expect which will require immediate intervention? A. a sluggish blood return B. cool sensation above the site C. streak tracking the vein D. circumferential skin irritation
C. streak tracking the vein
An older adult client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased? Which nonpharmacological intervention should the nurse implement? Use distraction and therapeutic communication skills. A. clarify reality with the client about delusional thoughts B. reduce the client's interaction with others during the day C. use distraction and therapeutic communication skills D. awaken the client for reality checks every 4 hours at night
C. use distraction and therapeutic communication skills
The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching? A. report when hematuria becomes pink tinged B. restrict all physical activities C. use the incentive spirometer D. monitor urinary stream for decreased output
Report when hematuria becomes pink tinged.
The nurse is performing preoperative care of a client for an open reduction and internal fixation (ORIF) of a fractured right tibia before the procedure, which action should the nurse prioritize?
Verify clients signed consent
The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A. viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg C. diabetic ketoacidosis whose glasgow coma scale score changed from 10 to 7 D. subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg
Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C).
To prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement? a. Dress each wound separately. b. Avoid sharing equipment between multiple clients. c. Use a gown, mask, and gloves with dressing change. d. Implement protective isolation.
a. Dress each wound separately.
Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions and cannot sleep at night. Which intervention is most important for the nurse to implement? A. ask the spouse if the client seems to be depressed B. tell the spouse to wait outside so the client can be assessed for depression C. explain that depression often occurs after life-threatening experience D. encourage the client to further describe his feelings.
D. encourage the client to further describe his feelings.
Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform? A. measure capillary refill time B. palpate for dependent edema C. determine degree of skin elasticity D. note hand and forearm strength.
D. note hand and forearm strength.
The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report? A. history of vomiting at home for 3 days prior to surgery B. declining to take ice chips for complaints of dry mouth C. soft abdomen, absent bowel sounds, no bleeding on dressing D. peripheral pulses with full range of motion of both legs
D. peripheral pulses with full range of motion of both legs
While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. hematocrit B. platelet count C. creatinine level D. white blood cell (WBC) count.
D. white blood cell (WBC) count.
Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which actions should the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists b) Move the ties so the restraints are secured to the side rails c) Ensure that the knot can be quickly released d) Tie the knot with a double turn or square knot.
Ensure the knot can be quickly released
A client who underwent an uncomplicated gastric bypass surgery has difficulty with diet management. What dietary instruction is most important for the nurse to explain to the client? a. Chew food slowly and thoroughly before attempting to swallow b. Plan volume-controlled evenly-spaced meals throughout the day c. Sip fluid slowly with each meal and between meals d. Eliminate or reduce intake of fatty and gas-forming food
b. Plan volume-controlled evenly-spaced meals throughout the day
. An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement FIRST? a. reconcile prescribed medication dosages with published recommended dosage ranges b. compare admission prescriptions with the list of medications previously taken by the client c. determine which medications may be given in generic form rather than brand name only d. provide client teaching regarding the desired effects of the client's admission prescriptions
b. compare admission prescriptions with the list of medications previously taken by the client
.assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains large amount of fecal liquid and an IV infusion of dextrose 5% in lactated ringer's infusing at a rate of 100ml/hour. Which assessment is most important for the nurse monitor? Serum electrolytes. a. urinary output b. serum electrolytes c. peristomal skin integrity d. skin turgor
b. serum electrolytes
Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take? a. Reposition the transdermal patch to the client's trunk. b. Remove the transdermal patch until the vomiting subsides. c. Notify the healthcare provider of the vomiting. d. Explain that this is a side effect of the medication in the patch.
c. Notify the healthcare provider of the vomiting.
The RN is assigned to care for four surgical clients. After receiving the report, which client should the nurse see first? a. Two days postoperative bladder surgery with continuous bladder irrigation infusing. b. One-day postoperative laparoscopic cholecystectomy requesting pain medication. c. Three days postoperative colon resection receiving a transfusion of packed RBCs. d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours
c. Three days postoperative colon resection receiving a transfusion of packed RBCs.
