HESI B Practice 1

Nurses working on a surgical unit are concerned about a physician's treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, which actions should the nurses take? (Arrange from the first action on top to last on the bottom). 1.Document concerns and report them to the charge nurse. 2. Submit a written report to the Director of Nursing. 3. Talk to the physician as a group in a non-confrontational manner. 4. Contact the hospital's Chief of Medical Services. 5. File a formal complaint with the state medical board.

1.Document concerns and report them to the charge nurse. 2. Submit a written report to the Director of Nursing. 3. Talk to the physician as a group in a non-confrontational manner. 4. Contact the hospital's Chief of Medical Services. 5. File a formal complaint with the state medical board.

An older client with a history of heart failure and admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A. Increasing confusion of the client. B. Fall at home as reason for admission. C. Client's healthcare power of attorney. D. Currently prescribed medication.

A. Increasing confusion of the client.

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs are: temperature 99 F (37.2 C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute and blood pressure 160/90 mmHg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement? A. Provide pillow for splinting. B. Administer an IV analgesic. C. Place a high Fowler position. D. Assess the IV site for patency.

B. Administer an IV analgesic.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. After obtaining vital signs, the nurse should implement which intervention? A. Keep the bed in the lowest position and initiate seizure and fall precautions. B. Test for a swallowing reflex and perform communication deficit assessments. C. Administer aspirin to prevent further clot formation and platelet clumping. D. Notify the stroke team to assist with acute assessment and management.

C. Administer aspirin to prevent further clot formation and platelet clumping.

A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first? A. Chronic low self-esteem as evidenced by feelings of worthlessness. B. Anxiety as evidenced by abdominal complaints secondary to depression. C. Risk for self-directed violence as evidenced by feelings of hopelessness. D. Imbalanced nutrition as evidenced by 25 pounds (11 kg) weight loss in four months.

D. Imbalanced nutrition as evidenced by 25 pounds (11 kg) weight loss in four months.

The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) are an indication of a postoperative complication? (Select all that applies) Reference Range White Blood Cell (WBC) [Reference Range: Newborn: 9000 to 30,000/mm3 or 9 to 10 x 109/L] a. Abdominal distention. b. White blood cell count of 10,000/mm3 (10x109/L). c. Poor feeding and vomiting. d. Hyperactive bowel sounds. e. Leakage of cerebral spinal fluid from the incisional site.

a. Abdominal distention. c. Poor feeding and vomiting. e. Leakage of cerebral spinal fluid from the incisional site.

A client tells the nurse about jogging every day with the hope of losing weight and sleeping better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement? a. Ask the client for a description of the exercise schedule that is being followed. b. Encourage the client to exercise very day to eliminate bedtime wakefulness. c. Determine the amount of weight the client has lost since increasing activity. d. Advise the client that lifestyle changes often takes several weeks to be effective.

a. Ask the client for a description of the exercise schedule that is being followed.

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? a. Clients who incurred disease complications promptly received rehabilitation. b. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. c. Clients reported having new confidence in making healthy food choices. d. At-risk clients received an increased number of routine health screenings.

a. Clients who incurred disease complications promptly received rehabilitation.

The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Condition of tooth enamel. b. Current height and weight. c. Skin of palms of the hand. d. Length of the menses.

a. Condition of tooth enamel.

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take? a. Continue to obtain client data needed to complete the fall risk survey. b. Place the client on a high fall risk protocol because of advanced age. c. Inform the client that falls occur more often in the hospital than at home. d. Record a minimal risk for falls, documenting the client's statement.

a. Continue to obtain client data needed to complete the fall risk survey.

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take? a. Elevate head of bed no higher than 30 degrees. b. Check for a stat intravenous diuretic prescription. c. Obtain a manual blood pressure measurement. d. Affirm blood glucose is below 160 mg/dL (8.88 mmol/L).

a. Elevate head of bed no higher than 30 degrees.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dL (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L). when reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L)] Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] a. Hydrocortisone. b. Regular insulin. c. Potassium chloride.

a. Hydrocortisone.

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication? a. Impaired gas exchange. b. Ineffective airway clearance. c. Self-care deficit. d. Activity intolerance.

a. Impaired gas exchange.

