HESI EXIT Part 2

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take a. Ask the older brother how he felt during the incident. b. Commend the older brother for his heroic actions c. Tell the older brother that he seems depressed d. Develop a water safety teaching plan for the family.

Ask the older brother how he felt during the incident Rationale: The brother's change in demeanor may indicate that he is experiencing post-traumatic stress that warrants further investigation, so the nurse should address the older brother's feeling.

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? a. Remind staff to follow protective environment precautions b. Gently flush the catheter lumen with sterile saline solution c. Cleanse the site and change the transparent dressing. d. Confirm the necessity for continued use of the CVC.

Confirm the necessity for continued use of the CVC Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the review of the need for continued use of the CVC. Effective hand hygiene and standard precautions should be maintained but protective environment precautions are not needed. B is not needed if continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the site to be visualized for any signs of infection but changing the dressing daily increases the risk for infection.

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? a. Maintain both lower extremities elevated on pillows. b. Remove the contracting antiembolic stocking c. Administer diuretics in the morning hours d. Restrict PO fluid intake to 500 ml per shift

Maintain both lower extremities elevated on pillows Rationale: Hepatocellular failure and hypertension contribute to third spacing of fluids. The clients complain best addresses by maintaining both extremities in an elevated position on pillows, which uses gravity to facilitate venous return and decrease peripheral edema. Stockings should be reapplied evenly to relieve constriction, but no removed.

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? a. Reposition the client in a side-lying position and support his abdomen with pillows. b. Elevate the client's feet on a pillow while keeping the head of the bed elevated. c. Raise the head of the bed to a Fowler's position and support his arms with a pillow Place the client in a shock position and monitor his vital signs at frequent intervals

Raise the head of the bed to a Fowler's position and support his arms with a pillow Rationale: The Ascites is the accumulation of fluid in the peritoneal or abdominal cavity, and this fluid pushes on the diaphragm, limiting the client's lung expansion and causing dyspnea. To relieve pressure, the head of the bed should be elevated with the arms supported for comfort.

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? a. Reposition the client with the head of the bed elevated. b. Commend the UAP for implementing the proper position c. Tell the UAP that this position is harmful to the client d. Encourage the child to ambulate in the room

Reposition the client with the head of the bed elevated. Rationale: Since children is sickle cell crisis often have shallow breathing due to acute chest syndrome, raising the head of the bed (A) will facilitate chest expansion by decreasing pressure of the diaphragm (B and C) are not be commended, nor should he UAP be corrected in front of the child. D is contraindicated because bed rest is warranted to conserve energy and promote oxygenation.

A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 83 Rationale: 1000 ml-----12hr. 1000/12 = 83.33

The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)

Answer: 12,160 Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? a. Be alert for possible cross-sensitivity to cephalosporin agents. b. Monitor peak ad trough levels whenever taking any antibiotic c. Watch daily urine output and weight gain while taking antibiotics d. Wear sun block and protective clothing to avoid exposure to sun.

Be alert for possible cross-sensitivity to cephalosporin agents Rationale: Cross-sensitivity with cephalosporin can occur in those who are allergic to penicillin, so the nurse should provide this warning.

When evaluating a client's rectal bleeding, which findings should the nurse document? a. Number of blood clots expelled with each stool. b. Unique odor noted with GI bleeding c. Evidence of internal hemorrhoids. d. Color characteristics of each stool.

Color characteristics of each stool Rationale: Color characteristics indicate if blood is coming from high in the GI tract, which would be black and tarry, or from lower area near rectum, which would be bright red blood.

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? a. Administer prescribed pain medication b. Assess surgical site c. Determine the client's vital sign. d. Apply warmed blankets

Determine the client's vital sign. Rationale: The First priority must be to obtain baseline vital signs. A and B should also be accomplished soon, but not until the initial vital signs are determined. C is a nice thing to do.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? a. Request that the CT scan be done immediately b. Review the client's history for use of illicit drugs c. Assess client's pupils for their reaction to light. d. Explain the reason for using only non-narcotics.

Explain the reason for using only non-narcotics. Rationale: The client needs to understand that any pain medication that can mask declining neurological symptoms, such as narcotics should be avoid. There is no indication that the CT scan needs to be done immediately. In the absent of additional information B is presumptive. Regular neurological assessment is necessary, but they do not address the client's pain.

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? a. Application of joint splints b. Effective body mechanisms c. Fall prevention measures. Low fat, high protein diet

Fall prevention measures Rationale: Client instruction should include measures to prevent falls, because elderly clients with decrease bone density are at high risk for bone fractures and impaired bone healing in fracture should occur.

