HESI exit pratice

A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. Which nursing interventions should be implemented in the immediate postprocedural period? Keep the client on bed rest for eight hours. Check vital signs every 15 minutes for two hours. Allow the client nothing by mouth until the gag reflex returns. Encourage fluid intake to promote the elimination of the contrast media.

Allow the client nothing by mouth until the gag reflex returns

The nurse completes a visual inspection of a client's abdomen. Which technique should the nurse perform next in the abdominal examination? Percussion. Auscultation. Deep palpation. Light palpation.

Auscultation.

The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his postoperative care and prognosis? "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." "I should always use a condom because I am at increased risk for acquiring a sexually tra

"I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle.

The nurse is caring for a young adult who is having an oral glucose tolerance test (OGTT). Which laboratory result should the nurse assess as a normal value for the two-hour postprandial result? 140 mg/dL. 160 mg/dL. 180 mg/dL. 200 mg/dL.

140 mg/dL.

Which client should be further assessed for an ectopic pregnancy? A 24-year-old with shoulder and lower abdominal quadrant pain. A 33-year-old with intermittent lower abdominal cramping. A 20-year-old with fever and right lower abdominal colic. A 40-year-old with jaundice and right lower abdominal pain

A 24-year-old with shoulder and lower abdominal quadrant pain.

Which client is at highest risk for compromised psychological adjustment after a hysterectomy? A 46-year-old woman with three children and a recent promotion at work. A 55-year-old woman with abnormal bleeding and pain for 3 years. A 62-year-old widow who has three friends who had uncomplicated hysterectomies. A 29-year-old woman whose uterus ruptured after giving birth to her first child.

A 29-year-old woman whose uterus ruptured after giving birth to her first child.

Which client should the nurse assess first? A 27-year-old reporting severe back pain. A 63-year-old describing foot and ankle pain. A 49-year-old with pancreatitis upset by unrelenting abdominal pain. A 55-year-old newly admitted client troubled by jaw pain and indigestion.

A 55-year-old newly admitted client troubled by jaw pain and indigestion.

A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family asks the nurse what this means. Which type of fracture should the nurse explain from these findings? A straight fracture line that is also a simple, closed fracture. A nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin. A fracture that bends or splinters part of the bone.

A fracture that bends or splinters part of the bone.

When planning care for a client with right renal calculi, which nursing problem has the highest priority? Acute pain related to movement of the stone. Impaired urinary elimination related to the obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to the need for prevention of recurrence of calculi.

Acute pain related to movement of the stone.

The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? Altered sexual response. Sterility. Urinary incontinence. Decreased pelvic muscle tone.

Altered sexual response

The nurse is caring for a client with acute pancreatitis and assesses the admission laboratory results. Which laboratory value should the nurse anticipate being elevated with this diagnosis? Triglycerides. Amylase. Creatinine. Uric acid.

Amylase

Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? Diuretic therapy. Pacemaker implantation. Anticoagulation therapy. Cardiac catheterization.

Anticoagulation therapy.

The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs of a client who returns to the unit after having a mastectomy for cancer. Which information should the nurse provide the UAP? Elevate the arm with an IV infusing on the operative side with a pillow. Apply the blood pressure cuff to the arm on the non-operative side. Position the arm on the operative side close to the body. Collect a fingerstick blood specimen from the arm on the operative side.

Apply the blood pressure cuff to the arm on the non-operative side

A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? Progress activity as soon as possible. Assess for signs of bleeding and hypovolemia. Place the client in the left lateral position. Monitor blood pressure, pulse and breathing every 4 hours.

Assess for signs of bleeding and hypovolemia

The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? Increase fluid intake. Monitor sodium chloride intake. Assist the client in coping with hot flashes. Encourage milk products to increase calcium intake.

Assist the client in coping with hot flashes.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. Which nursing intervention should be implemented? Obtain a prescription for a laxative. Withhold all oral fluid and food. Assist the client to ambulate in the hall. Administer the prescribed morphine sulfate.

