Hesi 4

A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

0.4

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

1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour

The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

12.5

A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

7

The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A.)Instructions about how much fluid the child should drink daily B.)information about non-pharmaceutical pain reliever measures C.)Referral for social services for the child and family D.)Signs of addiction to opioid and medications

A

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? A.)Confusion and tremors B.)Yellowing and itching of skin. C.)Abdominal pain and vomiting D.)Anorexia and abdominal distention

A

A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? A.)Wash hands before cleaning exit site B.)Keep the head of the bed flat at night C.)Feel for a thrill and a distal pulse nightly D.)Do not get up if fluid is left in the abdomen

A

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

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? A.)Overlook the client's behavior. B.)Distract client to interfere with the ritual. C.)Ask why the client checks the pulse. D.)Hold client's hand to stop the behavior.

A

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? A.)Research indicates that mirror therapy is effective in reducing phantom limb pain B.)You can try mirror therapy, but do not expect to complete elimination of the pain C.)Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective D.)Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

A

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? A.)The client has asymmetrical chest wall expansion B.)The clients complain of pain at the insertion site C.)The client chest's x-ray indicates decreased pleural effusion D.)The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

A

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? A.) 0.9% sodium chloride solution (normal saline) B.) 0.45% sodium chloride solution (half normal saline) C.) 10% Dextrose in 0.45% sodium chloride D.) 5% dextrose in 0.2% sodium chloride

A

A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? A.)Monitor the client's cardiac activity via telemetry. B.)Maintain venous access with an infusion of normal saline. C.)Assess glucose via fingerstick q4 to 6 hours. D.)Evaluate hourly urine output for return of normal renal function.

A

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A.)Prepare the skin for procedure. B.)Identify client's pulse points C.)Witness consent for procedure D.)Check telemetry monitoring

A

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? A.)Determine if the sensation feels uncomfortable. B.)Decrease the strength of the electrical signals. C.)Remove electrodes and observe for skin redness. D.)Check the amount of gel coating on the electrodes.

A

A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? A.)Pulse increase of 10 beats/minute B.)Proteinuria C.)Glucosuria D.)Fundal height 0f 22 centimeters

A

A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? A.)Stroke B.)Renal failure C.)Left ventricular hypertrophy D.)Pulmonary hypertension

A

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? A.)Determine the client's responsiveness and respirations B.)Bring the crash cart to the room to defibrillate the client. C.)Immediately initiate chest compressions. D.)Notify the emergency response team

A

A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? A.)Ask the client about his expected goals for the hospitalization B.)Explain the palliative care measures can be provided at home C.)Notify do radiation department to withhold the treatment for now D.)Determine if the client wishes to cancel further radiation treatment

A

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? A.)This hernia is a normal variation that resolves without treatment. B.)Restrictive clothing will be adequate to help the hernia go away. C.)An abdominal binder can be worn daily to reduce the protrusion. D.)The quarter should be secured with an elastic bandage wrap.

A

A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? A.)Offer to provide the influenza vaccination to the student while she is at the clinic B.)Encourage the student to obtain a vaccination prior to the next influenza season. C.)Confirm that a history of asthma can increase risks associated with the vaccine. D.)Advise the student that the nasal spray vaccine reduces side effects for people with asthma.

A

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide? A.)Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. B.)Encourage the client to seek genetic counseling to determine his risk for mental illness. C.)Informed the client that his mother schizophrenic has affected his psychological development. D.)Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

A

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? A.)Altered consciousness within the first 24 hours after injury. B.)Cushing reflex and cerebral edema after 24 hours C.)Fever, nuchal rigidity and opisthotonos within hours D.)Headache and pupillary changes 48 hours after a head injury

A

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A.)Explain that counseling will be provided to give her information about her cancer risk B.)Gather additional information about the client's family history for all types of cancer. C.)Offer assurance that there are a variety of effective treatments for breast cancer. D.)Provide information about survival rates for women who have this genetic mutation.