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? a. Turns to left the side to instill the irrigating solution into the stoma b. Keeps the irrigating container less than 18 inches above the stoma c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d. Inserts irrigating catheter deeper into stoma when cramping occurs

Keeps the irrigating container less than 18 inches above the stoma Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to flow slowly with little excessive peristalsis does not cause immediate release of stool.

The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? a. Treatment for acute uremic symptoms within 24 hours b. Change to a regular diet c. Large amounts of fluid and electrolyte replacement. d. Unrestricted sodium intake

Large amounts of fluid and electrolyte replacement. Rationale: This client, whose output is significantly high will need fluids and electrolyte replacement. The diuretic stage of ARF begins when the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur until the client's BUN and electrolytes indicate a significant improvement that will allow for such changes.

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? a. Maternal blood pressure of 90/60 b. Fetal heart rate of 170 beats per minute for 15 mints c. Maternal pulse rate of 162 beats per min d. Serum potassium of 2.3 mg/dl

Maternal pulse rate of 162 beats per min Rationale: The nurse checks the maternal pulse prior to administering the beta sympathomimetic drug terbutaline and notify the healthcare provider before administration of the drug if the pulse is over 140 beats in within normal limits because peripheral vasodilation accompanies pregnancy and causes the BP decrease.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Assess body temperature b. Monitor skin elasticity c. Observe aspiration site. d. Measure urinary output

Observe aspiration site.

The nurse should teach the client to observe which precaution while taking dronedarone? a. Stay out of direct sunlight b. Avoid grapefruits and its juice c. Reduce the use of herbal supplements d. Minimize sodium intake.

b. Avoid grapefruits and its juice Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking dronedarone.

During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

4-5th intercostal space midclavicular

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) a. Change a saturated surgical dressing for a client who had an abdominal hysterectomy. b. Take postoperative vital signs for a client who has an epidural following knee arthroplasty c. Start a blood transfusion for client who had a below-the knee amputation. d. Collect a sputum specimen for a client with a fever of unknown origin e. Ambulate a client who had a femoral-popliteal bypass graft yesterday

B, D, E Rationale: Measuring vital signs, collecting specimens, and ambulating a mobile client are within the scope of practice for a UAP

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Evaluate the client for sleep disturbances b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. d. Assess the client for weakness and fatigue e. Note and report the client's food and liquid intake during meals and snacks.

B,C,E Rationale: B, C and E are functions within the scope of practice for the UAO include reporting client complaints of pain.

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? a. Allow client to choose foods from a menu b. Assign a staff member to feed the client c. Have meals brought to the client's room d. Encourage the client to eat finger foods.

Encourage the client to eat finger foods Rationale: Eyes-hand coordination is often affected with dementia. Providing a way to eat without using utensils is likely to help the client maintain independence while obtaining adequate nutrition. A: increase frustration.

The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis? a. Hematuria and proteinuria b. Azotemia and anorexia c. Fever and dysuria. d. Straining on urination and nocturia

Fever and dysuria.

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? a. Administer PRN medication b. Titrate the oxygen to keep saturation above 92% c. Hold oral intake until swallow evaluation is done. d. Elevate the head of his bed at least 45 degrees.

Hold oral intake until swallow evaluation is done. Rationale: After oral intubation, the client is at high risk for swallowing difficulties. A swallowing evaluation should be done to determine what consistency of liquids the client can tolerate without aspirating. A, B and D helps but does not have the priority.

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? a. Jaundice b. Nausea c. Fever d. Fatigue

Jaundice Rationale: Macrolides can cause hepatotoxicity, which is manifested by jaundice and should be reported to the healthcare provider before further doses of the medication are administered, B is a common side effect of macrolides. Fever and Fatigue are expected finding when a client has an infection.

A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? a. Reassess readiness for SNF transfer. b. Obtain specimens for culture analysis c. Confer with family about home care plans d. Arrange physical therapy for strengthening.

Reassess readiness for SNF transfer. Rationale: Based on the client's symptoms, reassessing the client's readiness for rehabilitation in the SNF is critical

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. Tell the client that the vaccine for HPV is not indicated b. Inform the client that warts do not return following cryotherapy c. Recommended the use of latex condoms to prevent HPV transmission. d. Reinforce the importance of annual papanicolaou (Pap) smears.

Reinforce the importance of annual papanicolaou (Pap) smears.

