HESI EXIT Practice Qs (3)

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client's multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom) 1. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provider

1. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provider

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36 (1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18, back = 18, head = 9, pubic = 1 = 100%) Rationale: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equal 36% TBSA, other options are incorrect.

A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? a. Schedule a colonoscopy within the next month. b. Encourage screening for a peptic ulcer. c. Screen all family member for hepatitis A d. Eat small, frequent meals thought the day.

b. Encourage screening for a peptic ulcer. Rationale: Helicobacter pylori is a gram- negative organism than can colonize in the stomach and is associated with peptic ulcers formation.

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) 1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia.

Rationale: The American Heart Association guidelines recommend that the basic life support (BLS) algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate below 60 beats/minutes*** and exhibit signs of poor perfusion. This child is manifesting poor perfusion as evidenced by a low blood pressure and poor oxygenation, so chest compression and assisted manual ventilation should be provided first, followed by administration of drug therapy for persistent bradycardia. Preparation with pad placement for transthoracic pacing should be implemented next, followed by treatment indicated for the underlying cause of the child's bradycardia.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? a. Allopurinol (Zyloprim) b. Aspirin, low dose c. Furosemide (lasix) d. Enalapril (vasote)

a. Allopurinol (Zyloprim) Rationale: The effectiveness of allopurinol is diminished when aluminum hydroxide is used leading to an increased chance for gout flare ups. The healthcare provider should be alerted about the allopurinol interaction so any changes in medication regimen may be considered.

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? a. Antibiotics b. Anticoagulants c. Antihypertensive d. Anticholinergics

a. Antibiotics Rationale: Antibiotic use may be altering the normal flora in the GI tract, resulting in the onset of diarrhea, and several classes of antibiotics result in the overgrowth of Clostridium difficile, resulting in severe diarrhea.

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Brain damage with CP is not progressive but does have a variable course b. CP is one of the most common permanent physical disability in children c. Severe motor dysfunction determines the extent of successful habilitation d. Continued development of the brain lesion determines the child's outcome.

a. Brain damage with CP is not progressive but does have a variable course Rationale: CP is nonprogressive cerebral insult due to asphyxia, brain malformation, or toxicity, such as kernicterus. It is characterized by impair movement, posturing and may include perceptual, expressive and intellectual deficits, but the motor disabilities can vary as the child grows (A) and as interventions are implemented to prevent disuse complications.

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? a. Cardiac rhythm and heart rate. b. Daily intake of foods rich in potassium. c. Hourly urinary output d. Thirst and skin turgor.

a. Cardiac rhythm and heart rate. Rationale: Hypokalemia is a side effect of potassium-wasting diuretics, such as Lasix, and manifest as muscle weakness, hypotension, tachycardia, and cardiac dysrhythmias, so changes in the child's heart rate and cardiac rhythm should be reported to the healthcare provider. Although BCD can affect the serum potassium level, the most important finding is the effect of hypokalemia on the child's cardiac rate and rhythm.

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? a. Delirium b. Depression c. Dementia d. Psychotic episode

a. Delirium Rationale: The client's clinical findings-polypharmia, urinary tract infection, and possible fluid imbalance are the most common causes of cognition and memory impairment, which is characteristic of delirium.

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a. Ensure that the knot can be quickly released. b. Tie the knot with a double turn or square knot. c. Move the ties so the restraints are secured to the side rails. d. Ensure that the restraints are snug against the client's wrist.

a. Ensure that the knot can be quickly released.

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? a. Epinephrine Injection, USP IV b. Diphenhydramine IV c. Albuterol (Ventolin) inhaler d. Methylprednisolone IV

a. Epinephrine Injection, USP IV Rationale: Epinephrine should be administered immediately to open the airway and raise the blood pressure by vasoconstricting the blood vessels. All other medications should be administered after the epinephrine is given.