A

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement? A.)Determine current sexual practice B.)Prepare a female client for an ultrasound C.)Request an sperm sample for ovulation D.)Evaluate hormone levels on both client

A

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? A.)Blood pressure 170/98 B.)Joint and muscle aches C.)Urine output 300 ml/hr D.)Dark, rust-colored urine

A

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A.)Initiate intravenous fluid as prescribed B.)Notify the HCP of the need to reposition the catheter C.)Remove the catheter and apply direct pressure for 5 minute D.)Secure the catheter using aseptic technique

A

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? A.)Serum potassium B.)Urine ketones C.)Urine albumin D.)Serum protein

A

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? A.)Obtain a prescription for an anticholinergic medication B.)Determine how many hours declined slept last night C.)Administer the PRN prescription for severe anxiety D.)Watch the thyroid cartilage move while the client swallows

A

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today? A.)Assist client in identifying goals for the day. B.)Encourage client to participate for one hour in a team sport. C.)Schedule client for a group that focuses on self-esteem. D.)Help client to develop a list of daily affirmations.

A

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? A.)Explain that the client will start to lose consciousness and his body system will slow down B.)Reassure the spouse that the healthcare provider will let her know when to call the children C.)Offer to discuss the client's health status with each of the adult children D.)Gather information regarding how long it will take for the children to arrive

A

Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? A.)Transfuse Type A negative blood until type AB negative is available. B.)Recheck the client's hemoglobin, blood type and Rh factor. C.)Administer normal saline solution until type AB negative is available D.)Obtain additional consent for administration of type A negative blood

A

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse? A.)An immobile client receiving low molecular weight heparin q12 h. B.)A client who is receiving a continuous infusion of heparin and gets out of bed BID C.)A client who is being titrated off heparin infusion and started on PO warfarin (Coumadin) D.)An ambulatory client receiving warfarin (Coumadin) with INR of 5 second.

A

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? A.)Evaluate closet proximal pulse. B.)Asses skin elasticity of the stump. C.)Observe for swelling around the stump. D.)Note amount color of wound drainage.

A

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? A.)infectious process B.)metastatic process C.)autoimmune disorder D.)inflammatory disorder

A

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet? A.)Roasted turkey canned vegetables B.)Baked potatoes with skin raw carrots C.)Pancakes whole-grain cereal's D.)Roast pork fresh strawberries

A

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? A.)Remove the heating pads and place a soft blanket over the client's leg and feet. B.)Advise the UAP to observe the client's skin while the heating pads are in place. C.)Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently. D.)Instruct the UAP to reposition the heating pads to the sides of the legs and feet.

A

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? A.)Examine the genitalia as the last part of the total exam. B.)Use soothing statements to facilitate cooperation C.)Allow the child to keep underpants on to examine genitalia D.)Work slowly and methodically so not to stress the child

A

The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? A.)Reposition the infant every 2 hours. B.)Perform diaper changes under the light. C.)Feed the infant every 4 hours. D.)Cover with a receiving blanket.

A

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A.)Monitor for an elevated temperature B.)Measure the abdominal girth daily C.)Report the onset of sclera jaundice D.)Keep a record of daily urinary output

A

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? A.)headache, photophobia, and nuchal rigidity B.)high fever, skin rash, and a productive cough C.)nausea, vomiting, and poor skin turgor D.)malaise, fever, and stiff, swollen joints

A

To prevent infection by auto contamination 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 gown, mask and gloves with dressing change. D.)Implement protective isolation

A

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? A.)Withhold food and fluid intake. B.)Initiate IV fluid replacement. C.)Administer antiemetic as needed. D.)Evaluate intake and output ratio.

A

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? A.)Intravenous administration of thyroid hormones B.)Oral administration of hypnotic agents C.)Intravenous bolus of hydrocortisone D.)Subcutaneous administration of vitamin k

A

The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply A.)Avoid prolonged standing or sitting B.)Use recliner for long period of sitting C.)continue wearing elastic stocking D.)Maintain the bed flat while sleeping E.)Cross legs at knee but not at ankle

A,B,C

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) A.)Pasta, noodles, rice. B.)Egg, tofu, ground meat. C.)Mashed, potatoes, pudding, milk. D.)Brussel sprouts, blackberries, seeds. E.)Corn bran, whole wheat bread, whole grains.

