HESI Level 2 Practice Questions

Which information should the nurse provide clients about the advantages of an organic diet? A. Organic foods are easier to prepare than regular foods. B. Organic food is produced without using harmful chemicals. C. All populations have easy access to organic foods. D. Food produced by organic farming is more nutrient-dense.

B. Organic food is produced without using harmful chemicals.

A client with diabetes mellitus asks the nurse how many grams of carbohydrates can be consumed each day if the healthcare provider prescribes a 2000 calorie diet. What answer should the nurse provide? A. 300 Grams B. 250 Grams C. 200 Grams D. 350 Grams

250 Grams According to the American Diabetes Association, carbohydrates should be 50% of daily intake. Carbohydrates provide 4 calories/gram, so a 2000 calorie per day diet should include 1000 calories from carbohydrates, or 250 grams (1000 calories :: 4 calories/1 gram = 250 grams).

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What would be this client's expected date of delivery (EDD)? A. November 22. B. November 8. C. December 22. D. October 22.

A. November 22. November 22 is the answer. The nurse correctly applied Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. Gestational diabetes. B. Swelling in lower extremities. C. Elevated blood pressure. D. Urinary tract infection.

A. Gestational diabetes. The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.

The nurse is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the nurse assess as a normal value for the two hour postprandial result? A. 140 2. 180 C. 160 D. 200

A. 140mg/dl The two hour postprandial level should be less 140 mg/dl for a young adult client.

A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) A. Alcohol consumption can cause erectile dysfunction. B. Low testosterone levels affect sperm production. C. Marijuana cigarettes do not affect sperm count. D. Obesity has no effect on sperm production. E. Cessation of smoking improves general health and fertility.

A. Alcohol consumption can cause erectile dysfunction B. Low testosterone levels affect sperm production E. Cessation of smoking improves general health and fertility Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testosterone levels and obesity.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? A. Confusion and tachycardia. B. Polycythemia and crackles. C. Leukocytosis and febrile. D. Pharyngitis and sputum production.

A. Confusion and tachycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

The nurse is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. The nurse should prepare the client for which side effect that is most likely to persist during long-term use of opioids? A. Constipation. B. Sedation. C. Respiratory depression. D. Urinary retention.

A. Constipation. The client should be prepared to implement measures for constipation which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation and respiratory depression as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention but may subside. The most likely persistent side effect is constipation.

An 6-year-old child receives a prescription for the antibiotic tetracycline. Which side effect should the nurse review with the prescriber? A. Enamel hypoplasia and discoloration in developing teeth. B. Cross-hypersensitivity to penicillin's C. Skin rash last time ampicillin was prescribed. D. Nephrotoxicity and ototoxicity with long term use

A. Enamel hypoplasia and discoloration in developing teeth. Tetracycline's cause it in children who have not fully developed their permanent teeth,

The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? A. Encourage the family to give the client permission to die. B. Revoke the "do not resuscitate" advanced directive. C. Give the client pain medication during the end of life hours. D. Send the family to an area to seek spiritual comfort.

A. Encourage the family to give the client permission to die. Family members often have difficulty letting go of a dying family member. The nurse should encourage the family to give the client permission to die.

The nurse is assessing a client prior to administering the prescribed dose of atenolol (Tenormin) PO. The client's blood pressure is 120/68, and the telemetry monitor shows sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Based on this assessment, what intervention should the nurse implement? A. Give the medication as prescribed and continue to monitor the client. B. Prepare to administer atropine sulfate IVP. C. Hold the prescribed dose and contact the healthcare provider. D. Lower the head of the bed and assess the client for orthostatic vital sign changes.

A. Give the medication as prescribed and continue to monitor the client. Since the BP is within normal limits, and the pulse is above 50 with a first degree block, the medication can be administered. Atenolol (Tenormin) is a beta-blocker that slows the heart rate and lowers the blood pressure; this drug is generally held if the heart rate is less than 50 or the client exhibits dizziness related to hypotension.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder B. Perform leopolds maneuvers first C. Give the client some cold juice to drink D. Request the client lie on her left side.

A. Have the client empty her bladder. To avoid an elevation of the uterus, the client must empty the bladder prior to obtaining an accurate fundal height measurement.