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

a. Evaluate closet proximal pulse. Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? a. Fingerstick glucose assessment q6h with meals b. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose c. Review with the client proper foot care and prevention of injury d. Do not contaminate the insulin aspart so that it is available for iv use e. Coordinate carbohydrate controlled meals at consistent times and intervals f. Teach subcutaneous injection technique, site rotation and insulin management

a. Fingerstick glucose assessment q6h with meals c. Review with the client proper foot care and prevention of injury e. Coordinate carbohydrate controlled meals at consistent times and intervals f. Teach subcutaneous injection technique, site rotation and insulin management

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90% b. Administer diuretics via secondary infusion in the morning only c. Evaluate heart rate for effectiveness of cardio tonic medications d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples e. Ensure uninterrupted and frequent rest periods between procedures.

a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90% c. Evaluate heart rate for effectiveness of cardio tonic medications d. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples e. Ensure uninterrupted and frequent rest periods between procedures. Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT?

a. Her mother and sister have a history of breast cancer

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? a. Lethargy b. Decorticate posturing c. Fixed dilated pupil d. Clear drainage from the ear.

a. Lethargy Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP.

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) a. Move obstacle away from client b. Monitor physical movements c. Insert an oral padded tongue blade d. Observe for a patent airway e. Record the duration of the seizure f. Restrain extremity to avoid seizures

a. Move obstacle away from client b. Monitor physical movements d. Observe for a patent airway e. Record the duration of the seizure Rationale: Moving this away from the client helps prevent to unnecessary injurie. Observing for the pt airway alert the nurse to provide airway assistance as soon as the seizure stop D and E provide the healthcare provider with an accurate description of the seizure activities. C inserting something on the mouth can obstruct may cause further airway obstruction and is contraindicated even if the client is biting the tongue. F may cause further injury and is contraindicated.

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? Select all that Apply a. Poor feeding and vomiting b. Leakage of CSF from the incisional site c. Hyperactive bowel sound d. Abdominal distentione. WBC count of 10000/mm3

a. Poor feeding and vomiting b. Leakage of CSF from the incisional site d. Abdominal distentione. WBC count of 10000/mm3 Rationale: A, B and D are sign of postoperative complications. Shunt malfunction is most often caused by mechanical obstruction, which can result from ventricular exudate, distal end thrombosis or displacement, and/or infection. CNS infection is usually manifested by poor feeding, vomiting, elevated temperature, decreased responsiveness and seizure activity. Incisional leakage should be tested for glucose, an indication of CSF, which place the infant at risk for infection. Abdominal distention is a manifestation of peritonitis or a postoperative ileus from distal catheter placement. C is not a result of a shunt obstruction and E is a normal finding for one-week-old neonate.

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. a. Prepare medication reversal agent b. Check oxygen saturation level c. Apply oxygen via nasal cannula d. Initiate bag- valve mask ventilation. e. Begin cardiopulmonary resuscitation

a. Prepare medication reversal agent b. Check oxygen saturation level c. Apply oxygen via nasal cannula Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.

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

a. Prepare the skin for procedure.

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? a. Protect joint function b. Improve circulation c. Control tremors d. Increase weight bearing.

a. Protect joint function Rationale: Primary goal in the management of rheumatoid arthritis is to protect and maintain joint function.

A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? a. Provide an opportunity for him to clarify his values related to the decision b. Encourage him to share memories about his life with his wife and family c. Advise him to seek several opinions before making decision d. Offer to contact the hospital chaplain or social worker to offer support.

a. Provide an opportunity for him to clarify his values related to the decision

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? a. Provide supplemental oxygen b. Auscultate bilateral lung fields c. Administer a nebulizer treatment d. Reinforce occlusive CT dressing e. Give PRN dose of pain medication

a. Provide supplemental oxygen b. Auscultate bilateral lung fields d. Reinforce occlusive CT dressing Rationale: The air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths per minute, and blood pressure 90/60. Which intervention should the nurse implement first? a. Raise the client's legs and feet b. Administer 250 ml saline bolus c. Decrease blood flow from dialyzer d. Stop the hemodialysis procedure.

a. Raise the client's legs and feet Rationale: To raise the client's blood pressure is the most immediate and easiest intervention for the nurse to implement. B and C should be done asap to add volume to the vascular space by ceasing to pull fluid from the client. If the blood pressure does not increase, then the procedure may be needing to be stopped.