A client who is HIV positive receives a prescription for megestrol 400 mg daily. Which finding should the nurse identify as a therapeutic response to this prescription? a. Increase appetite. b. Healing sin lesions. c. Reduced serum viral load. d. No signs of thrombophlebitis.

a. Increase appetite.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped, and a sterile field is created. Which nursing intervention should the nurse implement for client safety? a. Instruct the client to keep hands under the sterile field. b. Verify that the client has given informed consent. c. Pour cleansing solution onto the sterile field. d. Assess for discomfort when procedure is completed.

a. Instruct the client to keep hands under the sterile field.

While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement? a. Instruct the family to adhere to contact precautions. b. Report any increase in the white blood cell count. c. Change the surgical wound dressing readily when soiled. d. Wear a face mask while performing wound care.

a. Instruct the family to adhere to contact precautions.

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instruction(s) should the nurse provide the mother? (Select all that apply) a. Keep away from pets with long hair. b. Stay indoors when grass is being cut. c. Close car windows and use air conditioner. d. Avoid sudden changes in temperature. e. Decrease the raw sugars in the diet.

a. Keep away from pets with long hair. b. Stay indoors when grass is being cut. c. Close car windows and use air conditioner. d. Avoid sudden changes in temperature.

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply) a. Level of physical activity and exercise. b. Current prescribed and over-the-counter medications. c. Methods currently used to treat constipation. d. Daily food and fluid intake. e. Next scheduled visit with healthcare provider.

a. Level of physical activity and exercise. b. Current prescribed and over-the-counter medications. c. Methods currently used to treat constipation. d. Daily food and fluid intake.

A client is transferred from the operating room to the post-anesthesia care unit with the following vital signs: temperature 99.8 F (37.7 C), heart rate 62 beats/minute, respirations 8 breaths/minute, blood pressure 95/54 mm Hg, and oxygen saturation 94%. Which medication should the nurse administer? a. Naloxone. b. Milrinone. c. Acetaminophen. d. Atropine.

a. Naloxone.

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend? a. Place the client's locked wheelchair on the client's strong side to the bed. b. Apply a gait belt around the client's waist once a standing position has been assumed. c. Hold the client at arm's length while transferring to better distribute the body weight. d. Pull the client into position by reaching from the opposite side of the bed.

a. Place the client's locked wheelchair on the client's strong side to the bed.

An older client with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? a. Provide assistance with ambulation. b. Instruct about healthy diet choices. c. Offer a PRN sleep aid at night. d. Keep the head of the bed elevated.

a. Provide assistance with ambulation.

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide? a. Remain non-judgmental and assure the client of confidentiality. b. Inform the client that complications will not result from reinfection. c. Provide counseling that most contraceptives protect against infection. d. Clarify that all STIs are transmitted through sexual intercourse.

a. Remain non-judgmental and assure the client of confidentiality.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care intervention(s) should the nurse include in the client's plan of care? (Select all that apply) a. Assess pain level and medicate PRN as prescribed. b. Teach client to use incentive spirometer every 2 hours while awake. c. Administer low molecular weight heparin as prescribed. d. Remove urinary catheter as soon as possible and encourage voiding. e. Maintain sequential compression devices while in bed.

a. Teach client to use incentive spirometer every 2 hours while awake. d. Remove urinary catheter as soon as possible and encourage voiding.

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure? a. Tingling on tongue or lips. b. Salty taste in the mouth. c. Episodes of shivering. d. Difficulty breathing.

a. Tingling on tongue or lips.

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply) a. Use recliner for long periods of sitting. b. Maintain the bed flat while sleeping. c. Continue wearing compression stockings. d. Avoid prolonged standing or sitting. e. Cross legs at knee but not at ankle.

a. Use recliner for long periods of sitting. c. Continue wearing compression stockings. d. Avoid prolonged standing or sitting.

93. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease? a. Wear gloves when removing packages from freezer. b. Walk regularly to increase circulation. c. Wear knee-high support stockings during the day. d. Use a heating pad at night to keep feet warm.

a. Wear gloves when removing packages from freezer.

When performing suctioning for a client with a tracheostomy, which action should the nurse include? a. Wear protective goggles while performing the procedure. b. Instruct the client to cough as the suction tip is removed. c. Apply a water soluble lubricant to the catheter. d. Instill 3 mL of normal saline before suctioning.

a. Wear protective goggles while performing the procedure.