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

A. Human papillomavirus. According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.

The nurse caring is caring for a client with advanced metastatic cancer that has not responded to treatment. The healthcare provider prescribes palliative care only. Which intervention should the nurse withhold? A. Intubation with mechanical ventilation. B. Regular diet as tolerated. C. Bronchodilators for shortness of breath. D. Around-the-clock pain medication.

A. Intubation with mechanical ventilation. Palliative care provides clients with comfort measures as they near the end of life. When the healthcare provider prescribes palliative care only, the nurse should withhold life-saving interventions, such as intubation with mechanical ventilation.

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? A. Make sure to include adequate folic acid in the diet. B. Continue to take any medications that are taken regularly. C. Discontinue all forms of contraception. D. Lose weight so more weight is gained during pregnancy.

A. Make sure to include folic acid in the diet A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period reduces the risk of neural tube defects. Recommendations to stop or continue medications during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy is not indicated as a generalization and may place the client at risk for nutritional deficiencies.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. Which action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Determine if the clients spouse is willing to sign the consent form. C. Administer an opioid antagonist prior to obtaining the clients signature. D. Read the consent form to the client before witnessing the clients signature.

A. Notify the surgeon that the consent form has not been signed. Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? A. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. B. Pain upon arising in the morning which is relieved after some stretching and exercise. C. Pain in the calf awakening him from a sound sleep. D. Calf pain on exertion which stops when standing in one place.

A. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place.

A healthcare provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the nurse to assess for what additional drug allergy before administering this prescription? A. Penicillin's B. Aminoglycosides C. Erythromycins D. Sulfonamides

A. Penicillin's Cross-allergies exist between penicillin's and cephalosporin's, such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.

The nurse is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats.

A. Phlegm production and wheezing. A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes.

The school nurse is teaching a group of male adolescent clients about testicular self-examination. Which teaching aid should the school nurse use? A. Plastic model of testicles. B. Illustrated pamphlet. C. Written instructions. D. Audio instructions.

A. Plastic model of testicles. Teaching aids for adolescents should promote student engagement. A plastic model is something the adolescents can touch and use to practice return demonstrations.

What teaching should the nurse provide a client who has received a new prescription for sildenafil (Viagra)? (Select all that apply.) A. Report rebound priapism that occurs for 4 hours or more. B. Can cause facial flushing and headache. C. Frequent use can lead to the development of hypertension. D. Most effective if taken after at least 6 hours of REM sleep. E. Take within 30 to 60 minutes of sexual stimulation.

A. Report rebound priapism that occurs for 4 hours or more. B. Can cause facial flushing and headache E. Take within 30-60 minutes of sexual stimulation Sildenafil (Viagra) enhances the natural response to sexual stimuli, so a client should be instructed to take Viagra within 30 to 60 minutes before sexual intercourse to provide adequate time to enhance penile erection. Sildenafil does not cause erection directly, but priapism can occur and should be reported to the healthcare provider if it persists. Common side effects include headaches, facial flushing, and diarrhea. Viagra can potentiate vasodilators, such as alpha-adrenergic blockers, nitroglycerin, and other nitrates used for angina pectoris, and may cause hypotension, which decreases perfusion to vital organs.

A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? A. Serum BUN and creatinine levels. B. Frequency of emesis in the last 8 hours. C. Appearance of the stool. D. Current blood sugar level.

A. Serum BUN and creatinine levels Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids.

A client calls the clinic and states that she forgot to take her oral contraceptives for the past two days. Which instruction is best for the nurse to provide to this client? A. Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. B. Take 4 pills now and use an alternate method of contraception for the rest of this cycle. C. Take one extra pill per day for the rest of this cycle, then resume taking pills as usual next cycle. D. Quit the pills for this cycle, use an alternate method of contraception, and resume pills on the fifth day of menstruation.

A. Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. If two pills are missed in a roll, the client should take 2 pills a day for two days and used an alternative form of birth control for seven days.

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? A. The growing uterus is putting pressure on the bladder B. The client may have a bladder or kidney infection C. Bladder capacity increases during pregnancy. D. During pregnancy a woman is especially sensitive to body functions.

