Hesi exit 4
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg -Then calculate total dose in units = 18units x 100kg = 1800 units/hr - 25000 units - in 250 1800 units ---in X ml x = 1800 x 250/25000 =18 mL/hr
A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine 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?
-convert weight to kg: 42/2.2 = 19.09 kg -dose/kg = 0.5x19.09 = 9.5454mg -amount per ml: 25mg ---- in 1ml 9.5mg ----in X ml X = 9.5 x1/25 = 0.38 = 0.4 mL
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth.
0.2 mL
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions?
1. Stop the infusion 2. Assess vital signs 3. Contact the healthcare provider 4. Document reaction to the drug 5. Initiate an adverse event report
What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy." B. "The dressing over my incision feels like it is too tight C. "I'm most comfortable when the head of the bed is raised" D. "This IV infusion makes me urinate more often than usual"
A. "When I get out of bed quickly, I feel a little dizzy."
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water t
A. Add sterile water to the suction control chamber
An older woman with history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? A. Administer Vitamin K injection B. Start continuous heparin infusion C. Continue warfarin at same dose D. Transfuse unit of packed red blood cells
A. Administer Vitamin K injection
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A client with leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain client's temperature q4 hours
A. Assess urine and stool for occult blood
The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess
A. Bacterial meningitis
Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A. Body mass index B. Breath sounds C. Self-description of pain D. Level of consciousness
A. Body mass index
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? A. Bring a heavy can close to body before lifting B. Locks knees while preparing food on the counter C. Widens stance while working near the sink D. Bends from the waist to pick trash off the floor E. Leans forward to pull a pan from a high shelf
A. Brings a heavy can close to body before lifting C. Widens stance while working near the sink
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. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin
A. Culture for sensitive organisms
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who's prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A. Determine the client's level of mobility and need for assistance B. Instruct the UAP that all clients deserve equal care C. Advise the client to maint
A. Determine the client's level of mobility and need for assistance
The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest expansion C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute
A. Diminished breath sounds over the trocar insertion site
Which instruction should the nurse provide a pregnant client who is reporting heartburn? A. Eat small meals throughout the day to avoid a full stomach. B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Limit fluids between meals to avoid overdistension of the stomach.
A. Eat small meals throughout the day to avoid a full stomach.
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food C. Instruct the client that these mild symptoms can generally be co
A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer
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. Offer assurance that there are a variety of effective treatments for breast cancer C. Gather additional information about the client's family history for all types of cancer D. Provide information about survival rates for women who have this g
A. Explain that counseling will be provided to give her information about her cancer risk
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A. Explore client's readiness to discuss the situation B. Discuss treatment options for abusive partners C. Report the finding to the police department D. Determine the frequency and type of client's abuse
A. Explore client's readiness to discuss the situation
After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? A. File a detailed incident report with the specific hiring facility B. Warn the colleague that their actions are unprofessional C. Comment anonymously about the action on a staff discussion board D. Communicate the colleague's actions to the unit charge nu
A. File a detailed incident report with the specific hiring facility
When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheese E. Pickled olives
A. Fruits without sauce C. Fresh or frozen vegetables without sauce D. Cottage cheese
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with the client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration
A. Have the client vocalize the instructions provided
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, glucose 54mg, and potassium 5.3 mEq/L. When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad spectrum antibiotic D. Potassium chloride
A. Hydrocortisone
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? A. Inspect skin for redness B. Avoid range of motion exercises C. Apply alcohol to the stump after bathing D. Use a residual limb shrinker E. Wash the stump with soap and water
A. Inspect skin for redness D. Use a residual limb shrinker E. Wash the stump with soap and water
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. Keep the nails trimmed short B. Apply baby lotion to the skin twice daily C. Bathe the child with bath oil D. Allow the child to wear only 100% cotton clothing
A. Keep the nails trimmed short
When conducing diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? A. Lentils B. Potato soup C. Tea D. Cheese E. Whole grain breads
A. Lentils B. Potato soup C. Tea
A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement during the admission process for this client? A. Obtain psychiatric and medical admission records B. Hold psychotropic medications until glucose is regulated C. Interview client about reason for admission to hospital D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages
A. Obtain psychiatric and medical admissions records C. Interview client about reason for admission to hospital E. Review the list of home medications and dosages
The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. What action should the nurse take next? A. Open the roller clamp on the tubing B. Label the bag of IV solution C. Attach the tubing to the saline lock D. Flush the saline lock with saline
A. Open the roller clamp on the tubing
The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Postpone the feeding until the infant's vital signs are stable B. Continue the insertion since this is a typical response C. Insert the feeding tube into the infant's nasal passage D. Pause and monitor for a continued drop of the heart rate
A. Postpone the feeding until the infant's vital signs are stable
The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.