A client with a history of chronic obstruction pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory ate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? a. Shortness of breath on exertion. b. Bilateral diffuse wheezing. c. Yellow expectorated sputum. d. Temperature of 100.5 F (38.1 C).

b. Bilateral diffuse wheezing.

The nurse manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? a. Employee's job security. b. Changes in job descriptions. c. New management's expectations. d. Potential changes in employee benefit.

b. Changes in job descriptions.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care? a. Assess skin turgor. b. Check for pedal edema. c. Measure body temperature. d. Observe color of urine.

b. Check for pedal edema.

The nurse discovers that a male client has attempted suicide by slashing his wrists.Which action(s) should the nurse do first? a. Estimate the amount of blood loss. b. Check the client's level of consciousness. c. Find the object used to cause the injuries. d. Determine the depth of the slashes.

b. Check the client's level of consciousness.

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important? a. Determine when the client last had medication. b. Confirm that the client has been NPO since midnight. c. Review postoperative instructions with the client. d. Offer to assist the client to the restroom to void.

b. Confirm that the client has been NPO since midnight.

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? a. Limit the client's fluids. b. Document in the client's record. c. Prepare the client for an echocardiogram. d. Notify the healthcare provider.

b. Document in the client's record.

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Experiences facial swelling after eating crab. c. Reports left chest wall pain prior to admission. d. Verbalizes a fear of bleeding in a confined space.

b. Experiences facial swelling after eating crab.

A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement? Reference Range Hemoglobin [Reference Range: 12-16 g/dL (120-160 g/L)] Hematocrit [Reference Range: Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative] Group B Streptococcus [Reference Range: negative] a. Inject hepatitis B immune globulin 0.5 mL. b. Give measles, mumps, rubella vaccine 0.5 mL. c. Transfuse two units packed red blood cells. d. Administer ampicillin 2 grams intravenously.

b. Give measles, mumps, rubella vaccine 0.5 mL.

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL. (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference range Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] a. Assess client for polyuria and polyphagia. b. Give the client a glass of orange juice. c. Collect a blood sample for hemoglobin A1c. d. Notify the healthcare provider.

b. Give the client a glass of orange juice.

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

b. Initiate a prescribed IV for parental fluid.

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)? a. Evaluate and update plans of care for clients. b. Insert urinary catheters for uncomplicated clients. c. Verify the readiness of clients for discharge. d. Receive a postoperative client and conduct the assessment.

b. Insert urinary catheters for uncomplicated clients.

91. When should the nurse conduct an Allen's test? a. To assess for presence of a deep vein thrombus in the leg. b. Just before arterial blood gasses are drawn peripherally. c. When pulmonary artery pressures are obtained. d. Prior to attempting a cardiac output calculation.

b. Just before arterial blood gasses are drawn peripherally.

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? (Select all that apply) a. Enjoy fast food restaurants only if dining with friends. b. Limit high fiber foods, such as beans, popcorn, seeds. c. Avoid eating fried, fatty foods and large meals. d. Drink dairy and effervescent sodas for hydration. e. Take a vitamin supplement daily with a meal.

b. Limit high fiber foods, such as beans, popcorn, seeds. c. Avoid eating fried, fatty foods and large meals. e. Take a vitamin supplement daily with a meal.

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care? a. Keep head of bed raised 45 degrees. b. Monitor blood glucose level. c. Maintain strict intake and output. d. Assess warmth of extremities.

b. Monitor blood glucose level.

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) infection. which intervention(s) should the nurse include in the plan of care? (Select all that apply) a. Use standard precautions and wear a mask. b. Monitor the client's white blood cell count. c. Explain the purpose of a low bacteria diet. d. Institute contact precautions for staff and visitors. e. Send wound drainage for culture and sensitivity.

b. Monitor the client's white blood cell count d. Institute contact precautions for staff and visitors. e. Send wound drainage for culture and sensitivity.

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? a. Use firmness and direct the client to sit for awhile. b. Move the client to a quiet place on the unit. c. Encourage the client to use the punching bag. d. Suggest to the client that he take a walk.

b. Move the client to a quiet place on the unit.