Assist the client to ambulate in the hall

A client arrives at the emergency department for treatment of injuries sustained in a motor vehicle collision. The nurse notes the asymmetrical expansion of the chest wall during respiration. Which action should the nurse implement next? Auscultate the lungs bilaterally. Inspect the overall skin color. Palpate for tactile fremitus. Percuss the chest for resonance.

Auscultate the lungs bilaterally

The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may b

Avoid allergy medications that contain pseudoephedrine or phenylephrine

A female client is recently diagnosed with Sarcoidosis. The client tells the nurse that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the nurse should include that sarcoidosis most commonly occurs in which ethnic group of women? Black women. Caucasian women. Asian women. Hispanic women.

Black women

A client is admitted after a blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration.

Bluish periumbilical skin discoloration.

Which instruction should the nurse include in the discharge teaching for a client who needs to perform the self-catheterization technique at home? Catheterize every 4 to 6 hours. Maintain sterile technique. Use the Crede maneuver before catheterization. Drink 500 mL of fluid within 2 hours of catheterization.

Catheterize every 4 to 6 hours

A client with a history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? Check for a pulse deficit. Palpate the apical impulse. Inspect jugular vein pulse. Examine for a carotid bruit.

Check for a pulse deficit.

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. Which action should the nurse implement? Encourage fluids to 3000 mL/day. Check stools for occult blood. Provide oral hygiene every 2 hours. Check for fever every 4 hours.

Check stools for occult blood

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Presence of carbonaceous particles in sputum.

Cherry red color to the mucous membranes

A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? Serum amylase of 132 units/L. Serum sodium of 134 mEq/L. Chest x-ray indicating a mediastinal shift. Abdominal x-ray with air noted throughout intestines.

Chest x-ray indicating a mediastinal shift

Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? Cough brought on by swallowing. Sore throat caused by speaking. Painful and dry oral cavity. Unintended weight loss.

Cough brought on by swallowing.

A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. Which action should the nurse implement? Notify the healthcare provider. Decrease the IV solution flow rate. Document the finding as the only action. Administer potassium replacement as prescribed

Document the finding as the only action

The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 °F (36.2 °C). Which intervention should the nurse implement? Document the temperature reading on the vital sign graphic sheet. Report the temperature to the healthcare provider immediately. Instruct the UAP to take the client's temperature again in 30 minutes. Advise the UAP to assist the client in returning to her bed.

Document the temperature reading on the vital sign graphic sheet.

Which is the primary nursing problem for a client with asymptomatic primary syphilis? Acute pain. Risk for injury. Sexual dysfunction. Deficient knowledge.

Deficient knowledge

Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? Drinks a six-pack of beer every day. Enjoys a hamburger once a month. Eats fortified breakfast cereal daily. Consumes beans and rice every day.

Drinks a six-pack of beer every day

The nurse is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the nurse to report to the healthcare provider? Lower back pain. Headache of 7 on a scale of 1 to 10. Blood pressure of 140/98 mmHg. Dyspnea.

Dyspnea.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. Which is the most important nursing action to implement? Limit the client's intake of oral fluids and food. Evaluate the effectiveness of narcotic analgesics. Encourage the client to ambulate as tolerated. Teach the client about the prevention of crises.

Evaluate the effectiveness of narcotic analgesics

After a liver biopsy is performed at the bedside, the nurse is assigned to care for the client. Which nursing intervention is most important for the nurse to implement? Position the client on the left side with a pillow placed under the costal margin. Assist the client with voiding immediately after the procedure. Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4. Ambulate the client 3 times in the first hour with a pillow held at the abdomen.

Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4.

The nurse is caring for a client with end-stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, which position should the nurse ask the client to demonstrate? Extend the left arm laterally with the left palm upward. Extend the arm, dorsiflex the wrist, and extend the fingers. Extend the arms and hold this position for 30 seconds. Extend arms with both legs adducted to shoulder width.