A. Provide high protein snacks
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting? A. Provide information on ways to increase activity for the family B. Have several teachers talk about health risks associated with obesity C. Distribute a shopping list of suggested healthy snack ideas D. Determine the parents' degree of concern
A. Provide information on ways to increase activity for the family
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling and edema D. Monitor abdominal girth E. Increase oral fluid intake to 1,500 mL daily
A. Report serum albumin and globulin levels C. Note signs of swelling and edema D. Monitor abdominal girth
Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands, and his anterior legs. Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? A. 50% B. 27% C. 9% D. 36%
B. 27%
The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease (CKD) C. A restaurant chef who was diagnosed one year ago with hepatitis A D. A sales person who travels internationally and eats food in foreign countries.
B. An office worker who requires hemodialysis for chronic kidney disease (CKD)
A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.
B. Antidepressants usually begin to improve your mood after 2 to 4 weeks.
When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? Select all that apply A. Sloughing tissue around wound edges B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity E. Weeping serosanguineous fluid from wounds
B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity
During a clinic visit, a client with a kidney transplant asks, "What will happen if chronic rejection develops?" Which response is best for the nurse to provide? A. A different combination of immunosuppressant medications will be implemented B. Dialysis would need to be resumed if chronic rejection becomes a reality C. Dialysis may be necessary until the chronic rejection can be reversed D. The immunosuppressant medication will be increased until the rejection subsides
B. Dialysis would need to be resumed if chronic rejection becomes a reality
A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A. Were your legs ever suddenly swollen, red, warm, and painful? B. Does the calf pain occur when walking short distances? C. Did you receive treatment for weeping ulcers on lower legs? D. Have you experienced ankle edema and varicose veins?
B. Does the calf pain occur when walking short distances?
The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? A. Positive Epstein-Barr, and malaise B. Ear pain and fever C. Elevated WBC and sedimentation rate D. Increased BUN and serum creatinine
B. Ear pain and fever
A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50mL/hr. The client's urine specific gravity is 1.035. Which action should the nurse implement? A. Assess bowel sounds in all quadrants B. Encourage popsicles and fluids of choice C. Evaluate postural blood pressure measurements D. Obtain a specimen for urinalysis
B. Encourage popsicles and fluids of choice
The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A. Swaddle the infant in a blanket for sleeping B. Ensure that the infant's crib mattress is firm C. Place the infant in a prone position whenever possible D. Prop the infant with a pillow when in a side-lying position
B. Ensure that the infant's crib mattress is firm
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. Evaluate swallow C. Reorient often D. Range of motion
B. Evaluate swallow
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. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down C. Reassure the spouse that the healthcare provider
B. Explain that the client will start to lose consciousness and the body systems will slow down
When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements
B. Give a dose of regular insulin as prescribed
A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Incr
B. Increase the warfarin dose
A client with metabolic syndrome plans to begin an exercise program. Which instruction is most important for the nurse to provide this client? A. Wear long sleeves and a hat when exercising outdoors in direct sunlight B. Monitor blood pressure and heart rate as exercise activity is increased C. Weight bearing exercises are most effective in improving bone strength D. Use hand-held weights to strengthen muscles and build muscle mass
B. Monitor blood pressure and heart rate as exercise activity is increased
A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local HIV support groups D. Observe for adverse drug reactions
B. Monitor for secondary infections
An older adult male who is in his early 70s admitted to the emergency department because of a COPD exacerbation. The client is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living will. Which action should the nurse take? A. Facilitate a family meeting with the palliative care team B. Notify the healthcare provider
B. Notify the healthcare provider of the client's wishes
An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? A. Document neurologic changes B. Reduce environmental stimuli C. Administer prescribed neuroleptic D. Review medications for interactions
B. Reduce environmental stimuli
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A. Report any allergies to shellfish or iodine B. Report any painful urination, blood in urine, or fever C. Lay prone for 24 hours after the procedure D. Avoid strenuous activity and sports for at least 2 weeks
B. Report any painful urination, blood in urine, or fever
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperatue D. Erythrocytes, hemoglobin, and hematocrit
B. Serum potassium, calcium, and phosphorus
When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this findings be most significant? A. Crying B. Sitting upright C. Vomiting D. Straining on stool
B. Sitting upright
The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predictable sequence B. The disease is characterized by alternating periods of flare-ups and remissions C. Once an acute attack subsides, the client can expect to feel fine again D. Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness
B. The disease is characterized by alternating periods of flare-ups and remissions
While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A. Use a topical lidocaine analgesic for cracked lips B. Use a water soluble lubricant on affected oral and nasal mucosa C. Ask the mother what she usually uses on the child's lips and nose D. Apply a petroleum jelly to the child's lips and nose
B. Use a water soluble lubricant on affected oral and nasal mucosa
The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Regional relocation center for earthquake victims B. Vitamin supplements for high-risk pregnant women C. Lead screening for children in low-income housing D. Case management and screening for clients with HIV
B. Vitamin supplements for high-risk pregnant women
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. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart
C. "His smaller size is probably due to the heart disease"
The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding? Sound: wheezing A. Chloroquine B. Enalapril C. Albuterol D. Losartan
C. Albuterol
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate action? A. A 16-year-old client diagnosed with major depression who refuses to participate in group B. A 14-year-old with anorexia nervosa who is refusing to eat the evening snack C. An 18-year-old client with antisocial behavior who is being yelled at by other clients D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby
C. An 18-year-old client with antisocial behavior who is being yelled at by other clients
At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? A. Pain (acute) B. Knowledge deficit C. Anxiety D. Anticipatory grieving
C. Anxiety
A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill". What question should the nurse ask the client next? A. When did these voices begin? B. Have you taken any hallucinogens? C. Are you planning to obey the voices? D. Do you believe the voices are real?