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? a. Impaired gas exchange related to narrowing of small airways b. Death anxiety related to concern about prognosis c. Anxiety related to fear of suffocation. d. Ineffective coping related to knowledge deficit about COPD

Anxiety related to fear of suffocation. Rationale: A common problem with clients who have COPD is anxiety. These clients cannot aerate their bodies, so they feel a perpetual state of suffocation which is worse during exacerbation of their COPD. A classic descriptor of COPD id impaired gas exchange (A). Because the client has typically adapted to impaired gas exchange over a long period of time, and the nurse has assessed a change in her appearance (A) is not the primary diagnosis at this time. Based on the data presented (B and D) are not the best diagnoses in this situation.

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a. Immediately apply a pressure dressing b. Document the ongoing wound healing. c. Irrigate the wound with sterile saline d. Obtain a capillary INR, measurement

Document the ongoing wound healing Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing

When implementing a disaster intervention plan, which intervention should the nurse implement first? a. Initiate the discharge of stable clients from hospital units b. Identify a command center where activities are coordinated c. Assess community safety needs impacted by the disaster d. Instruct all essential off-duty personnel to report to the facility.

Identify a command center where activities are coordinated

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone (Narcan) per PNR protocol b. Initiate seizure precautions c. Obtain a serum drug screen d. Instruct the family about withdrawal symptoms.

Initiate seizure precaution Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client

The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? a. Continue to administer the medication via the IV route b. Give half the prescribed oral dose until the provider is consulted. c. Administer the medication via the oral route as prescribed. d. Consult with the pharmacist regarding the error in prescription.

Administer the medication via the oral route as prescribe Rationale: Bioavailability refers to the percentage of drug available in the systemic circulation. An increase in dosage is necessary to provide a therapeutic effect for oral medications with significantly reduce bioavailability.

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a. Spironolactone b. Potassium c. Ampicillin sodium parental d. Digoxin.

Digoxin. Rationale: This infant is demonstrating early signs of heart failure due to an increase right ventricular workload caused by a left to right shunt through the VSD, son an inotropic, such as digoxin should be administered first to improve the efficiency of myocardial contractility. Next a high ceiling diuretic to reduce fluid volume and workload of the heart. If hypokalemia occurs as result of potassium-wasting diuretic, should be given to reduce the risk of digoxin toxicity.

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? a. Prior to exercising b. Immediately after meals c. Before going to bed d. During acute illness.

During acute illness Rationale: Client should be instructed to always check their blood glucose whenever they feel sick or nauseated. There is great variability in recommendations for frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test as often as four times a day or as little as once each week, depending on the consistency of their diet and exercise.

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? a. Increase the rate of the continuous bladder irrigation b. Manually irrigate the catheter with sterile normal saline c. Clam the catheter above the drainage. d. Ensure that no dependent loops are present in the tubing.

Ensure that no dependent loops are present in the tubing. Rationale: The nurse should ensure that the tubing is not kinked, and adequate flow is maintained to prevent bladder distention. Clear pale pink urine is desirable following TURP and indicates the absence of clots or excessive hemorrhage. A is implemented if the flow is dark red to prevent clot formation, and B if clots is present, to prevent obstruction. C is not a useful action in this situation and causes bladder distention while the bladder irrigation is still infusing

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 blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Instruct the mother to change the child's diaper more often. b. Encourage the mother to apply lotion with each diaper charge c. Tell the mother to cleanse with soap and water at each diaper change d. Ask the mother to decrease the infant's intake of fruits for 24 hours.

Instruct the mother to change the child's diaper more often. Rationale: Changing the diaper more often helps to decrease the amount of time the skin comes in contact with wet soiled diapers and helps heal the irritation.

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? a. Multiple organ dysfunction syndrome (MODS) b. Disseminated intravascular coagulation (DIC) c. Chronic obstructive disease. d. Acquired immunodeficiency syndrome (AIDS)

Multiple organ dysfunction syndrome (MODS) Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? a. An apical pulse of 120 beats per minute b. Extreme agitation with staff and family c. Client report being anxious d. No wheezing upon auscultation of the chest.

No wheezing upon auscultation of the chest. Rationale: No wheezing an auscultation indicates that the client is not exchanging air and is highly compromised immediate action is indicated A, B, and C are sign of hypoxia but no as critical as D

The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? a. Perform bilateral chest auscultation. b. Resume compression for 2 minutes c. Administer a dose of epinephrine d. Program the monitor for cardioversion.

Perform bilateral chest auscultation Rationale: With the ROSC and no respiratory effort intubation is indicated, and as soon as the procedure is completed, the position of the intubation tube should be assessed for proper placement. Auscultating for breath sounds is the first and quickest method to use to check for proper placement of the intubation tube and can be confirmed by a chest x ray.

