HESI Exit Take 2

A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion

PICTURE Primary bag drip chamber.

A client has an IV fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

Palpate at the radial pulse site with the pads of two or three fingers.

The nurse assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states the left knee is swollen and extremely pain to touch. Which instruction should the nurse include in the discharge teaching? a. Decrease consumption of red meat and most seafood B. Substitute natural fruit juices for carbonated drinks C. Limit use of mobility equipment to avoid muscle atrophy D. Use electric heating pad when pain is at its worse

A. Decrease consumption of red meat and most seafood

The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three- year-old should (a) discriminate between fantasy and reality (b) ride a tricycle independently (c) have a vocabulary of 7,000 words (d) play in a group of two or three with one being the leader

(b) ride a tricycle independently

Signs and Symptoms of Theophylline Toxicity

**Respiratory depression** Flushing Insomnia Headache n/v Restlessness anorexia tachycardia arrhythmias seizures

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low carbohydrate and high protein diet

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no DEPENDENT LOOPS are present in the tubing.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Evaluate the oxygen saturation

83. RN walks in on a UAP cleaning a diaphoretic patient, what should the RN do

Explain to UAP that these things need to be reported immediately

An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? (Highest to lowest priority) a. Send emesis sample to the lab b. Elevate the head of the bed c.Complete focused assessment d. Offer PRN pain medication

HIGHEST TO LOWEST PRIORITY a. Send emesis sample to the lab b. Elevate the head of the bed c.Complete focused assessment d. Offer PRN pain medication

. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with the client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration

A. Have the client vocalize the instructions provided

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) who is unable to effectively cough up thick mucus. When the nurse prepares to suction the airway using a yankauer suction catheter, which action should the nurse include?

Apply a water-soluble lubricant to the catheter

Acute Dystonia

S/S involuntary upward eye movement laryngeal spasms *** Facial grimacing Acute dystonia is an extrapyramidal symptom which is a common adverse effect to taking antipsychotic drugs to control psychosis especially schizophrenia.

Patient with diabetes states she is drinking cranberry juice to help with infection what should the nurse teach about cranberry juice.

sugar free cranberry juice is best for diabetic.

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

After I squeeze the inhaler and swallow, i always feel a slight wave of nausea, but it goes away.

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? A. Monitor the client's cardiac activity via telemetry. B. Maintain venous access with an infusion of normal saline. C. Assess glucose via fingerstick q4 to 6 hours. D. Evaluate hourly urine output for return of normal renal function.

AnswerA. Monitor the client's cardiac activity via telemetry. RationaleAs insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias (A) related to abnormal serum potassium levels. IV access (B), assessment of glucose level (C), and monitoring urine output (D) are important interventions, but do not have the priority of monitoring cardiac function (A).

What is the desired effect of atropine sulfate when used as a preoperative medication?

Atropine suppresses salivation, bronchial and gastric secretions; it has a drying effect

The nurse enters room of a client with Parkinson's disease who is taking Carbidopa- Levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? A) Demonstrate how to help the client move more efficiently. B) Affirm that the client should arise slowly from the chair. C) Tell the UAP to assist the client in moving more quickly. D) Offer a PRN analgesic to reduce painful movement.

B) Affirm that the client should arise slowly from the chair.

A client is receiving mesalamine 800mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

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

the mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course.

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Contact the medical records department supervisor.

A client is diagnosed with methicillin resistant staphylococcus aureus (MRSA) pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact

D) Contact

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

What is the most important expected outcome for a patient admitted with a history of schizophrenia? A. The patient is oriented to reality. B. The patient adheres to the medication regimen. C. The patient is free of psychotic symptoms. D. The patient does not harm himself or herself or others.

D. The patient does not harm himself or herself or others. Rationale: Safety is a priority concern with individuals with schizophrenia because the risk of suicide is high. The health care team must be vigilant to maintain the patient's safety and protect him or her from self-harm. Maintaining a medication regimen, freedom from psychotic symptoms, and reality orientation are important expected outcomes, but not harming himself or herself or others is the most important expected outcome.

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

The healthcare provider prescribes a sepsis protocol for a client with multi organ failure caused by rupture appendix which intervention is most important for the nurse to include in the plan of care?