A. The growing uterus is putting pressure on the bladder. Urinary frequency is a normal discomfort during the first trimester, when the enlarging uterus is still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on urination, and a kidney infection is usually accompanied by pain and fever. Bladder capacity does increase to about 1,500 mL during pregnancy, but increased capacity does not cause urinary frequency.

A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? A. The pregnancy should progress normally and be considered low risk. B. Natural child birth without analgesia is used to manage pain during labor. C. Birth in the home setting is the preference for a using a midwife for delivery. D. An obstetrician should also follow the client during pregnancy.

A. The pregnancy should progress normally and be considered low risk. A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client.

A client at 29-weeks' gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? A. Ultrasonography. B. Chorionic villus sampling. C. Maternal serum alpha-fetoprotein. D. Amniocentesis.

A. Ultrasonography. Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A. "It won't hurt because you're such a big boy." B. "It may hurt but we'll give you medicine to help you feel better." C. "It may hurt a little because of the incision made in your throat." D. "It won't hurt because we put you to sleep."

B. "It may hurt but we'll give you medicine to help you feel better." Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team.

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? A. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease." B. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." C. "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer." D. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle."

B. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.

An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client? A. Change the patch every other day while on the cruise. B. Apply the patch at least 4 hours prior to departure. C. Place the patch on a hairless area at the base of the skull. D. Drink no more than 2 alcoholic drinks during the cruise.

B. Apply the patch at least 4 hours prior to departure. Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours before departure on the cruise ship. The duration of the transdermal patch is 72 hours. Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so the best application site of the patch is behind the ear. Anticholinergic medications are CNS depressants, so the client should be instructed to avoid alcohol while using the patch.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What actions should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Obtain and place a portable commode by the bed. B. Ask the client to push the IV pole to the chair. C. Assess the client's blood pressure. D. Inform the client of the plan for moving to the chair. E. Clamp the indwelling catheter. F. Pre-medicate the client with an analgesic.

B. Ask the client to push the IV pole to the chair. C. Assess the client's blood pressure. D. Inform the client of the plan for moving to the chair. F. Pre-medicate the client with an analgesic. Pre-medicating the client with an analgesic reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair and encourage the client to participate by pushing the IV pole when walking to the chair. The nurse should assess the client's blood pressure prior to mobilization, which can cause orthostatic hypotension.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use? A. Volumetric controller. B. Cassette infusion pump. C. Nonvolumetric controller. D. Portable syringe pump.

B. Cassette infusion pump. A cassette pump should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as mL/hour. A syringe pump is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric and nonvolumetric controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variations in drop size.

The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? A. Number of years since diabetes was diagnosed. B. Degree of glycemic control during pregnancy. C. Mother's age. D. Amount of insulin required prenatally.

B. Degree of glycemic control during pregnancy. Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes. Risk assessment is best done by evaluating the woman's blood glucose and blood vessels, not by evaluating mother's age, number of years since diabetes was diagnosed, or the amount of insulin required prenatally.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks' gestation. What type of emotional response should the nurse anticipate? A. Relief of ambivalent feelings experienced with this pregnancy. B. Grief related to her perceptions about the loss of this child. C. Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

B. Grief related to her perceptions about the loss of this child. Clients can experience grief/loss response at all stages of pregnancy loss.

A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? A. Cheyne stokes respirations. B. Kussmaul respirations. C. Apnea. D. Orthopnea.

B. Kussmaul respirations. Metabolic acidosis in DKA causes compensatory responses to increase the blood pH which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The nurse should document the client's respiratory rate and Kussmaul respiratory pattern.

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? A. Palpate the pedal pulse volume. B. Measure the blood pressure. C. Assess for a carotid bruit. D. Count the brachial pulse rate.

B. Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Move about every hour. C. Avoid constrictive clothing. D. Reduce salt in her diet.

B. Move about every hour. Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.

The nurse receives the laboratory results of theophylline level of 25 mcg/dL for a child with asthma. What action should the nurse implement? A. Repeat the laboratory test after the next dose. B. Notify the healthcare provider. C. Share the results during end of shift report. D. Administer the medication as ordered.

B. Notify the healthcare provider. The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is outside the therapeutic range. The nurse should report the findings to healthcare provider so dose adjustments can be prescribed.