A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? a. Provide the man and his mother with a copy of the Patient's Bill of Rights b. Explain that the hospital adheres to all national accreditation standards c. Advise the man to discuss his concerns with his mother's healthcare provider d. Determine if he would like to review the hospital's manual of approved polices.

Provide the man and his mother with a copy of the Patient's Bill of Rights Rationale: The Patient's Bill of Rights is a universally used tool that describes the rights of clients in all healthcare settings and is essential in ensuring that clients care is provided in an ethical manner. (B) may be perceived as defensive and does not provide the man with specific information about expected standards of care. Concern about the quality of care should be addressed by the hospital staff rather than C. All the healthcare agencies are required to maintain policy and procedure manual for the purpose of standardizing delivery of care within the agencies, but the policy manual is unlikely to provide useful information for clients or family members.

To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement? a. Remind the client to keep his appointments to have his cholesterol level checked. b. Teach the client to weigh himself weekly and keep a log of the measurements c. Assess the elasticity of the client's skin at the next scheduled clinic appointment Encourage the client to keep a diary of his food intake until his next visit to the clinic.

Remind the client to keep his appointments to have his cholesterol level checked. Rationale: Ezetimibe lowers cholesterol and LDL levels, so it is important for the nurse to remind the clients to keep his appointments at the laboratory. D may influence his serum levels, but A provide better indicator.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? a. Arrange to transport the client to the hospital b. Instruct the client to keep a food journal, including portions size. c. Review the client's use of over the counter (OTC) medications. d. Reinforce the importance of keeping the feet elevated.

Review the client's use of over the counter (OTC) medications Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.

A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? a. Infection b. Increase intracranial pressure c. Shock d. Head Injury.

Shock Rationale: This client has symptoms of shock. Two signs of shock are decreased BP, and increased (often weak and thread) pulse, this client has both symptoms. A temperature of 98.6 F is average normal. An increase of temperature. D is correct but is vague and is not specifically related to the assessment date describe, so it is not the best answer.

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? a. Go to the emergency department and complete assigned tasks b. Shut all doors to client rooms on the unit in case a fire erupts c. Offer to assist the ICY with ventilator-dependent clients d. Tell all their assigned clients to stay in their rooms.

Tell all their assigned clients to stay in their rooms. Rationale: A power failure leaves a unit in total darkness except for battery operated lighting. The top priority should be ensuring client safety by having clients stay in their rooms, and UAP can implement this. A is a higher priority in external disaster. B would further compound the lighting problems and is not indicated unless file or smoke is visible. C contraindicated until client safety is ensured on the assigned unit.

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? a. The impending signs of death should be documented b. The client's need for pain medication should be determined. c. The nurse manager should be updated on the client's status d. The client's status should be conveyed to the chaplain

The client's need for pain medication should be determined. Rationale: Palliative care includes nursing interventions that provide relief for the dying client's suffering by assessment and treatment of pain and other problems that are physical, psychosocial and spiritual. After the family is notified for the client's impending death, the client's need for pain medication should be assessed.

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? a. Case management and screening for clients with HIV. b. Regional relocation center for earthquake victims c. Vitamin supplements for high-risk pregnant women. d. Lead screening for children in low-income housing.

Vitamin supplements for high-risk pregnant women Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.

The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? a. Yogurt and/or buttermilk. b. Avocados and cheese c. Green leafy vegetables d. Fresh fruits

Yogurt and/or buttermilk. Rationale: A should be encouraging to help maintain intestinal flora and decrease diarrhea, which is a common side effect of antibiotic therapy, particularly cephradine. B and C are contraindicated because they can increase bowel elimination, thereby exacerbating diarrhea as a side effect.

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. Explain the need for using lead shields for 2 to 3 weeks after the treatment b. Describe the signs of goiter because this is a common side effect of radioactive iodine c. Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately d. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider Rationale: A single dose of tasteless, colorless radioactive iodine is administered by mouth and the client is observed for signs of thyroid storm. 85% of clients are cure by one dose. The dose of radioactivity is not enough to warrant (A). B is indicated for a client receiving iodine or iodine compound medications in the treatment of hyperthyroidism. It takes 3 to 4 weeks for sings of hyperthyroidism to subside.

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? a. Reduced level of pain b. Full volume of pedal pulses c. Granulating tissue in foot ulcer d. Improved visual acuity.

Reduced level of pain Rationale: Pregabalin is prescribed to decrease the pain associated with diabetic peripheral neuropathy. A, C and D are not expected outcomes of this medication's effectiveness.

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? a. Inquire about an electric bed for the client's home use b. Submit a referral for an evaluation by a physical therapist. c. Explain the usual progression of osteoarthritis and HF d. Request social services to review the client's resources.