In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Evaluate the client's ability to use an incentive spirometer b. Monitor the amount of drainage from the client's incision c. Observe both lower extremities for redness and swelling d. Palpate all peripheral pulse points for volume and strength
d. Palpate all peripheral pulse points for volume and strength
The nurse assesses a client who had bilateral total knee replacement four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. What action should the nurse implement? a.Monitor the client's current WBC b.Withhold next scheduled dose of low molecular weight heparin c.Confirm that the continuous passive motion device is intact d.Determine if the wound drainage device is functioning correctly
d.Determine if the wound drainage device is functioning correctly
A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? A. place an indwelling urinary catheter and institute strict intake and output measurements. B. record pain score and administer sublingual nitroglycerine every 5 minutes up to 3 doses. C. verify troponin level assessments are scheduled every 3-6 hours for a series of three. D. Count and record the number of premature ventricular contractions per minute.
not sure
The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The HCP prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?
not sure
The nurse is educating parents about behaviors and risks that mostly impact health among adolescents. Which statement made by a parent about parental interaction with the adolescent should the nurse reorganize as needing additional discussions?
not sure
The family of an older adult client who received a lung transplant asks if the 2-year-old grandchild can visit. Which response should the nurse offer? A "Yes, grandchildren offer emotional support and positive diversion." B "No, protective precautions are required after a lung transplant." C "No, small children are often carriers of infectious organisms." D "Yes, if the child is not ill or has not recently received a live vaccine."
D "Yes, if the child is not ill or has not recently received a live vaccine."
After receiving report on an inpatient acute care unit , which client should the nurse assess first ? A The client with an obstruction of the large intestine who is experiencing abdominal distention . B The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid . D The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
D The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.22 mmol/L) about preventing complications related to diabetes mellitus. Which response by the client indicates understanding? Check blood sugar levels every four to six hours every day A) Eat a protein snack 30 minutes before any exercise workout. B) Do not take diabetes medication when feeling sick. C) Avoid seasoning foods with salt and salt-containing spices. D) Check blood sugar levels every four to six hours every day.
D) Check blood sugar levels every four to six hours every day.
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Express feelings of sadness and loneliness B. Neglects personal hygiene and has no appetite C. Lacks interest in the activity of the family and friends D. Begin to show signs of improvement in affect
D. Begin to show signs of improvement in affect
The nurse is preparing to obtain a rapid COVID-19 test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is the most important for the nurse to take? A. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient B. Assist the client to recall everyone possibly exposed since onset of symptoms C. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results. D. Move the client to a private room, keep the door closed, and initiate droplet precautions.
D. Move the client to a private room, keep the door closed, and initiate droplet precautions.
The nurse is planning to assess the client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and radial pulses that are weak and thready. What action should the nurse take? A. Document that an accurate oxygen saturation reading cannot be obtained. B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger. C. Increase the oxygen based on the client's breathing patterns and lung sounds. D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.
The nurse initiates the procedure to remove a clients picc line when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the (uap), which action should the nurse take? Finish the procedure A. respond to the code B. call for an assistant C. finish the procedure D. close the room door
Finish the procedure
An older adult client asks the nurse about the best foods to help prevent osteoporosis. Which type of foods should the nurse recommend to the client?
Low fat dairy products.
123. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning and prepping the client, rank the actions in the sequence they should be implemented. (place the first action at the top, and last action at the bottom) a. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus Open b. Cleans the urinary meatus using the solution, swabs, and forceps c. Don sterile gloves and prepare the sterile field d. the sterile catheter kit close to the clients perineum
Open the sterile catheter kit close to the client's perineum. Don sterile gloves and prepare to sterile field. Cleanse the urinary meatus using the solution, swabs, and forceps provided. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus.