Maintain strict I and O

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Monitor mental status Rationale: administer lactulose to a patient with hepatic encephalopahty to lower serum ammonia level, so mental status should be improving.

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Place a portable toilet next to the bed

The nurse assesses a child in 90-90 traction. Where should the nurse assess for signs of compartment syndrome? (Image of kid in traction)

Place pin on toe • Rationale: compartment syndrome is the result of swelling and subsequent reduction in circulation to the area distal to the compartment. This can be a complication of traumatic injury and cast administration, so it is important to assess circulation to toes for capillary refill.

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?

Remove cigarettes for the client's room

A 38-year-old client (gravida 6, para 6) at 40 weeks of gestation is admitted to the labor and delivery unit for a scheduled induction of labor. A vaginal examination is done, and it is determined that the cervix is 80% effaced and 4 cm dilated. The client is not experiencing contractions. The obstetrician prescribes IV oxytocin. The nurse starts the oxytocin infusion per agency protocol and monitors the client and the fetus on the fetal monitor to determine effectiveness of the oxytocin. Determine if each finding is a Therapeutic Outcome or an Adverse Outcome: a. Altered mental status b. Adventitious lung sounds c. Contractions every 3-5 minutes lasting 45 seconds each d.Sudden pain between contractions e.Decelerations on the fetal monitor f.Pain intensifying gradually with contractions

RATIONALE: Oxytocin is a hormone that is produced naturally by the posterior pituitary gland. Oxytocin produces uterine contractions during pregnancy and can be administered to induce labor for a term pregnancy. Additional therapeutic outcomes include milk ejection and control of postpartum hemorrhage. When given for labor, the client will experience intensifying contractions, including intensifying pain as the labor progresses, until eventually the contractions are occurring every 3 to 5 minutes and lasting 45 seconds each. Because oxytocin exerts an antidiuretic effect, water intoxication is an adverse outcome of oxytocin. Assessment findings related to water retention may be noted, such as altered mental status, adventitious lung sounds, and peripheral swelling. Another adverse outcome that can occur is uterine rupture. Sudden pain between contractions, excessive vaginal bleeding, and decelerations on the fetal monitor would be noted with this complication. The client with higher parity, specifically more than five pregnancies, is at higher risk for uterine rupture when given oxytocin. CJ Cognitive Skills: Evaluate Outcomes Content Area: Maternal-Newborn Nursing Priority Concept: Perfusion

Medication Directions for Patient with mouth sores

Swish, spit and then swallow the rest of the medication

A client with muscular dystrophy is concerned about becoming totally depending and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Teach family proper range of motion exercises

A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the Secondry IV. where should the nurse regulate the rate of the secondary IV?

The drip chamber on the secondary bag Picture

A client with history of bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A. Decreased urinary output B. Low blood glucose level C. Profound weight gain D. Ventricular arrhythmias

Ventricular arrhythmias.

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity

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

a. Reduced level of pain

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure(MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

A. Mean arterial pressure(MAP)

An older adult client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8 F (38.8 C), heart rate of 110 beats/minute, and a respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the health care provider? a. Capillary glucose reading of 110 mg/dL (6.1 mmol/L SI) b. serum creatine of 2.0mg/dL c. Hemoglobin of 12 g/dL (120 g/dL SI) d. blood pressure of 134/88 mm hg

b. serum creatine of 2.0mg/dL

diet, which foods should the nurse encourage the client to eat? (Select all that apply) a. lentills b. teas c. potato soup d. whole grain breads e. cheese

b. teas c. potato soup

A client with chronic alcoholism with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? a. Cheddar cheese and crackers b. Carrot and celery sticks c. Beef bologna sausage slices d. Dry roasted almonds

d. Dry roasted almonds Alcoholism promotes inadequate food intake and GI loss of magnesium include green leafy vegetables and nuts and seeds. Other snacks listed provide much lower amount of magnesium.

The nurse is assessing a client with a closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest neurologic functioning? A) Decerebrate posturing during position changes. B) Withdrawal from painful stimuli. C) Decorticate posturing during tracheal suctioning. D) Localization of a tactile stimulus.