Submit a referral for an evaluation by a physical therapist. Rationale: To promote independence and safety in the home, the client's decline in physical mobility and strength should be evaluated first by the physical therapist who is a member if the home health treatment team.

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? a. Decrease urinary output b. Low blood glucose level c. Profound weight gain d. Ventricular arrhythmias.

Ventricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.

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." What is the priority nursing diagnosis for this client? a. Knowledge deficit b. Anxiety c. Anticipatory grieving d. Pain (acute)

anxiety Rationale: The client is demonstrating only anxiety. There is no indication that the client is presenting signs of A, C or D

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? a. A client who is leaking clear fluid b. A mother who just delivered a 9 pounds boy c. A mother with an infected episiotomy. d. A client at 28- weeks' gestation in pre-term labor.

A mother with an infected episiotomy Rationale: An infected episiotomy is essentially an infected surgical incision, and an experienced emergency room nurse is likely be able to care for such a client. A, B and D required specialized maternity nursing care.

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a. An adult female who has been depress for the past several months and denies suicidal ideations. b. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. c. A young male with schizophrenia who said voices is telling him to kill his psychiatric. d. An elderly male who tell the staff and other client that he is superman and he can fly.

A young male with schizophrenia who said voices is telling him to kill his psychiatric. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk

Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply) a. Notify the food services department of the allergy. b. Enter the allergy information in the client's record. c. Document the statement in the nurse's notes d. Note the allergy on the diet intake flow sheet e. Add egg allergy to the client's allergy arm band.

A,B,E Rationale: The dietary department needs to screen menu selections for foods that are prepared with eggs. The client's chart should be clearly marked but the statement does not need to be documented in the nurse's note or included in the intake record. Allergy identification on the arm band is a universal location where allergies are noted while client is hospitalized.

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take a. Remind the client that a rescue inhaler might save his life b. Leave the client alone so that he can grieve his illness c. Ask the client what he is thinking about at his time. d. Gently touch the client then continue with teaching.

Ask the client what he is thinking about at his time.

The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? a. Administer a prescribed analgesia for pain. b. Increase IV infusion rate for rehydration c. Provide additional blankets to increase body temperature d. Feed one ounce of formula to correct hypoglycemia.

Administer a prescribed analgesia for pain Rationale: Since this child is exhibiting signs of pain, the prescribed analgesic should be administered. The behavioral signs of pain in an infant are facial grimaces, restlessness or agitation, and guarding the area of pain, in this case by pulling the knees to the chest

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

Assess the surroundings for noise and distractions.

Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? a. Bulimia nervosa b. Obsessive compulsive disorder c. Aural migraine headaches. d. Erectile dysfunction.

Aural migraine headaches

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) a. Apply oxygen via nasal cannula b. Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d. Monitor continuous oxygen saturation. e. Give PRN dose of regular insulin

B,C,D Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac ischemia. Oxygen saturation monitors for adequate oxygenation.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) a. Report feeling sad b. Interacts with a flat affect. c. Avoids eye contact. d. Has a disheveled appearance. e. Express suicidal thoughts.

B,C,D Rationale: Observed finding are objective and include the client's appearance, such as flat affect, lack of eyes contact, and disheveled appearance. A and E are subject only the client can express verbally.

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? a. Pupillary response b. Oxygen saturation c. Peripheral pulses d. Bowel patterns

Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.

A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a. Explain that it may take several weeks for the medication to be effective b. Confirm the desired effect of the medication has been achieved. c. Notify the health care provider than a change may be needed. d. Evaluate when and how the medication is being administered to the client.

Confirm the desired effect of the medication has been achieved. Rationale: Trazodone oR Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Convey to the client that birth is imminent. b. Prepare the client for spinal anesthesia c. Empty the client's bladder using a straight catheter d. Prepare the coach to accompany the client to delivery

Convey to the client that birth is imminent Rationale: The second stage of labor occurs when the client is fully dilated, and the fetus is crowning, so completing preparations and informing the client that birth is imminent, so A is the first action. B is usually administered immediately prior to delivery. C is usually performed prior of after delivery D is not the priority action at this time.

A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness but can bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? a. A quad cane b. Crutches with 2-point gait. c. Crutches with 3-point gait. d. Crutches with 4-point gait.

Crutches with 4-point gait. Rationale: Crutches using a 4-point gait provide stability and require weight bearing on both legs, which this client should be able to provide. A is used when is partial or complete leg paralysis or some hemiplegia. B requires at least partial weight bearing on each foot but does not provide the stability of D. C is useful when the client must bear all the weight on one foot and this is not the problem experienced by this client.