Extend the arm, dorsiflex the wrist, and extend the fingers.

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? Suprapublic pain and distention. Bounding pulse at 100 beats/minute. Fingerstick glucose of 300 mg/dL. Small vesicular perineal lesions.

Fingerstick glucose of 300 mg/dL.

A client with osteoarthritis receives a prescription for Naproxen. Which potential side effect should the nurse provide to the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance.

Gastrointestinal disturbance.

The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul-smelling fecal-like material. Which action should the nurse implement? Administer antiemetics every 2 to 3 hours. Position on the left side with knees drawn up. Encourage ice chips sparingly. Give IV fluids with electrolytes.

Give IV fluids with electrolytes.

A client who returns to the unit after having a percutaneous coronary intervention (PCI) with balloon angioplasty, complains of acute chest pain. Which action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic.

Give a sublingual nitroglycerin tablet

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing problem for this client? Risk for injury. Impaired comfort. Disturbed body image. Ineffective health maintenance.

Impaired comfort

The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? Thinning hair and dry scalp. Increase in appetite and taste-bud acuity. Increase in muscle tone but decreased muscle strength. Increase in abdominal fat deposits.

Increase in abdominal fat deposits.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? Large amounts of expelled flatus with mucus. Tympanic abdomen and hyperactive bowel sounds. Increased abdominal pain with rebound tenderness. Complaint of feeling weak with watery diarrheal stools.

Increased abdominal pain with rebound tenderness

A nurse is preparing to insert an IV catheter after applying a eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. Which action should the nurse take to maximize its therapeutic effect? Rub a liberal amount of cream into the skin thoroughly. Cover the skin with a gauze dressing after applying the cream. Leave the cream on the skin for 1 to 2 hours before the procedure. Use the smallest amount of cream necessary to numb the skin surface.

Leave the cream on the skin for 1 to 2 hours before the procedure.

A client with osteoarthritis requests information from the nurse about which type of exercise regimen would be most beneficial for him. The nurse should communicate which information? Low-impact exercise, walking, swimming, and water aerobics. Repetitive strength-building exercises with weights or resistance bands. Circuit training alternating with frequent rest periods. High-impact aerobic exercise.

Low-impact exercise, walking, swimming, and water aerobics

The nurse is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the nurse to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions. Avoid peripheral injections.

Maintain strict protective precautions

Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome? Carotid stenosis. Steatosis hepatitis. Metastatic cancer. Clavicular fracture.

Metastatic cancer

While caring for a client who has esophageal varices, which nursing intervention is most important for the nurse to implement? Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy (EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction.

Monitor infusing IV fluids and any replacement blood products

A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. Which rationale should the nurse use to evaluate the laboratory findings? Serum myoglobin levels are needed to confirm myocardial damage. The most reliable indicator of myocardial necrosis is serum CK-MB. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. Myocardial damage that occurr

Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. Which action should the nurse implement? Notify the healthcare provider. Increase the IV flow rate. Place the client in the supine position. Prepare the client for emergency echocardiography.

Notify the healthcare provider

During the assessment of a client who is 24 hours posthemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. Which action should the nurse implement? Notify the surgeon. Document the assessment. Secure a colostomy pouch over the stoma. Place petrolatum gauze dressing over the stoma.

Notify the surgeon.

The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, which action should the nurse implement? Ask the client to try to speak. Assess for respiratory distress. Auscultate for pulmonary crackles after the client drinks a small amount of clear water. Observe the client for coughing colored sputum after drinking a small amount of colored water.

Observe the client for coughing colored sputum after drinking a small amount of colored water.

The nurse is caring for a client who has a closed head injury from a motor vehicle collision. Which assessment finding could potentially indicate diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity. Polydipsia.

Polydipsia.

The nurse is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the nurse after the removal of the chest tube? Prepare the client for a chest x-ray at the bedside. Review arterial blood gases after removal. Elevate the head of the bed to 45 degrees. Assist with disassembling the drainage system.