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a. Recommend weigh bearing physical activity b. Reduce intake of foods high in vitamin D c. Decrease intake of foods high in fat d. Minimize heavy lifting and bending.

a. Recommend weigh bearing physical activity Rationale: Active weight-bearing exercise is a primary preventive measure for osteoporosis. C is indicated for client with cardiac and liver diseases. D may decrease injuries but is not directed toward slowing bone loss and promoting bone formation.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: a. Remove sequential compression devices. b. Apply PRN oxygen per nasal cannula. c. Administer a PRN dose of an antipyretic. d. Reinforce the surgical wound dressing.

a. Remove sequential compression devices. Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.

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

a. Remove the heating pads and place a soft blanket over the client's leg and feet.

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

a. Research indicates that mirror therapy is effective in reducing phantom limb pain Rationale: pain relief associated with mirror therapy may be due to the activation of neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain.

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? a. Send stool sample to the lab for a guaiac test b. Observe stool for a day-colored appearance. c. Obtain specimen for culture and sensitivity analysis d. Asses for fatty yellow streaks in the client's stool.

a. Send stool sample to the lab for a guaiac test Rationale: Thrombolytic drugs increase the tendency for bleeding. So, guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? a. Sudden dysphagia b. Blurred visual field c. Gradual weakness d. Profuse diarrhea

a. Sudden dysphagia Rationale: Osmotic demyelination, also known as pontine myelinolysis, results in destruction of the myelin sheath that covers nerve cell in the brainstem. This condition can be caused by rapid correction of hyponatremia and is often seen in those with syndrome of inappropriate antidiuretic hormone, Symptoms of pontine myelinolysis are sudden and can include dysphagia, para or quadriparesis and dysarthria. Due to the risk of aspiration the healthcare provider should be notified of the client's sudden onset of difficulty swallowing dysphagia (A). Diplopia not blurred vision (B) may be experienced. Weakness occurs suddenly, rather than gradually (C). Constipation, not diarrhea (D), is common due to decreased motility.

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? a. Supplemental feedings with formula b. Maternal diet high in protein c. Maternal intake of increased oral fluid d. Breastfeeding every 2 or 3 hours.

a. Supplemental feedings with formula Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant's time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply.

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan? a. Weigh every morning b. Eat a high protein diet c. Perform range of motion exercises d. Limit fluid intake to 1,500 ml daily

a. Weigh every morning should be instructed to weight each morning before breakfast with approximately the same clothing. A is not specifically to HF and fluid retention.

A client is scheduled to receive an IV dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? a. Ask a chemotherapy-certified nurse to administer the Zofran b. Administer the Zofran after flushing the saline lock with saline c. Hold the scheduled dose of Zofran until the client awakens d. Awaken the client to assess the need for administration of the Zofran.

b. Administer the Zofran after flushing the saline lock with saline Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? a. Provide a bedtime snack to be eaten before taking the medication. b. Administer the medication as prescribed with a glass of water c. Contact the prescriber about changing the time of administration. d. Check the client's blood pressure prior to administering the med.

b. Administer the medication as prescribed with a glass of water Rationale: Simvastatin (Zocor), a HMG co-enzyme A reductase inhibitor, interferes with cholesterol synthesis pathway. Zocor can be taken at any time.

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

b. Ask the new person to move belonging to accommodate others

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? a. Explain the temporary burning of the IV site may occur. b. Assess IV site frequently for signs of extravasation c. Apply a topical anesthetic of the infusion site for burning d. Monitor capillary refill distal to the infusion site.

b. Assess IV site frequently for signs of extravasation Rationale: Infiltration of a vesicant can cause severe tissue damage and necrosis, so the IV site should be assessed regularly for extravasation (B) of the chemotherapeutic agent. The client should be instructed to report any discomfort at the site (A). If pain and burning occur, the IV should be stopped and C is not indicated. Peripheral pulses, not D, provide the best assessment of perfusion distal to the infusion should the drug extravasate or infiltrate.