A client receives a new prescription for pentazocine (Talwin), a mixed opioid agonist-antagonist, after an opioid agonist is discontinued. What is the advantage for the client when the new prescription is implemented? A. Tolerance does not occur. B. Respiratory depression is less. C. The analgesic ceiling is higher. D. Less agitation is experienced.

B. Respiratory depression is less. Mixed agonist-antagonists bind as an agonist at the Kappa receptor and as antagonists or partial agonists on the mu receptor, which produces less respiratory depression than opioid agonists that are pure mu agonists.

During a home health visit, a male client reports to the nurse that he felt a solid testicular mass during self-exam, but that it wasn't painful. What instruction should the nurse provide the client? A. Continue to monitor the mass until the next scheduled annual medical exam. B. Schedule an appointment with the healthcare provider for prompt evaluation. C. Testicular nodules are of concern only if they feel matted or are not easily movable. D. Notify the healthcare provider if the mass becomes soft, painful, or starts to drain.

B. Schedule an appointment with the healthcare provider for prompt evaluation. A solid mass that is not painful is an abnormal finding that needs to be checked out by the doctor.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? A. Excretes prolactin and insulin. B. Secretes both estrogen and progesterone. C. Produces nutrients for fetal nutrition. D. Forms a protective, impenetrable barrier

B. Secretes both estrogen and progesterone. One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to maintain the pregnancy and support the embryo and fetus.

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Bruising on extremities. B. Skin cool to touch. C. Capillary refill less than 3 seconds. D. Darkened skin on extremities. E. Diminished hair on legs.

B. Skin cool to touch. E. Diminished hair on legs. Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other choices are not indicators for impaired peripheral circulation.

The nurse is giving preoperative instructions to a school-aged child who is scheduled for sedation for closed reduction for a broken tibia. Which response by the child best indicates understanding of self care? A. The same self care is indicated as a sibling who broke the arm. B. Swelling of the toes should be reported to the healthcare provider. C. Playing with friends has no restrictions after 24 hours. D. Written literature of instructions helps to remember self care.

B. Swelling of the toes should be reported to the healthcare provider Verbalizing self-care and observations about potential complications, such as swelling below the cast or below the fracture site, provide the best evaluation of teaching.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? A. Collateral circulation increases as the tumor grows. B. The cell count of the tumor reduces by half with each dose. C. Sensitivity of cancer cells to CT is based on cell cycle rate. D. Side effects are less likely if therapy is started early.

B. The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? A. " I will let you have one cracker, but that is all you can have for the rest of tonight" B. "The test you are having tomorrow requires that you have nothing by mouth tonight." C. "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight." D. "What did the healthcare provider tell you about the test you are having tomorrow?"

B. The test you are having tomorrow requires that you have nothing by mouth tonight Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

The nurse is caring for a client who has pernicious anemia. Which vitamin deficiency is associated with this type of anemia? A. Vitamin B6. B. Vitamin B12. C. Vitamin D. D. Vitamin C.

B. Vitamin B12. In pernicious anemia, a deficit of hydrochloric acid secretion by the stomach also results in a deficit of intrinsic factor which is needed for the body to absorb vitamin B12 for utilization by the bone marrow in erythropoiesis.

The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A. Check the client's apical pulse. B. Withhold the scheduled dose. C. Notify the healthcare provider. D. Repeat the serum potassium level.

B. Withhold the scheduled dose. The nurse should first withhold the scheduled dose of Cozaar because the client is hyperkalemic (normal range 3.5 to 5 mEq/l). Although hypokalemia is usually associated with diuretic therapy in heart failure, hyperkalemia is associated with several heart failure medications, including ARBs. Because hyperkalemia may lead to cardiac dysrhythmias, the nurse should check the apical pulse for rate and rhythm, and the blood pressure.

A mother and her early adolescent son ask questions about taking growth hormones by injection to help him grow taller. What information should the nurse provide to address their concerns? A. Growing too tall may interfere with self esteem and social status. B. Understanding there are more important qualities for males than height. C. Achieving the goal of growing taller requires medications by injections. D. Taking growth hormones is not always effective in improving height.

C. Achieving the goal of growing taller requires medications by injections It is important to validate feelings about hormone therapy during adolescence. The nurse should address the questions about the route of administration to achieve growth before the epiphyseal plates close. The information about achieving therapeutic effects of growth hormone should re-enforce that hormonal therapy by injection is often prescribed several times a week during the growth years.