A,B,C

An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) A.)Move personal items within client's reach B.)Lower bed to the lower possible position C.)Give directions to call for assistance D.)Assist client to the bathroom in 2 hours. E.)Encourage the use of the wheelchair F.)Raise all bed rails when the client is resting

A,B,C,D

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A.)Inspect skin for redness B.)Use a residual limb shrinker C.)Apply alcohol to the stump after bathing D.)Wash the stump with soap and water E.)Avoid range of motion exercises

A,B,D

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? SATA A.)Poor feeding and vomiting B.)Leakage of CSF from the incisional site C.)Hyperactive bowel sound D.)Abdominal distention E.)WBC count of 10000/mm3

A,B,D,

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A.)Administer a daily dose of lisinopril as scheduled. B.)Assess the client for postural hypotension. C.)Notify the healthcare provider immediately D.)Provide a PRN dose of acetaminophen for headache E.)Withhold the next scheduled daily dose of warfarin.

A,D

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) A.)Topical corticosteroid. B.)Topical scabicide. C.)Topical alcohol rub. D.)Transdermal analgesic. E.)Oral antihistamine

A,E

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? A.)Report finding to the healthcare provider. B.)Administer a prescribed bronchodilator. C.)Encourage the child to cough and deep breath D.)Determine what trigger precipitated this attack.

B

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? A.)Understand pain management scale B.)Maintain effective breathing patterns C.)Absence of ventilator associated pneumonia D.)No injuries refer to soft restrains occur

B

A client who underwent an uncomplicated gastric bypass surgery is having difficult 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-space meal thorough the day C.)Sip fluid slowly with each meal and between meals D.)Eliminate or reduce intake fatty and gas forming food

B

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? A.)Urinary incontinence B.)Left forearm hematoma C.)Disorientation to surroundings D.)Dislodge intravenous site

B

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A.)Sed rate (ESR) B.)Hemoglobin C.)Calcium D.)Osmolality.

B

A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? A.)Does she knows the person who raped her? B.)Has she taken a bath since the raped occurred? C.)Is the place where she lived a safe place? D.)Did she report the rape to the police Department?

B

A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? A.)Call poison control emergency number. B.)Determine type of chemical exposure. C.)Obtain equipment for gastric lavage. D.)Assess child for altered sensorium.

B

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? A.)Move to welcome and accommodate a new person B.)Ask the new person to move belonging to accommodate others C.)Tell the new person to move belongings because of limited space D.)Bring in additional chairs so that all staff members can be seated

B

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? A.)Examine the victim's body surfaces for arterial bleeding B.)Stabilize the victim's neck and roll over to evaluate his status C.)Return to the car to call emergency response 911 for help D.)Open the airway and initiate resuscitative measures

B

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A.)Pain scale rating at 9 on a 0-10 scale B.)Last menstrual period was 7 weeks ago C.)Reports white curdy vaginal discharge D.)History of irritable bowel syndrome IBS

B

After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client? A.)An older adult who is unable to communicate elimination needs. B.)An older man whose sheets are damped each time he is turned. C.)A woman with osteoporosis who is unable to bear weight. D.)A poorly nourished client who requires liquid supplement.

B

After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take? A.)Explain the procedure again in detail and clarify any misconceptions. B.)Notify the healthcare provider of the client's lack of understanding. C.)Call the client's next of kin and have them provide verbal consent. D.)Postpone the procedure until the client understands the risk and benefits.

B

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? A.)Hygiene-self-care deficit B.)Imbalance nutrition C.)Disturbed sleep pattern D.)Self-neglect

B

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take? A.)Ask family member to wear gloves when touching the patient B.)Send family to the waiting area while the client's history is taking C.)Obtain a blood sample to determine is the client is HIV positive D.)Complete the head to toes assessment to identify other sign of HIV

B

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? A.)Rebound abdominal tenderness B.)nausea and projectile vomit C.)rib pain with deep inspiration D.)diminished bilateral breath sounds

B

An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? A.)Examine the client's room for hidden food. B.)Assign staff to monitor what the client eats. C.)Ask the client if the food provided is being eaten or discarded. D.)Provide the client with a high calorie diet.