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

b. Avoid straining at stool, bending, or lifting heavy objects. Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? a. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. c. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. d. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie.

b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. Rationale: B is limited in sodium, is high in fiber, and no additional fat is added through cooking, so it is the best choice for an antihypertensive meal. A high in sodium and cholesterol, which should be avoid. C is high in fat and caffeine which can elevate the BP D is high in sodium and cholesterol and includes caffeine.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? a. Perform CPT after meals to increase appetite and improve food intake. b. CPT should be performed more frequently, but at least an hour before meals. c. Stop using CPT during the daytime until the child has regained an appetite. d. Perform CPT only in the morning, but increase frequency when appetite improves.

b. CPT should be performed more frequently, but at least an hour before meals. Rationale: CPT with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? a. Neutralize hydrochloric (HCI) acid in the stomach b. Decreases the amount of HCL secretion by the parietal cells in the stomach c. Inhibit action of acetylcholine by blocking parasympathetic nerve endings. d. Destroys microorganisms causing stomach inflammation.

b. Decreases the amount of HCL secretion by the parietal cells in the stomach Rationale: B correctly describe the action of histamine 2 receptor antagonist in helping to prevent peptic ulcer disease.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity a. Range of Motion b. Distal pulse intensity c. Extremity sensation d. Presence of exudate

b. Distal pulse intensity Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment does not have the priority of determining perfusion to the extremity.

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

b. Imbalance nutrition Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? a. Report the results to the healthcare provider. b. Increase ventilator rate. c. Administer a dose of sodium carbonate. d. Decrease the flow rate of oxygen.

b. Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate.

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? a. Assess the client's ability to use a numeric pain scale b. Initiate the dosage lockout mechanism on the PCA pump c. Instruct the client to use the medication before the pain become severe d. Assess the abdomen for bowel sounds

b. Initiate the dosage lockout mechanism on the PCA pump Rationale: Morphine depress respiration, so ensuring that the client cannot overdose on the medications.

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? a. High protein b. Low fat c. Low sodium d. High carbohydrate.

b. Low fat Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? a. Jaundice skin tone b. Muffled heart sounds c. Pitting peripheral edema d. Bilateral scleral edema

b. Muffled heart sounds Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one is sign of end stage liver disease related to alcoholism but are not immediately life- threatening.

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

b. Notify healthcare provider to prepare for pericardiocentesis Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? a. Determine client's level current blood alcohol level. b. Observe for changes in level of consciousness. c. Involve the client's family in healthcare decisions. d. Provide grief counseling for client and his family.

b. Observe for changes in level of consciousness. Rationale: Based on the client's history of drinking, he may be exhibiting sign of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.

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

b. Palpate the client's suprapubic area for distention Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.

In early septic shock states, what is the primary cause of hypotension? a. Peripheral vasoconstriction b. Peripheral vasodilation c. Cardiac failure d. A vagal response

b. Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? a. Abnormal responses for cranial nerves I and II b. Persistent coughing while drinking c. Unilateral facial drooping d. Inappropriate or exaggerated mood swings

b. Persistent coughing while drinking Rationale: After a stroke, clients may experience dysphagia and an impaired gag reflex that is evaluated by a speech pathology team. Coughing while drinking results from impaired swallowing and gag reflex, so a referral to a speech therapist is indicated to evaluate the coordination of oral movements associated with speech and deglutination. Cranial nerves I and II are sensory nerves for taste and sight and do not require a referral to speech pathology. Unilateral facial drooping is associated with stroke but is not a focus of rehabilitation. D sre not addressed by speech therapy.

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? a. Chew food slowly and thoroughly before attempting to swallow b. Plan volume-controlled evenly-space meal thorough the day c. Sip fluid slowly with each meal and between meals d. Eliminate or reduce intake fatty and gas forming food

b. Plan volume-controlled evenly-space meal thorough the day Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding decreasing risk of dumping syndrome and flatulence.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a. Replace the IV site with a smaller gauge. b. Redress the abdominal incision c. Leave the lights on in the room at night. d. Apply soft bilateral wrist restraints.

b. Redress the abdominal incision Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client's sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? a. Confirm that all the staff nurses are being assigned to equal number of clients. b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. c. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. d. Analyze the amount of overtime needed by the nursing staff to complete assignments.

b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity.