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea? a. Granola, strawberries, and tea. b. Oatmeal, banana, and herbal tea. c. Buttered whole wheat toast and coffee. d. Sausage, poached eggs, and milk.

b. Oatmeal, banana, and herbal tea.

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test should the nurse report to the healthcare provider? a. Babinski test that reveals fanning out of toes. b. Ortolani maneuver causing a click at the hip joint. c. Plumb line test indicates fetal position curvature. d. Moro test precipitating a startle response.

b. Ortolani maneuver causing a click at the hip joint.

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse she is experiencing jaw pain. How should the nurse respond? a. Determine how the client is administering the medication. b. Report the client's jaw pain to the healthcare provider. c. Confirm that this is a common symptom of osteoporosis. d. Advise the client to gargle with warm salt water twice daily.

b. Report the client's jaw pain to the healthcare provider.

The nurse is assessing a primigravida at 37-weeks gestation who believes she is in labor. Which assessment finding necessitates admission to the labor and delivery unit? a. Cervix 50% effaced and 1 cm dilated. b. Systolic blood pressure elevation. c. Positive fern test. d. Burning on urination.

b. Systolic blood pressure elevation.

The nurse is assessing an older client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family? a. The client's delirium may be due to depression and is possibly reversible. b. The client is exhibiting symptoms of dementia and because of age, it may be permanent. c. If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages. d. Delirium is often a sign of underlying mental illness and institutionalization is often necessary.

b. The client is exhibiting symptoms of dementia and because of age, it may be permanent.

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink popular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? a. This rash is characteristic of a medication reaction. b. This is a common newborn rash that will resolve after several days. c. The healthcare provider is being notified about the rash. d. The rash is due to distended oil glands that will resolve in a few weeks.

b. This is a common newborn rash that will resolve after several days.

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. White blood cell (WBC) count. c. Creatinine level. d. Platelet count.

b. White blood cell (WBC) count.

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory value(s) should the nurse monitor? (Select all that apply) a. Red blood cell (RBC) count. b. White blood cell WBC) count. c. Serum potassium. d. Sputum culture and sensitivity. e. Blood urea nitrogen (BUN). f. Urinalysis.

b. White blood cell WBC) count. d. Sputum culture and sensitivity.

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse the client next? a. "Have you taken any hallucinogens?" b. "Do you believe the voices are real?" c. "Are you planning to obey the voices?" d. "When did these voices begin?"

c. "Are you planning to obey the voices?"

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? a. "Does your child seem mentally slower than his peers also?" b. "You should not worry about the growth tables. They are only averages for children." c. "His smaller size is probably due to the heart disease." d. "Haven't you been feeding him according to recommended daily allowances for children?"

c. "His smaller size is probably due to the heart disease."

A parent brings their 2-month-old infant to the clinic to receive the recommend primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections? a. Administer children's aspirin to help prevent inflammation. b. Keep the infant home from daycare for the next two days. c. Apply a cool pack to the injection site to reduce discomfort. d. Any level of fever is serious and should be reported right away.

c. Apply a cool pack to the injection site to reduce discomfort.

A client with cancer is admitted 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 prescriptions include radiation therapy. Which action should the nurse implement? a. Notify the radiation department to withhold the treatments for now. b. Determine if the client wishes to cancel further radiation treatments. c. Ask the client about his expected goals for this hospitalization. d. Explain that palliative care measures can be provided at home.

c. Ask the client about his expected goals for this hospitalization.

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first? a. Defer the health history until the client is less anxious. b. Ask the family member to answer the questions. c. Assess the surroundings for noise and distractions. d. Provide a printed health care assessment form.

c. Assess the surroundings for noise and distractions.

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply) a. Weeping serosanguineous fluid from wounds. b. Sloughing tissue around wound edges. c. Change in the quality of the peripheral pulses. d. Complaint of increased pain and pressure. e. Loss of sensation to the left lower extremity.

c. Change in the quality of the peripheral pulses. e. Loss of sensation to the left lower extremity.

1. A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse? a. Clubbed fingernails. b. Unexplained fatigue. c. Coarse breath sounds. d. Rust colored sputum.

c. Coarse breath sounds.

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include? a. Select a 22 gauge 1 1⁄2 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 injections with volumes under 1 mL. d. Use a quick dart-like motion to inject into the dorsogluteal site.

c. Divide the medication into two injections with volumes under 1 mL.