Prepare the client for a chest x-ray at the bedside.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy.

Prevent the formation of effusion fluid.

The nurse is teaching a client who is newly diagnosed with emphysema on how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? Decreases respiratory rate. Increases O2 saturation throughout the body. Conserves energy while ambulating. Promotes CO2 elimination.

Promotes CO2 elimination.

The nurse is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the nurse report to the healthcare provider? Dry mucous membranes and lips. Rebound abdominal tenderness over the right lower quadrant. Dizziness when client ambulates from a sitting position. Poor skin turgor over the client's wrist.

Rebound abdominal tenderness over the right lower quadrant

The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) Empty surgical drains once a week using procedure gloves. Report inflammation of the incision site or the affected arm. Wear clothing with snug sleeves over the arm on the operative side. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head.

Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head.

Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? Respiratory effort. Unsteady gait. Intensity of pain. Ability to eat.

Respiratory effort

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client? Free from injury of drug side effects. Return to pre-illness weight. Adequate oxygenation. Maintenance of intact perineal skin.

Return to pre-illness weight.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. Which is the priority nursing problem that should guide the discharge instruction plan? Acute pain. Risk for infection. Disturbed body image. Risk for deficient fluid volume.

Risk for infection

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A scalp laceration oozing blood. Serosanguineous nasal drainage. Headache rated "10" on a 0 to 10 scale. Dizziness, nausea, and transient confusion.

Serosanguineous nasal drainage.

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin. Ischemia-modified albumin.

Serum troponin

The nurse is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." Which information should the nurse provide to the client about the prescribed treatment? The development of resistant strains of TB is decreased with a combination of drugs. Compliance with the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but are less effective. The treat

The development of resistant strains of TB is decreased with a combination of drugs.

A client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A graduate registered nurse (RN) with three weeks of experience. The registered nurse (RN) case manager for the unit with 1 year's experience. A "floating" registered nurse (RN) with five years of nursing experience. A Korean-American practical nurse (PN) with six years of nursing experience.

The registered nurse (RN) case manager for the unit with 1 year's experience

A client asks the nurse which possible treatments might be used for their tumor. How should the nurse reply? Radiation is never used on tumors. Chemotherapy is mandated for all types of cancer. Surgery is the only cancer treatment needed for tumors. The three hallmark treatments include surgery, radiation, and chemotherapy.

The three hallmark treatments include surgery, radiation, and chemotherapy

The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? Prognosis after treatment is excellent. Techniques for esophageal speech are relatively easy to learn with practice. The stoma should never be covered after this type of surgery. There is a radical change in appearance as a result of this surgery.

There is a radical change in appearance as a result of this surgery.

A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? Encourage fluids to 3000 mL per day. Change the client's position every two hours. Keep the head of the bed elevated by 30 degrees. Turn off the television and darken the room.

Turn off the television and darken the room

Which is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? Tell another staff member to bring extinguishing equipment to the bedside. Close the doors to the client's area when attempting to extinguish the fire. Use a bag-valve-mask resuscitator while removing the client from the area. Implement an emergency protocol to remove the client from the ventilator.

Use a bag-valve-mask resuscitator while removing the client from the area.

A client in the preoperative holding area receives a prescription for midazolam IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? Give the drug and allow the client to read and sign the consent form. Counter-sign the client's initials on the consent form after giving the drug. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Call the healthcare provide

Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form.

The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? Kyphosis with a reduction in height. Dilated superficial veins on both legs. External hemorrhoids with itching. Yellowish discoloration of the sclerae.

Yellowish discoloration of the sclerae

Which findings are within the expected parameters of a normal urinalysis for an older adult? (Select all that apply.) pH 6. Nitrate small. Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015.

pH 6. Sugar negative. Bilirubin negative. Specific gravity 1.015.

The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to 160 beats/minute lasting more than 10 minutes. Temperature of 103.1 °F (39.5 °C) and white blood cell (WBC) count of 16,000 mm3. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mmHg.