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

b. Send family to the waiting area while the client's history is taking Rationale: To protect the client privacy, the family member should be asked to wait outside while the client's history is take. Gloves should be worn when touching the client's body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? a. Instruct the client's family member to stay in the visitor waiting area until further notice b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed. c. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. d. Call the hospital operator to determine if the is indeed a real emergency or a fire drill.

b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed. Rationale: The charge nurse should treat the alarm as an actual fire emergency and instruct all clients and visitors to stay in the clients' room with doors closed until otherwise notified. A should be anxiety producing. Visitors should remain in the rooms with the clients. C is only necessary if the location and severity of the fire make the unit unsafe for inhabitants and would only be implemented after other measures to control de fire had failed. D should not be done until after measures are taken to protect clients and visitors.

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? a. They can contribute to increased dependency b. They decrease the risk for joint trauma c. They promote muscle strength d. They diminish range of motion ability.

b. They decrease the risk for joint trauma Rationale: Assistive devices of this kind are very beneficial in reducing joint trauma(B) caused by excessive twisting. These devices promote independence, rather that increasing dependency

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client a. Who is bedfast, with increased serum BUN and creatinine levels b. Who is confused and frequently forgets to go to the bathroom c. With hematuria and decreasing hemoglobin and hematocrit levels d. Who has a history of frequent urinary tract infections.

b. Who is confused and frequently forgets to go to the bathroom Rationale: Overflow incontinence occurs when the bladder becomes overly distended, which is common in the confused client (B) who does not remember to empty his/her bladder.

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

c. Encourage popsicles and fluids of choice Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.

Based on principles of asepsis, the nurse should consider which circumstance to be sterile? a. One inch- border around the edge of the sterile field set up in the operating room b. A wrapped unopened, sterile 4x4 gauze placed on a damp table top. c. An open sterile Foley catheter kit set up on a table at the nurse waist level d. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.

c. An open sterile Foley catheter kit set up on a table at the nurse waist level Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile object become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.

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

c. Assess compliance with routine prescriptions. Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)

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

c. Continue with the plan of care for this client. Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys.

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect a. Decrease in serum T4 levels b. Increase in blood pressure c. Decrease in pulse rate d. Goiter no longer palpable.

c. Decrease in pulse rate Rationale: Beta blockers such as propranolol help control the symptoms of hyperthyroidism, such as palpitations or tachycardia, but do not alter thyroid hormone levels, B is not a desired effect in hyperthyroidism. Beta blocker do not impact the presence of a goiter.

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

c. Divide the medication into two injections with volumes under 1ml Rationale: IM injection for children under 3 of age should not exceed 1ml. divide the dose into smaller volumes for injection in two different sites.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? a. Prepare the client to independently treat their disease process b. Reduce healthcare costs related to diabetic complications c. Enable clients to become active participating in controlling the disease process d. Increase client's knowledge of the diabetic disease process and treatment options.

c. Enable clients to become active participating in controlling the disease process Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A).

A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? a. Cluster care to conserve energy b. Initiate contact isolation c. Encourage him to use an electric razor d. Asses him for adventitious lung sounds

c. Encourage him to use an electric razor Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding.

Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse? a. Diarrhea and flatulence b. Abdominal cramps c. Muscle pain d. Altered taste

c. Muscle pain Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP.

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? a. Conduct face to face prevention education group session is Spanish b. Offer low literacy material that explain respiratory hygiene and handwashing techniques c. Establish trust with community leaders and respect cultural and family values. d. Provide public service announcements advising those who aril o seek prompt medical attention.

c. Establish trust with community leaders and respect cultural and family values.

