HESI Management

The healthcare provider prescribes dalleparin 200 units/kg SUBQ once a day for a client who weighs 154 lbs. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer?

0.6

An adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

B. Incorrectly administered too much insulin.

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

C. A Hemovac drain is partially full of serous drainage and is not compressed

An adolescent client who has been treated in the past for a seizure disorder is admitted to the hospital immediately after admission the client begins to have a grand mal seizure. Which action should the nurse implement?

D. Call the rapid response team

A client with persistent low back pain has received a prescription for an 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?

D. Determine if the sensation feels uncomfortable

An adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school. On the second day of hospitalization, the nurse asks the client to meet with the treatment team. After the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best?

D. Go to the client's room and ask what happened?

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTR's)?

D. If the client has an elevated blood pressure

The nurse discovers that an older adult client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, which information is most important for the nurse to obtain from the clients medical history?

D. Ingestion of shellfish or fish oil capsules daily

ORDERS 0330 -Place the client on cardiorespiratory monitor -NPO -Sputum Culture -Start a peripheral IV(PIV) infusion -Start oxygen 3L/minute via NC -Begin 0.9% sodium chloride IV infusion at 150ml/hr -Acetaminophen 350mg PO every 6 hours for temperature greater than To start the client on oxygen as ordered, which item(s) should the nurse collect from the supply room? Select all that apply. A. Humidifier bottle B. Suction cannister C. Sterile water D. Nasal Cannula E. Flowmeter F. Lamb's wool G. Tape

D. Nasal Cannula E. Flowmeter

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspect the client may have had a pulmonary embolus. Which action should the nurse take first?

D. Notify the healthcare provider

During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review. Which food choices include it on the clients list should the nurse encouraged? SATA. A) Cheddar cheese cubes. B) Canned fruit in heavy syrup. C) Lightly salted potato chips. D) Plain, air-popped popcorn. E) Natural whole almonds.

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

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Reference range: Blood alcohol level (0 to 0.05%) Lithium (0.8 to 1.2 mEq/L)

D. Serum Lithium level of 1.6 mEq/L

0500 -Increase oxygen to 8 L/minute via simple face mask, titrate to keep oxygen saturation greater than 94%

I can adjust the oxygen level on the flowmeter to keep the client's oxygen saturation greater than 94% (LEFT) The mask should cover only the mouth and leave the nose open for expiration (RIGHT) I should place the mask first over the nose and then cover the mouth (LEFT)

An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for enteral feedings after corrective surgery period to promote normal growth and development of the infant, which action should the nurse include in the plan of care?

Offer a pacifier for non-nutritive sucking

The client is a 34 year old female who had a surgical procedure to remove a benign abdominal tumor.

The tubing should be tucked under the chin and secured with the sliding adjustment piece---Left (Understanding) Humidification of oxygen is not needed for administration under 4 L/minute---Left (Understanding) The nasal cannula can deliver up to 10 L/minute of oxygen---Right (Not understanding) A nasal cannula delivers 100% oxygen to the client---RIght (Not understanding)

HISTORY AND PHYSICAL The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated "I feel so sad that I can't seem to feel anything at all." in addition to her father, the client has a large family and friend support system. She denies alcohol or drug use. Which statements need follow-up immediately?

"she only gets 2 to 3 hours of sleep due to nightmares about the crash" "She feels that she is "jumpy" after the accident, especially when she is in the car." "I feel so sad that I can't seem to feel anything at all"

NGN: (Nurses Notes)1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, ..... For each assessment finding, click to indicate whether the findings are associated with an infant of a diabetic mother or normal presentation. -Mongolian spot. -Acrocyanosis. -Jittery at 30 minutes of age. -Blood glucose 35. -Billirubin 7. -Respiratory rate 80 breaths per minute. -Apgar 7 at one minute, 8 at five minutes. -Soft fontanelles

-Mongolian spot. (NORMAL) -Acrocyanosis. (NORMAL) -Jittery at 30 minutes of age. (NOT NORMAL) -Blood glucose 35. (NOT NORMAL) -Billirubin 7. (NOT NORMAL) -Respiratory rate 80 breaths per minute. (NORMAL) -Apgar 7 at one minute, 8 at five minutes. (NORMAL) -Soft fontanelles (NORMAL)

NGN: Day 2 0630: Vitals have remained stable throughout the night. Oxygen 98% on 0.25 L per minute oxygen via nasal cannula. Mother to breast-feed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60, temp 97.8 F axillary when you return to warmer and Billy Rubin light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal limits. Direct bilirubin five. Discharge teaching initiated, with goal of discharging infant and mother on day three. Highlight notes that demonstrate improvement.