Pulse change from 85 to 160 beats/minute lasting more than 10 minutes

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing the final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleeping six to eight hours. Achieve a sense of control. Utilize problem-solving skills. Increased focus of attention.

Achieve a sense of control

The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? Administer medications for pain relief, shortness of breath, and nausea. Clarify family members' feelings about the meaning of the client's behaviors and symptoms. Develop a plan of care after assessing the needs of the client and family. Teach the family to recognize restlessness and grimacing as signs of client discomfort.

Administer medications for pain relief, shortness of breath, and nausea

A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is 70 beats per minute, respirations are 18 breaths per minute and blood pressure is 125/75 mmHg. Which action should the nurse implement next? Administer the medication. Inform the healthcare provider. Review the vital sign flowsheet. Reassess the apical heart rate.

Administer the medication

A male client with chronic atrial fibrillation and slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? Ventricular irritability is prevented by the constant rate setting of the pacemaker. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. An impulse is fired every second to maintain a heart rate of 60 bea

An electrical stimulus is discharged when no ventricular response is sensed.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer.

An image that describes metastatic sites of cancer

A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the nurse what she should expect as a common treatment. Which recommended plan of care should the nurse provide the client? Rest with liquid diet only. Drugs such as ursodiol. Cholecystectomy via laparoscopy. LaVeen vena caval shunt.

Cholecystectomy via laparoscopy.

A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? Collect a culture of the penile discharge. Palpate the inguinal lymph nodes gently. Observe for scrotal swelling and redness. Express the discharge to determine color.

Collect a culture of the penile discharge

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins.

Compress the flank and upper buttocks.

A client has been told that there is cataract formation over his both eyes. Which finding should the nurse expect when assessing the client? Decreased color perception. Presence of floaters. Loss of central vision. Reduced peripheral vision.

Decreased color perception

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. Which is the priority nursing action? Assessment of the client's vital signs. Document the finding as the only action. Determine the time the client last voided. Insert a rectal tube for the passage of flatus.

Determine the time the client last voided

A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? Inform the client how to protect sexual and needle-sharing partners. Teach the client about the medications that are available for treatment. Identify the need to test others who have had risky contact with the client. Discuss retesting to verif

Discuss retesting to verify the results, which will ensure continuing contact

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, which information is important to include? Dry, itchy skin changes may occur. There is a possibility of long bone pain. Permanent pigment changes to the breast may result. A low-residue diet may be ordered to reduce the likelihood of diarrhea.

Dry, itchy skin changes may occur

A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. What should the nurse evaluate? Determine the client's level of discomfort using a pain rating scale. Ask the client about her past experience with chronic pain. Observe the client's facial expressions for pain and discomfort. Evaluate the client's ability to adjust the voltage to control pain.

Evaluate the client's ability to adjust the voltage to control pain.

A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. Which response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." "You

Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? Body mass index. Skin elasticity and turgor. Thought processes and speech. Exposure to cold environmental temperatures.

Exposure to cold environmental temperatures.

The nurse is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the nurse instruct the client to report immediately? Fever related to infection. Weight loss and anorexia. Depressed mood. Break in tissue integrity.

Fever related to infection

A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. Which assessment finding is most important for the nurse to identify? Increased anxiety since the transfusion began. Drowsiness after receiving diphenhydramine. Reports feeling cold. Flushed skin and headache.

Flushed skin and headache

The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment should the nurse identify and document that is consistent with PUD? (Select all that apply). Hematemesis. Gastric pain on an empty stomach. Colic-like pain with fatty food ingestion. Intolerance of spicy foods. Diarrhea and stearrhea.

Gastric pain on an empty stomach Intolerance of spicy foods

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. Which is the best response for the nurse to provide? "Tell your friends and family so that they can help you." "Get involved with a support group. I will give you some names." "Talk only to other friends who are infertile since only they can help." "Start adoption proceedings immediately since obtaining an infant is very difficult."