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A. Ready the client to discharge B. Notify pastoral care to offer the client a blessing C. Ask the client what name she picked out for her infant D. Inquire if the client would like to see what was obtained from her D&C

C. Ask the client what name she had picked out for the infant. The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

An adolescent female reports to the nurse that she is experiencing a glutinous, gray-white vaginal discharge. A vaginal smear reveals no infectious organism in the sample. Which information should the nurse provide? A. Begin to douche with vinegar solution BID. B. Stop taking any current antibiotics. C. Avoid use of deodorant tampons. D. Use an over-the-counter sexual barrier.

C. Avoid use of deodorant tampons. Leukorrhea, a glutinous, gray-white discharge, is often caused by physical, chemical or infectious agents. Removal of the irritant is usually all that is necessary to reduce symtoms. The nurse should recommend that the client stop using deodorant tampons or bubble baths, that cause vaginal irritation.

A male client with meningitis is prescribed cefotaxime (Claforan) IV and asks the nurse why he cannot receive an oral drug, such as cefaclor (Ceclor) or cefadroxil (Duricef), that he has taken before for infections. How should the nurse respond when considering the actions of cephalosporins? A. Cefazolin (Ancef) is another IV antibiotic that can be prescribed. B. Cefadroxil (Duricef) is usually prescribed when the IV is discontinued. C. Cefotaxime (Claforan) provides therapeutic CNS concentrations. D. Cefaclor (Ceclor) is a good alternative to suggest to the healthcare provider.

C. Cefotaxime (Claforan) provides therapeutic CNS concentrations. According to research studies, only third generation cephalosporins such as cefotaxime (Claforan), and ceftazidime have been shown effective in treating bacterial meningitis with the exception of cefuroxime, the only second generation cephalosporin shown to be effective. First generation cephalosporins have not been successful in the treatment of bacterial meningitis. IV administration of these antibiotics are preferred route of administration due to oral administration medication levels tend to be too low to be effective in comparison to parental administration.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? A. Increase in heart sounds (S1 & S2) B. Increased in RBC production C. Decrease in pulse rate D. Decrease in blood pressure

C. Decrease in pulse rate. Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mmHg, a more audible splitting of S1 and S2 occurs, and there is an accelerated production of red blood cells.

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? A. Suprapubic pain and distention B. Bounding pulse at 100bpm C. Finger stick glucose of 300mg/dl D. Small vesicular perineal lesions

C. Finger stick glucose of 300mg/dl Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Explore the abdominal area for distension. B. Take vital signs for temperature elevation. C. Inquire about the source and type of pain. D. Examine the nose for congestion and discharge.

C. Inquire about the source and the type of pain Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain.

Which information should the nurse provide when teaching a client with diabetes about the role of glucose in the body? A. It synthesizes proteins B. It stimulates osteogenesis C. It provides energy for the cells D. It exacerbates cachexia.

C. It provides energy for the cells Normal control mechanisms ensure sufficient circulating blood glucose to meet the body's constant energy needs (including basal metabolic energy needs during sleep) because glucose is the body's preferred fuel. Under normal conditions, the body converts glucose to adenosine triphosphate (ATP), which provides the energy needed for the body's metabolic processes.

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? A. Continue to take any medications that are taken regularly. B. Discontinue all forms of contraception. C. Make sure to include adequate folic acid in the diet. D. Lose weight so more weight is gained during pregnancy.

C. Make sure to include adequate folic acid in the diet. A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period reduces the risk of neural tube defects. Recommendations to stop or continue medications during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy is not indicated as a generalization and may place the client at risk for nutritional deficiencies.

The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the nurse use to determine the client's pain? A. FACES pain scale. B. Review documentation. C. Observe for facial grimacing. D. Ask client to rate pain on a scale of 1 of 10.

C. Observe for facial Grimacing Observing for facial grimacing is the best method for evaluating pain for a client who cannot communicate due to Alzheimer's disease.

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

C. Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.

A healthcare provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the nurse to assess for what additional drug allergy before administering this prescription. A. Sulfonamides B. Amino glycerides C. Penicillin D. Erythromycins

C. Penicillin's Cross-allergies exist between penicillins and cephalosporins, such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.