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? a. Assess the client's dressing for bleeding b. Determine client's pulse, blood pressure, and respirations c. Administer a PRN dose of IV Morphine d. Check the client's orientation to time and place.

Determine client's pulse, blood pressure, and respirations Rationale: Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum level. Before administering a central nervous system depressing analgesia, the client's vital signs should be assessed to determine the client's current level of CNS depression. In the immediate postoperative period, during administration to PACU (A, C and D) should be evaluated.

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? a. Administer oxygen by face mask at 6L/mint b. Transport the client for a cesarean delivery c. Elevate the presenting part off the cord. d. Place the client to a knee-chest position.

Elevate the presenting part off the cord Rationale: The nurse should immediately elevate the presenting part off the cord because when the cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and reduces perfusion to the fetus. A can be delayed until pressure is removed from the cord. B and D are important but do not have priority.

After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? a. Evaluate her response to narcotic analgesia b. Asses the skin under the traction moleskin c. Place a pillow under the involved lower left leg d. Ensure proper alignment of the leg in traction.

Ensure proper alignment of the leg in traction. Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the application of Buck's skin traction proper alignment ensures the transaction S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize muscle spasms and surrounding tissue injury related to the fracture. A should be implement but improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but the greatest risk is improper alignment of the traction.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? a. Assess the client's ability to communicate with the other staff members b. Arrange a meeting with the family to discuss the client's situation c. Administer the client's antidepressant medication as prescribed. d. Establish a structured routine for the client to follow.

Establish a structured routine for the client to follow

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? a. High pitched or fine crackles. b. Rhonchi c. High pitched wheeze d. Stridor

High pitched or fine crackles.

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? a. How many departments can use this equipment? b. Will the equipment require annual repair? c. Is the cost of the equipment reasonable? d. Can the equipment be updated each year?

How many departments can use this equipment?

An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? a. Obtain a medical history b. Record pain evaluation c. Assess blood glucose d. Identify pills in the bag.

Identify pills in the bag Rationale: Comorbidity places the client at risk for multiple drug interaction and side effects, and the client's gout therapy may need to be modified. A review of the medication in the bag (D) is the most important way to analyze the client's polypharmacy. And therapeutic response for comorbidities. Obtain a medical history (A), pain evaluation (B), and assessing blood glucose level (C) should be done in a timely manner.

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care? a. Allow the family to visit whenever they wish b. Medicate as needed for pain and anxiety. c. Allow client to participate in care provided d. Maintain quiet, low lighting environment

Medicate as needed for pain and anxiety. Rationale: Neuropathic pain in MS is related to damage to peripheral nerves or structures in the CNS can be sudden, intense or lingering, and shooting, electric shock-like sensations that results for paroxysmal firing of injured nerves. Once the client enters palliative care, the primary goal is comfort.

Which intervention should the nurse include in the plan of care for a child with tetanus? a. Open window shades to provide natural light b. Reposition side to side every hour. c. Minimize the number of stimuli in the room. d. Encourage coughing and deep breathing

Minimize the amount of stimuli in the room Rationale: Tetanus is an acute, preventable, and often fatal disease caused by an exotoxin produces by the anaerobic spore forming gram positive bacillus clostridium tetani, which affect neuromuscular junction and causes painful muscular rigidity. In planning caring for a child with tetanus, any environmental stimulation should be minimized.

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? a. Dark yellow-brown colored urine b. Nonspecific muscle and joint pain c. New onset of purple skin lesions. d. Weakness when getting up to walk.

New onset of purple skin lesions. Rationale: During the convalescence period of hepatitis A, the client major complain is malaise and fatigability. Purple skin lesions may be indicative of the liver's impaired ability to produce clothing elements and should be reported to the healthcare provider (C) for further analysis. Urine may become dark when excess bilirubin is excreted by the kidney, which is expected even when the client is not jaundice during the acute phase hepatitis (A). Myalgia and arthralgia (B) are intermittent complains with ongoing malaise, fatigue and weakness (D) during convalescence of hepatitis A.

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? a. Family history is more important than calcium intake in determining the occurrence of osteoporosis b. Calcium should be taken once a day, preferable at the same time of day c. Smoking cessation is more important than calcium intake in preventing osteoporosis. d. Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

Postmenopausal women need an intake of at least 1,500 mg of calcium daily

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? a. Provide daily care of tong insertion sites using saline and antibiotic ointment b. Modify the client's diet to prevent constipation c. Encourage active range of motion q2 to 4 hours. d. Instruct the client to report any symptoms of upper extremity paresthesia.