B

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? A.)Observe neck for jugular vein distention B.)Notify healthcare provider to prepare for pericardiocentesis C.)Asses for paradoxical blood pressure D.)Monitor oxygen saturation (Sp02) via continuous pulse oximetry

B

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? A.)Obtain a urine specimen for culture and sensitivity B.)Palpate the client's suprapubic area for distention C.)Advise the client to maintain a voiding diary for one week D.)Instruct in effective technique to cleanse the glans penis

B

During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first? A.)Determine when the client last had an influenza vaccination. B.)Discuss the concerns expressed by the client about the vaccination. C.)Ask about any recent exposure to persons with the flu or other viruses. D.)Review the informed consent form for the vaccination with the client.

B

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? A.) Varicella Virus Vaccine Live B.) Hemophilic Influenza Type B (HiB) vaccine C.) Pneumococcal vaccine D.) Palivizumab vaccine for RSV

B

In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? A.)Elevated thyroid hormone level. B.)Hematocrit of 28%. C.)Heart rate of 92 beats per minute. D.)Systolic murmur.

B

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care? A.)Encourage Progressive active range of motion B.)Teach need for dietary and supplementary vitamin D3 C.)Explain the need for skin exposure to sunlight without sunscreen D.)Instruct the client to use of muscle strengthening exercises

B

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? A.)Opening the package B.)Picking up the second glove C.)Picking up the first glove D.)Positioning of the table

B

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A.)A listing of African-American women so live in the community B.)Participation of community leaders in planning the program C.)Morbidity data for breast cancer in women of all races D.)Technical assistance to produce a video on breast self-examination.

B

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? A.) White blood count of 19,000 mm3 B.) Oral temperature of 100.6 F C.) Fundus deviated to the right side D.)Breasts are firm when palpated

B

The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber? A.)Lower the IV bag to a flat surface B.)Compress the drip chamber C.)Open the roller clamp D.)Squeeze the bag of IV solution

B

The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? A.)Body mass index of (BMI) of 31 B.)20 pack-year history of cigarette smoking C.)Birth control pill usage until age 45 D.)Diabetes mellitus in family history

B

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? A.)High salt can damage the lining of the blood vessels B.)Too much salt can cause the kidneys to retain fluid C.)Excessive salt can cause blood vessels to constrict D.)Salt can cause information inside the blood vessels

B

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? A.)Identifies 2 treatments for constipation due to immobility. B.)Names 3 home safety hazards to be resolve immediately. C.)State 4 risk factors for the development of osteoporosis. D.)Lists 5 calcium-rich foods to be added to her daily diet.

B

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? A.)Do not read without direct lighting for 6 weeks. B.)Avoid straining at stool, bending, or lifting heavy objects. C.)Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. D.)Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

B

The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching? A.)Ask the adolescent to describe his level of comfort with injecting himself with insulin. B.)Observe him as he demonstrates self-injection technique in another diabetic adolescent C.)Have the adolescent list the procedural steps for safe insulin administration. D.)Review his glycosylated hemoglobin level 3 months after the teaching session.

B

The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client? A.)Put his behavior on extinction and continue talking with the newly admitted. B.)Inform him that the nurse is busy admitting a new client and will talk to him later. C.)Encourage him to go to the nurse's station and talk with another nurse. D.)Introduce him to the newly admitted client and ask him to him to join in the conversation.

B

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A.)Massage the uterus to decrease atony B.)Check for a destined bladder C.)Increase intravenous infusion D.)Review the hemoglobin to determined hemorrhage

B

A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) A.)Check urine for ketones B.)Measure blood glucose C.)Monitor vital signs D.)Assessed level of consciousness E.)Obtain culture of wound

B,C,D

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) A.)Decrease laxative use to every other day, and use oil retention enemas as needed. B.)Include oatmeal with stewed pruned for breakfast as often as possible. C.)Increase fluid intake by keeping water glass next to recliner. D.)Recommend seeking help with regular shopping and meal preparation. E.)Report constipation to healthcare provider related to cardiac medication side effects.