A deficiency of intrinsic factor should alert the nurse to assess a client's history for which condition? A. Emphysema. B. Oxalic acid toxicity. C. Pernicious anemia. D. Hemophilia.

C. Pernicious anemia. Pernicious anemia is a type of anemia due to failure of absorption of cobalamin (Vit B12). The most common cause is lack of intrinsic factor, a glucoprotein produced by the parietal cells of the gastric lining.

Which social detriment has shown to increase the rate of teen pregnancies in a community? A. Age B. Ethnicity C. Poverty D. Culture

C. Poverty A social detriment of health that influences the teen pregnancy rate is poverty. One-third of pregnant teenagers come from a low socioeconomic background regardless of ethnicity. Other risk factors for teen pregnancy rates include education, social support systems, and living environment.

The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider? A. Presence of expiratory wheezes in the lower lobes. B. History of COPD. C. Prescription for an additional respiratory treatment. D. Admission today with difficulty breathing.

C. Prescription for an additional respiratory treatment. The SBAR reporting format uses client information that includes the Situation, Background, Assessment, Recommendation. The nurse should complete the report with a recommendation, such as a prescription for an additional breathing treatment.

The nurse should explain to a 30-year-old primigravida client that alpha fetoprotein testing is recommended for which purpose? A. Monitor the placental functioning. B. Detect cardiovascular disorders. C. Screen for neural tube defects. D. Assess for maternal pre-eclampsia.

C. Screen for neural tube defects. Alpha-fetoprotein (AFP) is a screening test used in pregnancy to rule out neural tube defects. Elevated AFP may indicate an increased rish of neural tube defects such as anencephaly and spinal bifida.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. Her hobby is playing classical music on the piano. B. Her healthcare provider now prescribes a calcium channel blocker for hypertension. C. She sustained and insect bite to her left arm yesterday. D. She has lost twenty pounds since the surgery.

C. She sustained an insect bite to her left arm yesterday. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A. Polyuria, polydipsia, polyphagia. B. Fruity breath, tachypnea, chest pain. C. Sweating, trembling, tachycardia. D. Nausea, vomiting, anorexia.

C. Sweating, trembling, tachycardia. Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar.

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A. Encourage older siblings to visit B. give small, frequent feedings of fluids C. Have a bulb syringe readily available to relieve secretions D. Accurately chart observations regarding breath sounds

C. have a bulb syringe readily available to remove secretions A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and having suction equipment at the crib side the highest priority to maintain a patent airway.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. Veins are located deep in the feet and ankles, resulting in a more painful procedure. B. A cannulated extremity is more difficult to move when the leg or foot is used. C. It is more difficult to find a superficial vein in the feet and ankles. D. A decreased flow rate could result in the formation of a thrombosis.

D. A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation which, if dislodged, could be life-threatening.

The nurse is teaching a male adolescent and his family about receiving injections of growth hormone for idiopathic hypopituitarism. Which information should the nurse plan to discuss with the adolescent and his family? A. Lethargy and fatigue requiring hospitalization B. Increased Facial hair C. Weight and height measured on awakening D. Administration at bedtime

D. Administration at bedtime Growth hormone (GH), somatotropin hormone STH), is produced by the anterior pituitary gland, which normally releases GH during the first 45-90 minutes after the onset of sleep. The nurse should explain that the most effective time to administer GH is at bedtime.

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? A. Amount of weight gain or weight loss during the previous year. B. Skin pigmentation and hair texture for evidence of hormonal changes. C. Previous birth-control methods and beliefs about the calendar method. D. An accurate menstrual cycle diary for the past 6 to 12 months.

D. An accurate menstrual cycle diary for the past 6-12 months The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and being compliant in recording the menstrual diary is the basis of the calendar method.

A female client visits the clinic stating she had a positive result on a home pregnancy test. The first day of her last period was July 13. What is the estimated date of birth? A. October 20. B. January 16. C. December 10. D. April 20.

D. April 20. Naegele's rule estimates expected delivery dates by subtracting 3 months and adding 7 days from a client's last menstrual period. If the first day of the last period was July 13, the client is due April 20.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A. Find out if the client has a special outfit for the infant after the birth. B. Discuss with the parents which funeral home should be notified. C. Inquire if the parents want a picture taken after the infant is born. D. Ask the family if they would like to see and hold the infant after birth.