Get involved with a support group. I will give you some names

The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. Which precautions should the nurse implement? A mask should be worn by anyone entering the client's room. Handwashing is required before and after contact with the client. Gloves should be worn during direct contact with the client's skin. No precautions in addition to standard precautions are necessary.

Gloves should be worn during direct contact with the client's skin.

The nurse is giving discharge instructions to a client with chronic prostatitis. Which instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week.

Have intercourse or masturbate at least twice a week.

A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the nurse identify in the client's history? Chronic bronchitis. Gastroesophageal reflux disease (GERD). Heart failure (HF). Chronic pancreatitis.

Heart failure

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and irritability. Which symptom is not frequently associated with PMS? Heart palpitations. Anorexia. Hypersomnia. Stress incontinence.

Heart palpitations.

A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis? Take a multivitamin daily. Use only low fat milk products. Perform weight resistance exercises. Bicycle for at least 3 miles every day.

Perform weight resistance exercises

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? Neisseria gonorrhoea. Chlamydia trachomatis. Herpes simplex virus. Human papillomavirus.

Human papillomavirus

A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? "Well, I don't have to worry about getting pregnant anymore." "I can't wait to go on the cruise that I have planned for this summer." "I know I will miss having sexual intercourse with my husband." "I have asked my daughter to stay with me next week after I am discharged."

I know I will miss having sexual intercourse with my husband

A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the nurse which medication should she use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain? Aspirin. Codeine. Ibuprofen. Acetaminophen.

Ibuprofen

A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal antiinflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis? Production of replacement cartilage is stimulated. Further destruction of the articular cartilage is prevented. Inflammation is reduced by inhibiting prostaglandin synthesis. Bradykinin is inhibited, thereby reducing acute and chronic pain.

Inflammation is reduced by inhibiting prostaglandin synthesis

A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? Cleanse the perineum with warm soapy water 3 times per day. Instill the first dose of nystatin vaginally per applicator. Perform glucose measurement using a capillary blood sample. Obtain a blood specimen for sexually transmitted diseases (STDs).

Instill the first dose of nystatin vaginally per applicator.

The nurse is caring for a client after transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Change drainage unit tubing.

Irrigate the catheter.

A male client who had a transurethral resection of the prostate (TURP) due to benign prosatic hyperplasia (BPH) is preparing for discharge. What should the nurse ensure the client understands? Ongoing antibiotic therapy is needed for one year. The client should not undergo magnetic resonance imaging. Increased frequency of assessment for prostatic cancer is needed. It can take several weeks, or longer until continence is restored.

It can take several weeks, or longer until continence is restored.

The healthcare provider prescribes a high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? It is quickly digested. It does not cause diarrhea. It does not dilate the stomach. It is slow to leave the stomach.

It is slow to leave the stomach.

In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Lateral position alternating sides every 2 hours. Left lateral, supine, brief periods on the right side, and prone.

Left lateral, supine, brief periods on the right side, and prone.

A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/mL. Which conclusion regarding this lab data is accurate? Probable prostatitis. Low risk for prostate cancer. The presence of cancer cells. A biopsy of the prostate is indicated.

Low risk for prostate cancer

The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? Helps to minimize pain and anxiety. Maintains correct spinal alignment to protect the surgical area. Prevents dizziness while stabilizing the spine. Allows the nurse to move the client freely without assistance.

Maintains correct spinal alignment to protect the surgical area

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? Palpate the pedal pulse volume. Count the brachial pulse rate. Measure the blood pressure. Assess for a carotid bruit.

Measure the blood pressure

The nurse is caring for a client scheduled to undergo the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? Method of insertion. Location of the tubes. Diameter of the tubes. Procedure for feedings.

Method of insertion.

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Nail polish. Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. Wedding band. Left leg brace. Contact lenses. Partial dentures.