A female client on the mental health unit frequently asks the nurse when she can be discharged. Becoming more anxious, the client begins to pace in the hallway. Which intervention should the nurse implement first? a. Determine if the client has PRN medication for anxiety. b. Review the current treatment plan with the client. c. Explore the client's reasons for wanting to be discharged. d. Inform the healthcare provider about the client's behaviors.

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

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity? a. Low bioavailability. b. Short half life. c. High therapeutic index. d. Highly protein bound.

c. High therapeutic index.

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority? a. Interrupted Family Process. b. Noncompliance with treatment regimen. c. Imbalanced Nutrition: less than body requirements. d. Disturbed Body Image.

c. Imbalanced Nutrition: less than body requirements.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blister or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Encourage the mother to apply lotion with each diaper change. b. Tell the mother to cleanse with soap and water at each diaper change. c. Instruct the mother to change the child's diaper more often. d. Ask the mother to decrease the infant's intake of fruits for 24 hours.

c. Instruct the mother to change the child's diaper more often.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Bathe the child daily with bath oil. b. Apply baby lotion to the skin twice daily. c. Keep the nails trimmed short. d. Allow the child to wear only 100% cotton clothing.

c. Keep the nails trimmed short.

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care? Reference Range Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] a. Monitor and document strict intake and output. b. Elevate glucose levels before and after meals. c. Obtain a 12-lead electrocardiogram daily. d. Assess the serum potassium level every 4 hours.

c. Obtain a 12-lead electrocardiogram daily.

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. Obtain vital signs and breath sounds.

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). when providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include? a. Monthly appointment with the dietician. b. Limit calories on days unable to exercise. c. Regular exercise with medical approval. d. Monitor blood glucose levels daily.

c. Regular exercise with medical approval.

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse? a. Take the medication with antacids. b. Monitor for changes in stool color. c. Report any difficulty with breathing. d. Avoid the consumption of grapefruit juice.

c. Report any difficulty with breathing.

An older client with a history of heart failure is admitted with influenza and requests assistance to sit up in bed to eat lunch. The nurse observes the unlicensed assistive personnel (UAP) wearing a gown and gloves to assist the client. Which action should the nurse take? a. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. b. Remind the UAP to apply a fitted respirator mask before entering the client's room. c. Review the need for the UAP to wear a face mask while in close contact with the client. d. Assign the UAP to provide care for another client and assume full care of the client.

c. Review the need for the UAP to wear a face mask while in close contact with the client.

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next? a. Place an indwelling urinary catheter and institute strict intake and output measurements. b. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. c. Secure client consent for coronary angiography and percutaneous coronary intervention. d. Evaluate upper and power extremities for perfusion, pulse volume, and pitting edema.

c. Secure client consent for coronary angiography and percutaneous coronary intervention.

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? a. She is over 35 years of age. b. The second stage of labor lasted 10 minutes. c. She is a gravida 6, para 5. d. She received butorphanol 2 mg IVP during labor.

c. She is a gravida 6, para 5.

When should intimate partner violence (IPV) screening occur? a. As soon as the clinician suspects a problem. b. Once the clinician confirms a history of abuse. c. Only when a client presents with an unexplained injury. d. As a routine part of each health care encounter.

d. As a routine part of each health care encounter.

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, which action(s) should the nurse take before inserting the catheter? (Select all that apply) a. Complete perianal care with soap and water. b. Secure the urinary drainage bag to the bed frame. c. Gently palpate the client's bladder for distension. d. Ask the client to bear down as if voiding to relax the sphincter. e. Hold the catheter 3 to 4 inches (7.5 to 10 cm) from its tip.

d. Ask the client to bear down as if voiding to relax the sphincter. e. Hold the catheter 3 to 4 inches (7.5 to 10 cm) from its tip.

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide? a. Following a well-balanced diet is a much healthier approach to good nutrition than on a multivitamin. b. Multivitamins are contraindicated during treatment with weight-control medications such as orlistat. c. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals. d. Be sure to tale the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

d. Be sure to tale the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

After falling, an older adult presents to the Emergency Department with shallow, labored breathing, a respiratory rate of 32 breaths/minute, paradoxical chest movement, and severe rib-cage pain with inspiration and movement. The nurse applies 100% oxygen per non rebreathing mask. Which action should the nurse take next? a. Contact the om-call respiratory therapist. b. Obtain arterial blood gases (ABGs). c. Prepare for mechanical ventilation. d. Call for a portable chest x-ray.

d. Call for a portable chest x-ray.