D. Ask the family if they would like to see and hold the infant after birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth. The other actions should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant.

A client who is 5 foot 5 inches (165 cm) tall and weighs 200 pounds (90.9 kilograms) is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. Do you feel that you are overweight?" B. "Will a clear liquid diet be okay after surgery?" C. "What is your daily calorie consumption?" D. "What vitamin and mineral supplements do you take?"

D. "What vitamin and mineral supplements do you take?" In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.

Which client has the greatest risk for developing community-acquired pneumonia? A. A 75-year-old retired secretary with exercise-induced wheezing. B. A 35-year-old aerobics instructor who skips meals and eats only vegetables. C. A 40-year-old first-grade teacher who works with underprivileged children. D. A 60-year-old homeless person who is an alcoholic and smokes.

D. A 60-year-old homeless person who is an alcoholic and smokes. Although age is a factor in the development of community-acquired pneumonia, other lifestyle behaviors, such as smoking, alcoholism, and exposure factors related to homelessness increase one's risk due to impaired nutrition and immune function.

Which change in data indicates to the nurse that the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved? A. Pulse rate reduced from 150 to 90 beats/minute. B. Dependent edema reduced from +3 to +1. C. Serum HDL increased from 35 to 55 mg/dl. D. Blood pressure reduced from 160/90 to 130/80.

D. Blood pressure reduced from 160/90 to 130/80. Diovan is an angiotensin receptor blocker, prescribed for the treatment of hypertension. The desired effect is a decrease in blood pressure.

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

D. Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.

The nurse formulates the nursing diagnosis "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Cannot identify signs or symptoms of high and low blood glucose. C. Occasionally forgets to take daily prescribed medication. D. Eats anything and does not think diet makes a difference in health.

D. Eats anything and does not think diet makes a difference in health The nursing diagnosis of ineffective health maintenance related to lack of motivation refers to the client's choice not to identify, manage, and/or seek out help to maintain health. This is best exemplified in the client's demonstration and belief about the interaction between diet and health maintenance of Type 2 diabetes.

Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A. Breasts feel lumpy when palpated. B. Excessive diaphoresis occurs at night. C. History of white nipple discharge. D. Episodes of vaginal bleeding.

D. Episodes of vaginal bleeding. Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the healthcare provider.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Allow the situation to continue until a family member's action may harm the client. B. Suggest that other cultural practices be substituted by the family members. C. Explain to the family that multiple visitors are exhausting to the client. D. Examine one's own culturally based values, beliefs, attitudes, and practices.

D. Examine one's own culturally based values, beliefs, attitudes, and practices. Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias.

Which items should the nurse include when developing a daily meal plan for a client with hypertension? A. Two servings of whole grains. B. Four servings of dairy. C. Nine servings of fruit. D. Five servings of vegetables.

D. Five servings of vegetables. When developing a daily meal plan for a client with hypertension, the nurse should include four to five servings of vegetables in the client's meal plan as recommended by the National Institutes of Health in the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH diet is recommended to prevent and control hypertension.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Decreased serum sodium, an increased urine specific gravity. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased WBC, decreased RBC. D. Increased protein in the urine, slightly increased serum glucose levels.

D. Increased protein in the urine, slightly increased serum glucose levels. As older adults aged, the protein found in urine slightly rises as a result of kidney changes and the serum glucose increases slightly, also due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A. Stage II. B. T1N0M0. C. Invasive infiltrating ductal carcinoma. D. Inflammatory with peau d'orange.

D. Inflammatory with peau d'orange. Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender.

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A. Tell them there is nothing to fear. B. Respect their wishes release the body to the morgue. C. Insist that they hold infant so they can grieve. D. Keep the body available for a few hours in case they change their minds.

D. Keep the body available for a few hours in case they change their minds. Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated.

A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? A. Gait characteristics. B. Bladder control ability. C. Presence of trauma. D. Level of consciousness.

D. Level of consciousness. Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level of consciousness. It is necessary to determine if the client is demonstrating signs of meningitis before planning immediate care.