Nail polish Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. Contact lenses. Partial dentures

Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? New onset of coughing. Low resting heart rate. Distended neck veins. Decreased shallow respirations.

New onset of coughing.

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? The X-ray procedure may last for several hours. A nasogastric tube (NGT) is inserted to instill the barium. Enemas are given to empty the bowel after the procedure. Nothing by mouth is allowed for 6 to 8 hours before the study.

Nothing by mouth is allowed for 6 to 8 hours before the study.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. Which action should the nurse implement first? Notify the client's healthcare provider. Document the finding in the client record. Prepare a warm enema solution for rectal instillation. Obtain a large bore needle for aspiration of the corpora cavernosa.

Notify the client's healthcare provider

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? Obtain a prescription for an adjusted dose of insulin. Administer an oral antidiabetic agent. Give an insulin dose using the parameters of a sliding scale. Withhold insulin while the client is NPO.

Obtain a prescription for an adjusted dose of insulin

A client with a recent history of blood in his stools is scheduled for a proctoscopy/sigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure.

Obtain consent for the procedure Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure

The nurse recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) Older males. School-age females. Older females. Adolescent males.

Older females. School-age females Older males Adolescent males.

A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction? Oral contraceptives. Senile osteopenia. Levothyroxine therapy. Pernicious anemia.

Oral contraceptives

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Parenteral antibiotics for 2 to 3 weeks, then oral ant

Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.

The nurse obtains a client's history that includes a right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem potentially could be a consequence of radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest.

Pathologic fracture of two ribs on the right chest

During the initial outbreak of genital herpes simplex for a female client, which should be the nurse's primary focus in planning care? Promotion of comfort. Prevention of pregnancy. Instruction in condom use. Information about transmission.

Promotion of comfort

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. Which action should the nurse take? Obtain a specimen for a serum glucose level. Administer insulin per sliding scale. Provide cheese and bread to eat. Collect a glycosylated hemoglobin specimen.

Provide cheese and bread to eat.

The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately? Terrible nightmares. Increased nocturia. Severe muscle pain. Visual disturbances.

Severe muscle pain.

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine, but his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cu

Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Full thickness burns rather than partial thickness. Supinates extremity but is unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Inability to distinguish sharp versus dull sensations in the extremity.

Slow capillary refill in the digits with absent distal pulse points

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. Which information is best for the nurse to provide? (Select all that apply.) Only marijuana cigarettes affect sperm count. Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility. Sperm specimens should be collected

Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility.

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? Perform active range of motion three times daily. Monitor for Battle's sign every four hours. Teach measures to avoid the Valsalva maneuver. Maintain the head of bed in a flat position.

Teach measures to avoid the Valsalva maneuver

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? Upper chest subcutaneous emphysema. Tidaling (fluctuation) of fluid in the water-seal chamber. Constant air bubbling in the suction-control chamber. Pain rated "8" (0 to 10) at the insertion site.

Upper chest subcutaneous emphysema.

The nurse is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the nurse that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 beats per minute and blood pressure 76/42 mmHg. Urine specific gravity 1.001. Tented skin on the dorsal surface of hands.

Urine output of 40 mL/hour.

Which intervention should the nurse implement that best confirms the placement of an endotracheal tube (ETT)? Use an end-tidal CO2 detector. Auscultate for bilateral breath sounds. Obtain pulse oximeter reading. Check symmetrical chest movement.

Use an end-tidal CO2 detector

Which method elicits the most accurate information during a physical assessment of an older client? Ask the client to recount one's health history. Obtain the client's information from a caregiver. Review the past medical record for medications. Use reliable assessment tools for older adults.

Use reliable assessment tools for older adults

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Vagal stimulation. An increased level of stress. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells.

Vagal stimulation Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent hospital-associated infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room.

Wash hands after caring for the client.

Which assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? Wheezing becomes louder. Cough remains unproductive. Vesicular breath sounds decrease. Bronchodilators stimulate coughing.

Wheezing becomes louder