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? a. Prepared both client's medication and take to them at once b. Determine when each client last received pain medication. c. Evaluate both client's pain using a standardized pain scale d. Provide non-pharmacologic pain management interventions.

c. Evaluate both client's pain using a standardized pain scale Rationale: Before administering pain medication, each client' s level of pain should be evaluated using a standardizing scale to determine what type and how much pain medication the clients need.

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? a. Resume normal physical activity b. Drink electrolyte fluid replacement c. Give a dose of regular insulin per sliding scale d. Measure urinary output over 24 hours.

c. Give a dose of regular insulin per sliding scale Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingerstick glucose level and self-administer a dose of regular insulin per sliding scale.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? a. Hypoglycemia b. Fluid balance c. Heat loss d. Bleeding tendencies

c. Heat loss Rationale: Adequate thermoregulation is the nurse next priority. The newborn is at risk for significant heat loss due to a large surface area exposed to the environment, a thin layer of subcutaneous fat, and distribution of brow fat. Heat loss increases the neonate's metabolic pathway's utilization of oxygen and glucose.

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness? a. Body max index (BMI) between 20 and 24 b. Blood pressure reading less than 120/80 mm Hg c. Hemoglobin A1C (HbA1C) reading less than 7% d. Self-reported glucose levels of 120-150 mg/dl.

c. Hemoglobin A1C (HbA1C) reading less than 7% Rationale: Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood glucose to rise slowly after a meal. The best indicator of acarbose effectiveness is a serum hemoglobin A1 no greater than 7%, an indication of glucose level over time. Acarbose has no effect on pain or blood pressure. Self-reported glucose levels of 120-150 reflect the blood sugar at the time taken and are not the best indicator of drug effectiveness.

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

c. Increase intravenous infusion Rationale: a fundus that is dextroverted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention.

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

c. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first? a. Put a cold cloth on his head and administer acetaminophen. b. Listen to lung sounds and place him in a mist tent. c. Notify the healthcare provider and obtain a tracheostomy tray d. Assist the child to lie down and examine his throat.

c. Notify the healthcare provider and obtain a tracheostomy tray Rationale: This child exhibiting signs and symptoms of epiglottitis, a bacterial infection causing acute airway obstruction, so is the immediate action to take.

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? a. Headache b. Joint stiffness c. Persistent fever d. Increase hunger and thirst

c. Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

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

c. Prepare a woman for a bone density screening Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client's fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.

The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? a. Give the child syringes or hospital mask to play it at home prior to hospitalization. b. Include the child in pay therapy with children who are hospitalized for similar surgery. c. Provide a family tour of the preoperative unit one week before the surgery is scheduled. d. Provide doll an equipment to re-enact feeling associated with painful procedures

c. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? a. Ask the UAP to take the blood pressure in the other arm b. Tell the UAP to use a different sphygmomanometer. c. Review the client's serum calcium level d. Administer PRN antianxiety medication.

c. Review the client's serum calcium level Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? a. When the client's stroke symptoms started b. If the client is oriented to time c. The client's previous GCS score. d. The client's blood pressure and respiration rate.

c. The client's previous GCS score. Rationale: The normal GCS is 15, and it is most important for the nurse determine if this abnormal score is a sign of improvement or deterioration in the client's conditions. A is irrelevant. B is part of the GCS. The classic vital signs in late or sudden increasing ICP are Cushing's triad (widening pulse pressure, bradycardia with full, bounding pulse, and irregular respirations) Additional vital signs and trending of values are needed to evaluate the current finding(D) and C is a more sensitive, consistent evaluation

The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? a. The fasting blood sugar was 120 mg/dl this morning. b. Urine ketones have been negative for the past 6 months c. The hemoglobin A1C was 6.5g/100 ml last week d. No diabetic ketoacidosis has occurred in 6 months.

c. The hemoglobin A1C was 6.5g/100 ml last week Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is: a. Two days postoperative bladder surgery with continuous bladder irrigation infusing. b. One day postoperative laparoscopic cholecystectomy requesting pain medication. c. Three days postoperative colon resection receiving transfusion of packed RBCs. d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

c. Three days postoperative colon resection receiving transfusion of packed RBCs.