The nurse administers the initial dose of a fentanyl (Duragesic) transdermal patch to a client with chronic pain. When monitoring the client an hour later, which assessment is most important for the nurse to obtain? A. Moistness of mucosa. B. Level of consciousness. C. Bowel sound activity. D. Numeric pain scale.

D. Numeric pain scale. Transdermal fentanyl, an opioid analgesic, has an onset and peak of 6 to 12 hours after the initial dose, so it is most important to determine the client's level of pain, which can persist as breakthrough pain throughout the 72-hour duration of the patch.

The nurse is teaching a 5-year-old child with type 1 diabetes mellitus. Based on developmental skills of a 5-year-old, which task is most appropriate for the nurse to teach the child? A. Selection of high carb food from a chart. B. Administration of subQ insulin injections. C. Preparation of a the correct insulin dose. D. Performance of glucose testing.

D. Performance of glucose testing. Developmentally, a 5-year-old should have the cognitive and psychomotor skills to use a glucose monitoring device and read or repeat the numeral results displayed on the digital screen.

A client with heart failure is prescribed spironolactone (Aldactone). Which information is most important for the nurse to provide to the client about diet modifications? A. Restrict fluid intake to 1000 ml per day. B. Do not add salt to foods during preparation. C. Increase intake of milk and milk products. D. Refrain for eating foods high in potassium.

D. Refrain for eating foods high in potassium. Spironolactone (Aldactone), an aldosterone antagonist, is a potassium-sparing diuretic, so a diet high in potassium should be avoided, along with table salt substitutes that generally contain potassium chloride that can lead to hyperkalemia.

The nurse is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the nurse instruct the client to use at home? A. Weekly medication box. B. Blood glucose monitor. C. Exercise bicycle. D. Sphygmomanometer.

D. Sphygmomanometer. Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.

A child is admitted to the postanesthesia care unit (PACU) after receiving general anesthesia in surgery. When the child becomes reactive, the nurse identifies that the child is febrile and has rigid muscles. Which finding requires the nurse to immediately call the urgent response team, including the surgeon and anesthesiologist? A. Diaphoresis. B. Flushed skin. C. Brown or cola-colored urine. D. Tachydysrhythmias.

D. Tachydysrhythmias. Malignant hyperthermia, a potentially life threatening genetic myopathy, causes a reaction to general anesthesia and is manifested by a significantly change in vital signs that demands immediate intervention in the perioperative period. Tachycardia and tachydysrhythmias, including muscle rigidity, require prompt treatment with antiarrythmic drugs and muscle relaxants, such as dantrolene (Dantrium) to stop muscular metabolism.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The order in which the information is presented. B. The client's educational background. C. The extent to which the pregnancy was planned. D. The client's readiness to learn.

D. The clients readiness to learn When teaching any client, readiness to learn is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery, but is probably very ready to learn about ways to relieve morning sickness.

The nurse is reviewing the use of the patient-controlled analgesia (PCA) pump with a client in the immediate postoperative period. The client will receive morphine 1 mg IV per hour basal rate with 1 mg IV every 15 minutes per PCA to total 5 mg IV maximally per hour. What assessment has the highest priority before initiating the PCA pump? A. The type of anesthesia used during the surgical procedure. B. The client's subjective and objective signs of pain. C. The expiration date on the morphine syringe in the pump. D. The rate and depth of the client's respirations.

D. The rate and depth of the client's respirations. A life-threatening side effect of intravenous administration of morphine sulfate, an opiate narcotic, is respiratory depression. Prior to the initiation of the PCA pump, the nurse should assess the client's respirations to obtain a baseline of their respiratory rate and depth. Once the PCA pump is initiated and if the client's respiratory rate falls below 12 breaths per minute, the PCA pump should be stopped and the healthcare provider notified immediately.

The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation? A. Ask the pharmacy to provide an enteric tablet. B. Administer the medication using an oral syringe. C. Mix the medication in water. D. Use a colorful straw.

D. Use a colorful straw. A liquid iron preparation should be administered through a straw to help prevent staining of the teeth and may help the child to accept the medication since young children consider drinking from a colorful straw fun.

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? A. Tented skin on dorsal surface of hands. B. Urine specific gravity 1.001. C. Apical pulse 100 and blood pressure 76/42. D. Urine output of 40 mL/hour.

Urine output of 40mL/hour The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.