A) Decerebrate posturing during position changes.

A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures D. Provide a numeric pain scale

A. Ask the client to describe the pain

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely?SATA A. Bring a heavy can close to body before lifting B. Locks knees while preparing food on the counter C. Widens stance while working near the sink D. Bends from the waist to pick trash off the floor E. Leans forward to pull a pan from a high shelf

A. Bring a heavy can close to body before lifting C. Widens stance while working near the sink

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) A. Collect multiple site screening culture for MRSA B.Call healthcare provider for a prescription for linezolid (Zyrovix) C. Place the client on contact transmission precautions D. Obtain sputum specimen for culture and sensitivity E.Continue to monitor for client sign of infection.

A. Collect multiple site screening culture for MRSA C. Place the client on contact transmission precautions E.Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicatedD) based on the client's history is a wound infection.

***MATH *** A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solutions is heparin sodium 25,000 units in 5%Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number)

ANSWER 18 1st calculate the weight to KG. 220 / 2.2 = 100kg 2nd calculate total dose in units dose= 18 units x 100= 1800 units/hr USE THE REFERENCE to GET FINAL ANSWER 25000 units in 250 mL 1800 Units in x mL x= 1800 * 250/25000=18

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply) A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips

B. Plain, air-popped popcorn. D. Natural whole almonds.

While caring for a client's postoperative dressing, the nurse observes purulent draining at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the clients laboratory values? A.) Serum albumin B.) Culture for sensitive organism C.) Serum blood glucose level D.) Creatinine level

B.) Culture for sensitive organism

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

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

C. It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? a. Regular contractions occurring every 10 minutes b. Sterile vaginal exam revealing 3cm dilation c. Biophysical profile results showing oligohydramnios d. Fetal heart tones located in upper right quadrants

D. Fetal heart tones located in upper right quadrants

A client is admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow.

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L).

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

a . Reduced level of pain

A nurse assessing a postpartum patient notices excessive bleeding. What should be the nurse's first action? a) Massage the boggy fundus until it is firm. b) Nothing--excessive postpartum blood loss is normal. c) Document the findings. d) Call the physician

a) Massage the boggy fundus until it is firm. RATIONALE:The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

a 6 year old who has asthma is demonstrating a prolonged expirotory rate & wheezing and has 35% personal best peak expiratory flow rate. Based on these findings, which action should the nurse implement first? a. Administer the prescribed bronchodilator b. report findings to the health care provider c. encourage the child to cough and deep breathe d. determine what trigger precipitated this attack

a. Administer the prescribed bronchodilator

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)

The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which action will the nurse take when administering a prescribed feeding through the client's G-tube? a.Check for gastric residual before starting feeding. b.Position the client with the head of the bed at a 20° angle. c.Use a syringe plunger to administer the feeding. d.After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2 minutes.

a. Check for gastric residual before starting feeding. The nurse should check for gastric residual before starting feeding by gently aspirating from the tube with a syringe or positioning the tube below the level of the stomach with only the barrel of the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After feeding, the nurse should flush the tube with a small amount of water, unless contraindicated, and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? a. Determine if the sensation feels uncomfortable b. Decrease the strength of the electrical signals c. Remove electrodes and observe for skin redness d. Check the amount of gel coating on the electrodes

a. Determine if the sensation feels uncomfortable Rational: electronic stimulators, such as a transelectrical nerve stimulator (TENS) unit, have been found to be effective in reducing low back pain by "closing the gate" to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching. Decreasing the electrical signal may be indicated if the sensation is too strong. Other options are not necessary because the tingling sensation is expected.