B,C,D

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply). A.)Apply soft upper limb restrains and raise all four bed rails B.)Report mental status change to the healthcare provider C.)Assess the client's breath sounds and oxygen saturation D.)Assign the UAP to re-assess the client's risk for falls E.)Review the client's most recent serum electrolyte values

B,C,E

A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A.)Evaluate postural blood pressure measurements B.)Obtain specimen for uranalysis C.)Encourage popsicles and fluids of choice D.)Assess bowel sounds in all quadrants

C

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A.)Conversion of the client's PPD test from negative to positive. B.)Length of time of the exposure to tuberculosis. C.)Current diagnosis of hepatitis B. D.)History of intravenous drug abuse.

C

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? A.)Review the heart rhythm on cardiac monitors B.)Check urinary catheter for obstruction C.)Auscultated bilateral breath sounds D.)Give PRN dose of lorazepam (Ativan)

C

A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? A.)Lorazepam (Ativan) B.)Famotidine (Pepcid) C.)Thiamine (Vitamin B1) D.)Atenolol (Tenormin)

C

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? A.)Arrange transport for admission to the hospital. B.)Insert saline lock for IV diuretic therapy. C.)Assess compliance with routine prescriptions. D.)Instruct the client to monitor daily caloric intake.

C

A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication? A.)Administer the entire pre-filled syringe deep in the dorsogluteal site. B.)Use a separate syringe to remove 15mg from the pre-filled syringe and give in the back of the arm. C.)Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site. D.)Call the healthcare provider to request a prescription change to match the dispensed 30mg dose.

C

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? A.)Loud hallway noise. B.)Fever C.)Full bladder D.)Frequent cough.

C

A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action? A.)Postpone discharge instructions at this time and offer to contact the client by phone in a few days B.)Invite the client to return to the unit for discharge teaching in a few days, when there is less anxiety C.)Provide only necessary information in short, simple explanations with written instructions to take home D.)Give detailed instructions speaking slowly and clearly while looking directly at the client when speaking

C

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A.)Collect a clean catch urine specimen. B.)Instruct the client to empty the bladder. C.)Obtain vital signs and breath sounds. D.)No specific nursing action is required

C

A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take? A.)Provide the client with information about treatment options for breast cancer. B.) Reassure the client that the final diagnosis has not been made. C.)Encourage the client to continue expressing her fears and concerns. D.)Suggest to the client that she seek a second opinion.

C

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take? A.)Since treatment is completed, assign the nurse to the route RN responsibilities B.)Ask to meet with impaired nurse's therapist before allowing her back on the unit. C.)Allow the impaired nurse to return to work and monitor medication administration D.)Meet with staff to assess their feelings about the impaired nurse's return to the

C

A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? A.)Identifies his ethnocentric values and behaviors B.)States an understanding of the medical treatment C.)Participated actively in all treatments regimens D.)Expresses a desire for cultural assimilation

C

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? A.)Low-grade fever, headache, and malaise for the past 72 hours B.)Unable to bear weight on the left foot, with the swelling and bruising C.)Chest discomfort one hour after consuming a large, spicy meal D.)One-inch bleeding laceration on the chain of the crying five-year-old

C

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? A.)discontinue the magnesium sulfate immediately B.)Decrease the client's iv rate to 50 ml per hour C.)Continue with the plan of care for this client D.)Change the client's to NPO status

C

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? A.)Report the incident to the local child protective services. B.)Find a home health agency that specializes in brain injuries. C.)Determine the mother's basic skill level in providing care. D.)Consult the ethics committee to determine how to proceed.

C

After receiving report, the nurse can most safely plan to assess which client last? The client with... A.)A rectal tube draining clear, pale red liquid drainage B.)A distended abdomen and no drainage from the nasogastric tube C.)No postoperative drainage in the Jackson-Pratt drain with the bulb compressed D.)Dark red drainage on a postoperative dressing, but no drainage in the Hemovac

C

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) A.)Encourage the woman at risk for cancer to obtain colonoscopy. B.)Present a class of breast-self examination C.)Prepare a woman for a bone density screening D.) Explain the follow-up need it for a client with prehypertension.