The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

clubbing

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medication b. The mother of a child who was involved in a physical fight at school today. c. A client diagnosed with depression who is experiencing sexual dysfunction. d. A family member of a client with dementia who has been missing for five hours

d. A family member of a client with dementia who has been missing for five hours Rationale: safety is always the priority concern and the family member of the missing client with dementia needs assistance with contacting authorities as well as psychological support during this time.

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? a. Assess the client's vital signs b. Observe the client's pupils for dilation c. Document the client's drug tolerance d. Administer the analgesic as requested

d. Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe, but should be treated with analgesics as indicated

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? a. Give the wife a straw to help facilitate the client's drinking. b. Assist the wife and carefully give the client small sips of water c. Obtain a thickening powder before providing any more fluids. d. Ask the wife to stop and assess the client's swallowing reflex.

d. Ask the wife to stop and assess the client's swallowing reflex. Rationale: Until a swallowing reflex has been established, giving oral fluids can be dangerous, even life-threatening. The nurse should immediately stop the dangerous situation and assess the client. It is most important to determine if the client can swallow before giving him anything by mouth.

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? a. Discontinue intravenous therapy b. Obtain a prescription for a diet change c. Assess for abdominal distention and tenderness. d. Auscultate bowel sounds in all four quadrants

d. Auscultate bowel sounds in all four quadrants

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises but walk regularly.

d. Avoid all isometric exercises but walk regularly. Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.

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

d. Avoid crowds for first two months after surgery.

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? a. Administer antiemetic agents b. Bivalve the cast for distal compromise c. Provide high- calorie, high-protein diet d. Begin parenteral antibiotic therapy

d. Begin parenteral antibiotic therapy Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? a. Express feelings of sadness and loneliness b. Neglects personal hygiene and has no appetite c. Lacks interest in the activity of the family and friends d. Begin to show signs of improvement in affect

d. Begin to show signs of improvement in affect

The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? a. Pulmonary embolus with an intravenous heparin infusion and new onset hematuria b. Myocardial infarction with sinus bradycardia and multiple ectopic beats c. Adult respiratory distress syndrome with pulse oximetry of 85% saturation. d. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

d. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation Rationale: A slight bilirubin elevation and anemia are expected finding in a stable client with chronic liver failure who should be transferred to a less-acute medical unit.

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? a. Consistently applies TED hose before getting dressed in the morning. b. Frequently elevated legs thorough the day. c. Inspect the leg frequently for any irritation or skin breakdown d. Completely stop cigarette/ cigar smoking.

d. Completely stop cigarette/ cigar smoking. Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.

The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a. Encourage the client's family to visit more often b. Schedule a daily conference with the social worker c. Encourage the client to participate in group activities d. Engage the client in a non-threatening conversation.

d. Engage the client in a non-threatening conversation.

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/ benzocaine otic solution? a. Place the dropper on the upper outer ear canal and instill the medication slowly. b. Warm the medication in the microwave for 10 seconds before instilling. c. Keep the medication refrigerated between administrations. d. Have the child lie with the ear up for one to two minutes after installation.

d. Have the child lie with the ear up for one to two minutes after installation.

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? a. Remove the catheter and insert into urethral opening b. Observe for urine flow and then inflate the balloon. c. Insert the catheter further and observe for discomfort. d. Leave the catheter in place and obtain a sterile catheter.

d. Leave the catheter in place and obtain a sterile catheter.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? a. Prepare to administer atropine 0.4 mg IVP b. Gather emergency tracheostomy equipment c. Prepare to administer lidocaine at 100 mg IVP d. Place cardiac monitor leads on the client's chest.

d. Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias.

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? a. Limit the intake of high calorie foods. b. Eat meals at the same time daily. c. Maintain a low protein diet. d. Restrict daily fluid intake.

d. Restrict daily fluid intake. Rationale: the client is exhibiting signs of Cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relieve the edema and decrease workload on the right-side of the heart.

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

d. Restrict unvaccinated children from attending school until measles outbreak is resolved.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? a. Crying b. Straining on stool c. Vomiting d. Sitting upright.

d. Sitting upright. Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.