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period? a. Provide an eye shield to be worn while sleeping. b. Obtain vital signs every 2 hours during hospitalization. c. Teach a family member to administer eye drops. d. Encourage deep breathing and coughing exercises.

d. Encourage deep breathing and coughing exercises.

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgement. Which intervention is most important for the nurse to include in this client's plan of care? a. Offer the client frequent reassurance that he/she will be safe. b. Arrange the client's environment so the client can move about freely. c. Assign a UAP to provide the client with total personal care. d. Engage the client in regularly scheduled activities during the day.

d. Engage the client in regularly scheduled activities during the day.

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond? a. Reinforce the need to avoid social contact for several weeks. b. Recommend the use of a face mask during family events. c. Encourage family gatherings to reduce feelings of isolation. d. Explain the need to avoid persons with respiratory infections.

d. Explain the need to avoid persons with respiratory infections.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take? a. Call for an assistant. b. Close the room door. c. Respond to the code. d. Finish the procedure.

d. Finish the procedure.

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? a. Protect the site from getting wet during bathing. b. Use a sponge to debride the affected area. c. Gently pat the skin dry after rinsing with water. d. Frequently apply moisturizers to prevent dry skin.

d. Frequently apply moisturizers to prevent dry skin.

A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the burse implement next? a. Assess laboratory results to confirm a thyroid crisis. b. Obtain a complete set of vital signs. c. Encourage relaxation and slow deep breathing. d. Initiate intravenous access.

d. Initiate intravenous access.

A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the nurse implement next? a. Access laboratory results to confirm a thyroid crisis. b. Obtain a complete set of vital signs. c. Encourage relaxation and sow deep breathing. d. Initiate intravenous access.

d. Initiate intravenous access.

After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dL (22.9 umol/L). which action should the nurse implement? Reference Range Creatinine [Reference Range: 0.5 to 1.1 mg/dL (44 to 97 umol/L)] a. Evaluate the client's serum BUN level. b. Initiate the urine collection as prescribed. c. Assess the client for signs of hypokalemia. d. Notify the healthcare provider of the results.

d. Notify the healthcare provider of the results.

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement? a. Ask the client how often episodes of sundowning are experienced. b. Assist the client with values clarification about end-of-life care option. c. Encourage the client to lie as still as possible during then assessment. d. Question the client about the frequency of falls in recent months.

d. Question the client about the frequency of falls in recent months.

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first? a. Presence of gastric pain. b. Dosage of ibuprofen taken. c. Amount of pain control. d. Reason for taking the aspirin.

d. Reason for taking the aspirin.

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring 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. Replace dietary table salt with salt substitutes. c. Use electric heating pad when pain is at its worse. d. Report experiencing right upper quadrant discomfort.

d. Report experiencing right upper quadrant discomfort.

A client with end stage Alzheimer's disease is brought to the clinic by the caregiver for an appointment with the healthcare provider. The caregiver speaks privately to the nurse about not sleeping well at night and experiencing frequent periods of crying. Which intervention should the nurse implement? a. Advise to have a case management evaluation of the client's home environment. b. Proposed the extended family could return to the area to help provide assistance. c. Tell the caregiver to consider hiring a private duty nurse for time to be away. d. Suggest social services be contacted to find a respite care facility for the client.

d. Suggest social services be contacted to find a respite care facility for the client.

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care? a. Administer IV opioids as needed for pain. b. Observe for signs of increased bleeding. c. Monitor for confusion and restlessness. d. Teach how to use incentive spirometry.

d. Teach how to use incentive spirometry.

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. a. Ask another nurse to finish giving medications and attend to the client immediately. b. Instruct the UAP to notify the client's spiritual advisor of her need for counseling. c. Provide the client with a PRN antianxiety medication and allow privacy for her to grieve. d. Tell the client that the nurse will be back to talk to her after medication are given.

d. Tell the client that the nurse will be back to talk to her after medication are given.