C. Are you planning to obey the voices?
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis
C. Begin supplemental oxygen
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. At-risk clients received an increased number of routine health screenings B. Clients reported having new confidence in making healthy food choices C. Clients who incurred disease complications promptly received rehabilitation D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign
C. Clients who incurred disease complications promptly received rehabilitation
A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? A. Depression B. Peripheral neuropathy C. Confusion D. Right lower abdominal pain
C. Confusion
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 every 2 hours. Which finding should the nurse report immediately to the healthcare provider? A. Anorexia and abdominal distention B. Abdominal pain and vomiting C. Confusion and tremors D. Yellowing and itching of skin
C. Confusion and tremors
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? A. Prepare the client for spinal anesthesia B. Empty the client's bladder using a straight catheter C. Convey to the client that birth is imminent D. Prepare the coach to accompany the client to delivery
C. Convey to the client that birth is imminent
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. Verbalizes a fear of being in a confined space C. Experiences facial swelling after eating crab D. Reports left chest wall pain prior to admission
C. Experiences facial swelling after eating crab
In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin
C. Glucose
While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? A. Do you often have feelings of sadness? B. Are you having problems concentrating? C. Have you thought about taking your life? D. What problems are you facing right now?
C. Have you thought about taking your life?
After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? A. Take prednisone doses before meals on an empty stomach B. Wear sunglasses when exposed to bring sunlight C. If sequential doses are missed, notify the healthcare provider D. Schedule a monthly laboratory visit for a complete bloo
C. If sequential doses are missed, notify the healthcare provider
When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement? A. Tell the client to stop the inappropriate behavior B. Complete an unusual occurrence report C. Leave the room and close the door quietly D. Ignore the behavior and hang the IV antibiotic
C. Leave the room and close the door quietly
The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. What actions should the nurse implement? A. Insert a bite block B. Restrain the client C. Loosen restrictive clothing D. Note the duration of the seizure E. Ease the client to the floor
C. Loosen restrictive clothing D. Note the duration of the seizure E. Ease the client to the floor
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit
C. Neutrophil count
The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the nurse take first? A. Instruct the UAP to raise the bed level B. Provide gloves for the UAP to apply C. Offer to help reposition the client D. Place the side rails in an up position
C. Offer to help reposition the client
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. What action should the nurse take? A. Instruct the UAP to return to the client's room to perform handwashing B. Supervise the UAP in the next client's room to evaluate hand hygiene C. Remind the UAP to continue rubbing the hands together until they are dry D. Advice the UAP to wear gloves when obtaining vital signs for all clients
C. Remind the UAP to continue rubbing the hands together until they are dry
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? A. Administer PRN oral analgesics to a client with a history of chronic pain B. Transport a client who is receiving IV fluids to the radiology department C. Supervise a newly hired graduate nurse during an admission assessment D. Complete ongoing focused assessments of a client with wrist restraints
C. Supervise a newly hired graduate nurse during an admission assessment
A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should this nurse implement first? A. Document as specifically as possible the client's behavior in the nurse's notes B. Discuss with the client why he is making sexual advances toward the nurse C. Tell the client in a matter-of-fact manner to stop the sexual advances D. Request an immediate team meeting to discuss the inappropriate behavior
C. Tell the client in a matter-of-fact manner to stop the sexual advances
The nurse assesses a child in 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome?