C

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

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? A.)The intravenous fluid replacement contains a hypertonic solution of sodium chloride B.)Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst C.)Insensible loss of body fluids contributes to the hemoconcentration of serum solutes D.)Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

C

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

C

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is 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 transfusion of packed RBCs. D.)Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

C

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? A.)Decreased white blood cell count B.)Pruritus and muscle aches C.)Elevated liver function tests D.)Vomiting and diarrhea

C

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? A.)Determine the client's level of emotional functioning' B.)Assess functional ability of the primary support system. C.)Evaluate the client's mood, cognition and orientation. D.)Review the client's pattern of adaptive coping skill

C

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? A.)Empty the urinary drainage bag B.)Feed the client a snack C.)Offer the client oral fluids D.)Assess the breath sounds

C

The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? A.)Hold the client at arm's length while transferring to better distribute the body weight. B.)Apply the gait belt around the client's waits once standing position has been assumed. C.)Place a client's locked wheelchair on the client's strong side next to the bed. D.)Pull the client into position by reaching from the opposite side of the bed.

C

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? A.)Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection B.)Administer into the deltoid muscle while the parent holds the infant securely C.)Divide the medication into two injection with volumes under 1ml D.)Use a quick dart-like motion to inject into the dorsogluteal site.

C

What action should the school nurse implement to provide secondary prevention to a school-age children? A.)Collaborate with a science teacher to prepare a health lesson B.)Prepare a presentation on how to prevent the spread of lice C.)Initiate a hearing and vision screening program for first-graders D.)Observe a person with type 1 diabetes self-administer a dose of insulin

C

When should intimate partner violence (IPV) screening occur? A.)As soon as the clinician suspects a problem B.)Only when a client presents with an unexplained injury C.)As a routine part of each healthcare encounter D.)Once the clinician confirms a history of abuse

C

When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? A.)Wash hands frequently B)Avoid drinking lake water C.)Wear long sleeves and pants D.)Do not share personal products

C

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A.)Serum albumin B.)Creatinine level C.)Culture for sensitive organisms. D.)Serum blood glucose (BG) level

C

While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? A.)Apply a pressure dressing around the chest tube insertion site. B.)Assess the client for allergies to topical cleaning agents. C.)Measure the area of swelling and crackling. D.)Administer an oral antihistamine per PRN protocol.

C

A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the client's blood pressure hourly

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) Cleanse the urinary meatus using the solution, swabs, and forceps provided Don sterile gloves and prepare to sterile field Open the sterile catheter kit close to the client's perineum. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

Correct : ODCP 1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? A.)Continuous bubbling in the water seal chamber B.)Decrease bright red blood drainage C.)Tachypnea and difficulty breathing D.)Tracheal deviation toward the left lung.

D

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A.)Patch one eye. B.)Reorient often. C.)Range of motion. D.)Evaluate swallow

D

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? A.)Irrigate the indwelling urinary catheter. B.)Prepare the client for external pacing. C.)Obtain capillary blood glucose measurement. D.)Titrate the dopamine infusion to raise the BP.

D

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide? A.)Vanilla-flavored yogurt B.)Low fat chocolate milk. C.)Calcium fortified juice D.)Cinnamon applesauce

D

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? A.)Cheddar cheese and crackers. B.)Carrot and celery sticks. C.)Beef bologna sausage slices. D.)Dry roasted almonds.

D

A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A.)Check the visual difficulties B.)Note most recent hemoglobin level C.)Assessed for he and Hand joint pain D.)Observe rhythm on telemetry monitor

D

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? A.)Phosphate 4 mg/dl (1.293 mmol/L SI) B.)Fasting glucose 95 mg/dl (5.3 mmol/L SI) C.)Total calcium 9 mg/dl (2.25 mmol/L SI) D.)Creatinine 4 mg/dl (354 micromol/L SI)

D

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A.)Ask the client with her children present if she fully understands the decision she has made. B.)Discuss success of clinical trials and ask the client to consider participating for one month. C.)Explain to the family that they must accept their mother's decision. D.)Explore the client's decision to refuse treatment and offer support

D

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? A.)"I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best" B.)" I never use the inhaler unless I am feeling really short of breath" C.)I always shake the inhaler several times before I start" D.)"After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

D

A nurse working on an endocrine unit should see which client first? A.)An adolescent male with diabetes who is arguing about his insulin dose. B.)An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). C.)An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. D.)A client taking corticosteroids who has become disoriented in the last two hours.