Provide daily care of tong insertion sites using saline and antibiotic ointment Rationale: Crutchfield tongs, a skeletal traction device for cervical immobilization, requires daily care of the surgically inserted tongs to minimize the risk of infection of the insertion site and cranial bone. Daily cleansing with normal saline solution and antibiotic applications minimizes bacterial colonization and helps to prevent infection.

During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? a. Keep a daily weight record b. Obtain weight at the same time every day c. Limit intake of dietary salt. d. Report weight gain of 2 pounds (0.9kg) in 24 hours

Report weight gain of 2 pounds (0.9kg) in 24 hours

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? a. Hydrocodone/Acetaminophen (Lortab) b. Simethicone (Mylicon) c. Promethazine (Phenergan) d. Nalbupine (Nubain)

Simethicone (Mylicon) Rationale: Simethicone is an antiflatulent that is used to increase the client's ability to expel flatus (B), which relieves the clients discomfort (A and D) are analgesic used to manage pain but do not alleviate the causes of the pain (C) is an antiemetic used to treat nauseas and does not relive excess flatus.

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? a. Establish the second IV site b. Asses the IV for blood return c. Stop the normal saline infusion. d. Discontinue the 24-gauge IV

Stop the normal saline infusion. Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge needle is preferable.

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. Supervise a newly hired graduate nurse during an admission assessment. b. Transport a client who is receiving IV fluids to the radiology department. c. Administer PRN oral analgesics to a client with a history of chronic pain d. Complete ongoing focused assessments of a client with wrist restrain.

Supervise a newly hired graduate nurse during an admission assessment. Rationale: The admission assessment of a client should be completed by a professional nurse. A graduate nurse should be supervised by the RN to ensure that the graduate nurse understand and performs within the expected scope of practice. The UAP transport a stable client. (B) The PN can complete C and D

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement a. The client should be kept in the recovery room b. Assess the client's respiratory status immediately c. Notify the client's surgeon immediately d. Transfer the client to the surgical floor.

Transfer the client to the surgical floor. Rationale: A score of 7 to 8 is normal and indicates that the client can be discharge from PACU. The PACU assessment form includes 5 mints areas of assessment: muscle activity, circulation, consciousness level, and oxygen saturation. Each of these 5 areas receives two points for normal. A, B, C are interventions that are not indicated for a score of 8.

A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) a. Recommend a 24-hour caregiver on discharge to the long-term facility. b. Notify the healthcare provider of the client's change in mental status. c. Include q2 hour's reorientation in the client's plan of care. d. Request immediate evaluation by Rapid Response Team e. Apply soft wrist restraints so that the operative site is protected.

-Notify the healthcare provider of the client's change in mental status. -Include q2 hour's reorientation in the client's plan of care. Rationale: The client's condition reflects mental changes that could be related to post procedure stress, sundowner's syndrome, or cerebral complications, the nurses should inform the healthcare provider of the client's change in mental status for the client's safety, q2 hour orientation evaluations and reorientation should be included in the plan of care.

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? a. Keep an antidote available in the event of hemorrhage b. Continue obtaining scheduled laboratory bleeding test c. Eliminate spinach and other green vegetable in the diet. d. Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID). Rationale: Dabigatran, a directed reversible thrombin inhibitor, is prescribe to reduce the risk of stroke in client with atrial fibrillation. The risk of bleeding and GI event can be significant and the concomitant use of NSAID and other anticoagulants should be avoided.

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? a. Increased Glasgow coma scale score. b. Nuchal rigidity and papilledema. c. Confusion and papilledema d. Periorbital ecchymosis.

Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? a. Provide reassurance to the client that these feeling are normal after delivery b. Discuss delaying the client's discharge from the hospital for another 24 hrs. c. Determine if she can ask for support from family, friend, or the baby's father. d. Explain the differences between postpartum blues and postpartum depression.

Determine if she can ask for support from family, friend, or the baby's father Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety about transitioning to parenthood. The nurse should ask the client who is available to support her.

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a. Perform the drainage immediately after meals b. Instruct the client to breath shallow and fast c. Obtain arterial blood gases (ABG's) prior to procedure d. Explain that the client may be placed in five positions

Explain that the client may be placed in five positions Rationale: Frequently, the client is placed in five positions (head down, prone, right and left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be performed before meals to prevent nausea, vomiting and aspiration(A). The client should breath slow and exhale through pursed lips to help keep airway open so that secretions can be drained while assuming the various positions. C is not required

A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? a. Elevate the client's upper extremity before counting the pulse rate b. Auscultate directly below the IV site with a Doppler stethoscope c. Turn off the intravenous fluids that are infusing while counting the pulse. d. Palpate at the radial pulse site with the pads of two or three fingers.