Which instruction should the nurse provide a pregnant client who is reporting heartburn? a. Eat small meals throughout the day to avoid a full stomach b. Take an antacid at bedtime and whenever symptoms worsen c. Maintain a sitting position for two hour after eating d. Limit fluids between meals to avoid over distension of the stomach

a. Eat small meals throughout the day to avoid a full stomach

A client's older daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? a. Encourage increased intake or high protein foods b. Instruct the daughter to check her mother's temperature c. Review the client's current food and medication allergies d. Ask if the mother is experiencing any pain with urination e. Determine if the mother has recently experience a fall

a. Encourage increased intake or high protein foods b. Instruct the daughter to check her mother's temperature d. Ask if the mother is experiencing any pain with urination

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. a. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer b. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food c. Instruct the client that these mild symptoms can generally be controlled with changes in his diet d. Advise the client that he needs to seek immediate medical evaluation and treatment of these symtpoms

a. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach to 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 removed 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 removed

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a. Hypernatremia b. Excessive thirst c. Elevated heart rate d. Poor skin turgor

a. Hypernatremia

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a. Hypokalemia b. Ketonuria c. Peripheral edema d. Elevated blood pressure

a. Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias.

The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? a. Measure ankle circumference b. record usual eating patterns c. Evaluate for muscle cramping d. Document abdominal girth

a. Measure ankle circumference

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

a. Report any client complaint of pain or discomfort d. Weigh the client and report any weight gain e. Note and report the client's food and liquid intake during meals and snacks

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student screening record? a. excessive concave curvature of the lumbar spine b. posterior curvature that is convex in the thoracic cavity c. rounded spine from head to hips without concave curves d. lateral curvature that creates asymmetry of the shoulders

a. excessive concave curvature of the lumbar spine

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 gray-colored appearance c. Obtain specimen for culture and sensitivity analysis d. Assess 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.

the nurse should withhold which medications of the client's serum of potassium level is 6.2 mEq/L? a. spironolactone b. metolazoe c. furosemide d. hydrocholorthiazide

a. spironolactone

Which assessment finding for a client who is experiencing pontine myelionolysis should the nurse report to the hcp? a. sudden dysphagia b. blurred visual field c. gradual weakness d. profuse diarrhea

a. sudden dysphagia

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this clients discharge teaching plan? a. weight every morning b. Eat a high protein diet c. perform range of motion exercises d. limit fluid intake to 1500ml

a. weight every morning

client who experienced a CVA is aphasic and has left sided paralysis. Which nurse should be responsible for coordinating the progression of the client's care:

an adult nurse practitioner

A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer one unit of packed red blood cells as seen in the picture. What action should the charge nurse take? a) verify that a 22-gauge intravenous catheter is used for the transfusion b) assist the nurse in changing the intravenous tubing attached to the blood ? c) tell the nurse to take the client's vital signs and then start the transfusion ? d) assume responsibility for the care of the client during the blood transfusion

b) assist the nurse in changing the IV tubing attached to the blood?

The nurse requests a meals tray for a client who follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply.) a. A. Hot chocolate. b. Apple juice c. Chicken broth d. D. Orange juice. e. E. Black coffee.

b. Apple juice c. Chicken broth

An adult who is 5 feet 5 inches tall and weights 90 lb. is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? a. Examine the client's room for hidden food. b. Assign staff to monitor what the client eats. c. Ask the client if the food provided is being eaten or discarded. d. Provide the client with a high calorie diet.

b. Assign staff to monitor what the client eats. Rationale: clients with an eating disorder have an unhealthy obsession with food. The client's continued weight loss, despites indication that the client has consumed 100% of the diet, should raise questions about the client's intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary.

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? a. taking a sedative at bedtime slows respiratory rate, which decreases oxygen b. Avoid administration of oxygen at high levels for extended periods c. Increase oxygen rate during sleep to compensate for slower respiratory rate d. Oxygen is less toxic when it is humidified with hydration source

b. Avoid administration of oxygen at high levels for extended periods

When assessing a multigravia the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three finger breadths 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 the IV infusions d. Review the hemoglobin to determine hemorrhage

b. Check for a distended bladder A fundus that is dextroverted (up to the right ) and elevated above the umbilicus is indicative of bladder distension/urine retention