Click spot right on toes on injured foot
During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? A. The census report has not been completed B. A client's wife has asked to speak with the charge nurse C. One staff member has not reported to work D. A bucket of water was spilled in the hallway
D. A bucket of water was spilled in the hallway
A nurse working on an Endocrine Unit should see which client first? A. An older client with Addison's disease whose current blood sugar level is 62 mg/dL B. An adult with a blood sugar of 284 mg/dL and a urine output of 350 mL in the last hour C. An adolescent male with type 1 diabetes who is arguing about his insulin dose D. A client taking corticosteroids who has become disoriented in the last two hours
D. A client taking corticosteroids who has become disoriented in the last two hours
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask and requiring staff to observe airborne, as well as standard precautions? A. A female adolescent admitted with multiple genital herpes simplex II lesions B. An older client with scabies who is admitted from an extended care facility C. Twin siblings admitted with scarlet fever that is complicated with pneumonia D. A c
D. A client with a positive Mantoux and sputum cultures results positive for AFB
A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? A. Decrease in intracranial pressure and cerebral edema B. Increased time of ambulation between periods of rest C. Normal electroencephalogram after drug administration D. Absence of seizure activity for the duration of treatment
D. Absence of seizure activity for the duration of the treatment
The nurse is caring for client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Increasing the client's fluid intake D. Administering narcotics for pain relief
D. Administering narcotics for pain relief
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? A. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. A 34-year-old admitted today after an emergency appendectomy who has a periphe
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied
The nurse is caring for a client with chronic obstructive disease (COPD) who uses oxygen at 2L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxiety B. Auscultate the client's bilateral lung sounds and oxygen saturation C. Notify the healthcare provider about the client's distress D. Assess the d
D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula
A male client who fell of a roof has right and left femur fractures and crushing injuries to both ankles. he is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention i
D. Assess the extremities for signs of compartment syndrome q2 hours
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. Assess skin elasticity of the stump B. Observe for swelling around the stump C. Note amount and color of wound drainage D. Evaluate closest proximal pulse
D. Evaluate closest proximal pulse
An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Assess client's pupils for their reaction to light B. Request that the CT scan be done immediately C. Review client's history for use of illicit drugs D. Expla
D. Explain the reason for using only non-narcotics
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Difficulty locating the uterine fundus B. Excessive lochia C. Saturation of more than one pad per hour D. Hypertension
D. Hypertension
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's uri
D. Increase the infusion rate of Lactated Ringer's solution
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. Signs of addiction to opioid pain medication B. Information about non-pharmaceutical pain relief measures C. Referral for social services for the child and family D. Instructions about how much fluid the child should drink
D. Instructions about how much fluid the child should drink
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? A. Determine if the newborn is in the nursery B. Activate the lockdown procedure C. Ask the mother if any visitors were expected to arrive D. Match ID bands of all infants and mothers on the unit
D. Match ID bands of all infants and mothers on the unit
When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every 2 hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about this client? A. Rehabilitative prognosis is an expected full recovery B. Risk for irreversible cerebral damage related to increased ICP C. Insertion of an ICP monitoring device is necessary D. Neu
D. Neurologically stable without indications of an increased ICP
An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Explain the purpose of each medication the client is currently taking C. Ask the client to wr
D. Play a board game with the client and begin talking about stressors
To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A. Have an alert family member administer medications B. Encourage taking medications at the same times daily C. Instruct the client to wear glasses when reading labels D. Provide education both verbally and in written format
D. Provide education both verbally and in written format
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A. Urine specific gravity is 1.040 B. Systolic blood pressure decreases 10 points when standing C. The client denies being thirsty D. Skin tenting occurs when the client's forearm is pinched
D. Skin tenting occurs when the client's forearm is pinched
An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? A. Use hand and arm gestures to improve communication and comprehension B. Provide additional light in the room to promote sensory stimulation C. Place a clock and calendar in the room to improve orientation D. Teach the client to turn his head from side to side for visual scanning
D. Teach the client to turn his head from side to side for visual scanning
The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client will express acceptance of their newly diagnosed health status. B. The nurse will encourage the client to walk thirty minutes every day C. The client's blood pressure readings will be less than 160/90 mmHg D. The client's skin on the lower legs will be intact at t
D. The client's skin on the lower legs will be intact at the next clinic visit
The nurse is caring for four clients. Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 14,000 mm3. Which intervention should the nurse implement? A. Move Client D into an isolation room 24 hours before surgery B. Increase Client A's oxygen to 4 liters a minute per cannula C. Ask the die
D. Verify that Client B has two units of packed cells available
A client is receiving a nitroglycerin infusion at 20 mcg/min. The pharmacy dispenses an IV solution of nitroglycerin 75 mg in 250 D5W. The nurse should program the infusion pump to deliver how many mL/hr?
pump rate is mL/hr (so we have to convert min to hr) Dose received = 20mcg/min= 1200mcg/hr = 1.2mg/hr to know how much mL in 1.2 mg, we use the fixed solution 75 mg in 250 mL as a reference. 75mg --- 250mL 1.2mg -- X mL X = 1.2 x 250/75 = 4 mL/hr