D

At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A.)Encourage the client to turn on her left side. B.)Place a pillow under the client's head and knees. C.)Explain to the client that her position is not safe. D.)Place a wedge under the client's right hip.

D

Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? A.)Review the immunization records of all children in the elementary school B.)Report the measles outbreak to all community health organizations C.)Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. D.)Restrict unvaccinated children from attending school until measles outbreak is resolved.

D

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A.)A 64 year old client who had a total hip replacement the previous day. B.)A 75 year old client with renal calculi who requires urine straining. C.)An adolescent with multiple contusions due to a fall that occurred 2 days ago. D.)A 30 year old depressed client who admits to suicide ideation.

D

The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take? A.)Ask the client if the stocking feel comfortable. B.)Supervise the UAP in the removal of the stockings. C.)Place a cover over the client's toes to keep them warm. D.)Discussed effective use of the stockings with the client on UAP

D

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? A.)Monitor daily sodium intake. B.)Record usual eating patterns. C.)Measure ankle circumference. D.)Auscultate for irregular heart rate.

D

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? A.)Lip smacking and frequent eye blinking B.)Shuffling gait and stooped posture C.)Rocks back and forth in the chair D.)Muscle spasms of the back and neck

D

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

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? A.)Document that an accurate oxygen saturation reading cannot be obtained B.)Elevate to client's hands for five minutes prior to obtaining a reading from the finger C.)Increase the oxygen based on the clients breathing patterns and lung sounds D.)Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

D

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? A.)Limit intake fatty foods for one month after surgery. B.)Notify the healthcare provider if edema occurs. C.)Increase activity and exercise gradually, as tolerated. D.)Avoid crowds for first two months after surgery.

D

The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first? A.)Flush the vein with 3 ml of sterile normal saline. B.)Assess the IV catheter insertion site for infiltration. C.)Verify the threading of the tubing through the IV pump. D.)Determine if the clamp on the IV tubing is released

D

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings? A.)Squeeze the nipple base to introduce milk into the mouth B.)Position the baby in the left lateral position after feeding C.)Alternate milk with water during feeding D.)Hold the newborn in an upright position

D

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? A.)Tell the UAP to offer more choices during the personal care to prevent anxiety B.)Meet with the UAP later to role model more assertive communication techniques C.)Assume care of the client to ensure that effective communication is maintained. D.)Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

D

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? A.)Clean up the spilled blood to reduce infection transmission. B.)Notify the healthcare provider that the client appears to be bleeding. C.)Apply direct pressure to the client's IV site. D.)Identify the source and amount of bleeding.

D

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? A.)Transfer a client to another unit B.)Monitor the central telemetry C.)Perform the admission D.)Assist cardiac nurses with their assignments

D

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? A.)Rectus femenis B.)Ventrogluteous C.)Vastus lateralis D.)Deltoid

D

When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond? A.)Replace the dressing and remove the drainage device B.)Reposition the drainage device and keep the plug open C.)Notify the healthcare provider that the drain is not working D.)Recompress the wound suction device and secure to plug

D

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? A.)Obtain a urine sample from the bed pan B.)Remove dressing and assess surgical site C.)Insert an indwelling urinary catheter D.)Measure the client's oral temperature

D

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A.)Assist the client to lie back in bed B.)Call for an Ambu resuscitating bag c.)Increase oxygen to 6 litters/minute D.)Administer a nebulizer Treatment

D

When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply) A.)Seeds, spices, lettuce B.)Consomme, celery, carrot C.)Oranges, orange juice, bananas D.)Fortified whole wheat cereals, whole-grain pasta, brown rice E.)Spinach, kale, dried raisins and apricots

D,E

A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Observe the amount of urine in the client's urinary drainage bag

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

The family reports a great reduction in client's maniac behavior