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a. aerobic exercise b. recommend weight bearing physical activity c. muscle stretching and toning d. core strengthening

b. Recommend weight bearing physical activity

in formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority? a. Risk for constipation relative to muscle weakness b. Risk for aspiration related to muscle weakness c. self care deficit relative to motor disturbance d. impaired physical mobility

b. Risk for aspiration related to muscle weakness

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? a. a 12 year old with complaints of neck and lower back discomfort b. an 11 year old with a headache, nausea and projectile vomiting c. a six year old with multiple superficial lacerations of all extremities d. an 8 yo with a full leg air splint for possible broken tibia

b. an 11 year old with a headache, nausea and projectile vomiting

A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then she vomits. What should be the nurse's next action? a) Reassure the patient that this is a normal reaction to the procedure. b) Stop the procedure, prepare to administer CPR, and notify the physician. c) Stop the procedure, assess vital signs, and notify the physician. d) Stop the procedure, wait five minutes, and then resume the procedure.

c) Stop the procedure, assess vital signs, and notify the physician. When a patient complains of dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the physician. The vagal nerve may have been stimulated.

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? a. Diabetic ketoacidosis whose Glasgow coma Scale score changed from 10 to 7 b- Myxedema coma whose blood pressure changed from 80/50 to 70/40 c- Viral meningitis whose temperature changed from 101F to 102 F. d-Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

c- Viral meningitis whose temperature changed from 101F to 102 F.

A nurse working in a clinic is doing teaching regarding sexually transmitted Infections. The client cannot understand how syphillis was contracted because there has been no sexual activity for several days. As part of teaching, the nurse explains that the incubation period for syphilis is about: a. 1 month b. 1 week c. 2-3 weeks d. 2- 4 months

c. 2-3 weeks The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days). Health Promotion and Maintenance

An adult female client is admitted to the psychiatric unit because of a complex hand washing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's hand washing is an example of which clinical behavior? a. Addiction b. Phobia c. Compulsion d. Obsession

c. Compulsion

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the clients laboratory values? a. Platelet count b. Serum sodium level c. Neutrophil count d. Hematocrit

c. Neutrophil count

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 he blood pressure in the other arm b. tell the UAP to use a different sphygmomanometer c. Review the clients serum calcium level d. Administer PRN antianxiety medication

c. Review the clients 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.

A 7-year old is admitted to the hospital with persistent vomiting, and nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? a. Shift intake of 640mL IV fluids plus 30mL PO ice chips b. Serum pH of 7.45 c. Serum Potassium of 3.0 mg/dl d. Gastric output of 100 mL in the last 8 hours

c. Serum Potassium of 3.0 mg/dl

A client with chronic renal insufficiency is preparing for the discharge from the hospital. Which information is most important for the nurse to include in this client's discharge teaching? a. use of topical applications to manage pruritis b. Need for maintaining good oral hygiene c. instructions regarding a restricted protein diet d. strategies to promote independent self care

c. instructions regarding a restricted protein diet

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? a. I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best. b. I never use the inhaler unless I am feeling really short of breath c. I always shake the inhaler several times before i start d. After I squeeze the inhaler and swallow, I aways feel a slight wave of nausea, but it goes away

d. After I squeeze the inhaler and swallow, I aways feel a slight wave of nausea, but it goes away

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the client is experiencing any anxiety. b. Auscultate the client's bilateral lung sounds and oxygen saturation. c. Notify the healthcare provider about the client's distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Monitor daily sodium intake b. Record usual eating patterns c. Measure ankle circumference d. Auscultate for irregular heart rate

d. Auscultate for irregular heart rate Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? a. Rectus femenis b. Ventrogluteous c. vastus lateralis d. Deltoid

d. Deltoid Rationale: The acromion process is a parameter identified for the deltoid site.

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 minute after installation

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

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b.The nurse will encourage the client to walk thirty minutes everyday. c.The client's blood pressure readings will be less than 160/90 mmHg. d. The client's skin on the lower legs will be intact at the next clinical visit.

d. The client's skin on the lower legs will be intact at the next clinical visit.

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? a. rectus femenis b. ventrogluteous c. vastus lateralis d. deltoid

d. deltoid The acromion process is a parameter identified for the deltoid site.

The nurse is providing preoperative education for a jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? a. As the burn heals, the graft permanently attaches b. Grafts are later removed by a debriding procedure c. Grafting increases the risk for bacterial infections d. The xenograft is taken from non human sources

d. xenograft is taken from nonhuman sources.

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

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

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

dry roasted almonds