Palpate at the radial pulse site with the pads of two or three fingers Rationale: The radial pulse is easily accessible and palpable unless an IV is placed at the client wrist. A may make the pulse more difficult to palpate B places the stethoscope over a vein rather than an artery and is unlikely to provide an accurate pulse rate. The pulse rate can be accurately counted without implementing.

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? a. Assign a sitter for constant observation b. Screen future visitors for contraband c. Document suicide monitoring frequently d. Remove cigarettes for the client's room.

Remove cigarettes for the client's room Rationale: Safety is the priority, and any items that might cause self-harm, such as cigarettes should be removed immediately to create a safe environment.

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a. Elevate lower extremities while out of bed b. Teach family proper range of motion exercises. c. Maintain proper body alignment when in bed d. Encourage diaphragmatic breathing exercises.

Teach family proper range of motion exercises. Rationale: Performing proper range of motion exercised helps maintain maximum mobility by preventing excessive muscle atrophy and joint contractures. Elevating lower extremities decreases the amount of peripheral edema. Proper body alignment reduces strain on joints, tendons, ligaments and muscles and minimizes contractures in an abnormal position. Diaphragmatic breathing exercises may decrease the risk of pulmonary complications.

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply a. Written at a twelfth-grade reading level b. Contains a list with definitions of unfamiliar terms c. Uses common words with few Syllables d. Printed using a 12-point type font e. Uses pictures to help illustrate complex ideas

b. Contains a list with definitions of unfamiliar terms c. Uses common words with few Syllables e. Uses pictures to help illustrate complex ideas Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner's attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) a. Take an additional dose for signs of hyperglycemia b. Recognize signs and symptoms of hypoglycemia. c. Report persist polyuria to the healthcare provider. d. Use sliding scale insulin for finger stick glucose elevation. e. Take Glucophage with the morning and evening meal.

b. Recognize signs and symptoms of hypoglycemia. c. Report persist polyuria to the healthcare provider. e. Take Glucophage with the morning and evening meal. Rationale: Glucophage, an antidiabetic agent, acts by inhibiting hepatic glucose production and increases peripheral tissue sensitivity to insulin. The client and family should be taught to recognize signs and symptoms of hypoglycemia. If the dose of Glucophage is inadequate, signs of hypoglycemia, such as polydipsia and polyuria, should be reported to the healthcare provider. Glucophage should be taken with meals to reduce GI upset and increase absorption (E).

A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) a. All family must agree about the need for hospice care. b. Hospice services are covered under Medicare Part B. c. A client must be willing to accept palliative care, not curative care. d. The healthcare provider must project that the client has 6 months or less to live. e. All medications except pain treatment will be stopped during hospice care.

c. A client must be willing to accept palliative care, not curative care. d. The healthcare provider must project that the client has 6 months or less to live. Rationale: The eligibility criteria for Medicare coverage requires that the client is willing to accept palliative care, not curative care (C). The healthcare provider should provide an expected prognosis of 6 months or less to live (D) which can be extended by the healthcare provider. It is not necessary for all family members to agree with the need for hospice.

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? a. Place the records in a separate trash bag and tie the bag securely closed b. Point out the record to a worker in the medical records department c. Contact the medical records department supervisor. d. Immediately remove and shred the records.

Contact the medical records department supervisor Rationale: Notify the department supervisor of a Privacy officer alerts the appropriate people to a possible internal procedural problem and provides an opportunity of education a prevention of recurrence.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a. Monitor abdominal girth. b. Increase oral fluid intake to 1500 ml daily. c. Report serum albumin and globulin levels. d. Provide diet low in phosphorous. e. Note signs of swelling and edema.

A,C,E Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Place personal religious artifacts on the body. b. Confirm the client's wishes for tissue donation c. Observe consent for autopsy signature by family. d. Attach identifying name tags to the body. e. Follow cultural beliefs in preparing the body.

A,D,E Rationale: With adequate supervision and instruction (A, D and E) can be delegate to the UAP.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? a. Decrease morbidity in the elderly population b. Decrease prevalence of glaucoma in the population. c. Increase mortality in the elderly population d. Increased incidence of glaucoma in the population.

Decrease prevalence of glaucoma in the population.

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? a. Slow onset of facial drooping associated with headache b. Inability to close the affected eye, raise brow, or smile c. A flat nasolabial fold on the right resulting in facial asymmetry. d. Drooling is present on right side of the mouth, but not on the left.

Inability to close the affected eye, raise brow, or smile Rationale: Because the motor function controlling eye closure, brow movement and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell's palsy has occurred.