-Vitals have remained stable -Oxygen 98% on 0.25 L per minute oxygen via nasal cannula -Able to tolerate breastmilk. -Glucose after feeding was 60, temp 97.8 F axillary -Calcium and magnesium within normal limits. -Direct bilirubin five

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom) -Document reaction to the drug -Contact the healthcare provider -Assess vital signs -Stop the infusion -Initiate adverse event report

1. Stop the infusion 2. Assess the vital signs 3. Contact healthcare provider 4. Initiate adverse event report 5. Document reaction to the drug

A client who is 65 kg receives a prescription for lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th)

1.4

A client receives a prescription for Aceta medicine 1000 mg PO every eight hours PRN for pain. The bottle is labeled acetaminophen for oral suspension, US P 500 mg per 15 mL. How many tablespoons should the nurse administer with each dose? (Enter numerical value only.)

2

A client is receiving IV fluids by gravity infusion and exhibit signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess first?

A

NGN: For newborn baby. Which six orders take priority? A) Transfer to neonatal intensive care unit. B) Blood glucose level. C) Feed immediately. D) Bolus of 2 mL per kilogram glucose 10% IV. E) Monitor for respiratory distress. F) Echocardiogram. G) Contact respiratory therapy for ABG and oxygen therapy. H) Monitor temperature every 30 minutes. I) Keep in warmer with bilirubin lights. J) Apply dextrose gel inside the babies cheek.

A) Transfer to neonatal intensive care unit. B) Blood glucose level. C) Feed immediately. D) Bolus of 2 mL per kilogram glucose 10% IV. E) Monitor for respiratory distress. J) Apply dextrose gel inside the babies cheek.

A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory test indicate an elevated thyroid stimulating hormone (TSH) and low trilodothyronine (T3) and thyroxine (T4) levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement?

A. Administer prescribed dose of levothyroxine

The nurse is assigned to care for four surgical clients. After receiving report, which clielnt should the nurse see first?

A. An older client who is receiving packed red blood cells on the third day postoperative for colon resection.

A client is receiving mesalamine 800 mg PO three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

A. Bowel patterns Ulcerative colitis medication that helps with inflammation in the GI

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. Which action should the nurse implement first? A) Check for a distended bladder. B) Review the hemoglobin to determine hemorrhage. C) Increase IV infusion rate. D) Massage the uterus to decrease atony.

A. Check for a distended bladder

When conducting diet teaching for a client who is on a postoperative full liquid diet, which food(s) should the nurse encourage the client to eat? SATA A. Clear beef broth B. Vanilla frozen yogurt C. Vegetable juice D. Creamy peanut butter E. Canned fruit cocktail

A. Clear beef broth C. Vegetabel juice

Before leaving the room of a confuse client, the nurse notes that a half bow not was used to attach the clients wrist restraints to the movable portion of the clients bed frame. What action should the nurse take before leaving the room?

A. Ensure that the knot can be quickly released

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA. Which nursing intervention should the nurse include in the plan of care? SATA. A) Institute contact precautions for staff and visitors. B) Use standard precautions and wear a mask. C) Send wound drainage for culture and sensitivity. D) Monitor the clients white blood cell count. E) Explain the purpose of a low bacteria diet.

A. Institute contact precautions for staff and visitors C. Send wound drainage for culture and sensitivity. D. Monitor the client's white blood cell count.

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action should the nurse take? SATA. A) Instruct the adult child to check the clients temperature. B) Encourage increased intake of high protein foods. C) Determine if the client has recently experienced a fall. D) Reviewed the clients current food and medication allergies. E) Ask if the client is experiencing any pain with urination.

A. Instruct the adult child to check the client's temperature C. Determine if the client has recently experienced a fall E. Ask if the client is experiencing any pain with urination

A child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A) Instructions about how much fluid the child to drink daily. B) Referral for social services for the child and family. C) Signs of addiction to opioid pain medications. D) Information about nonpharmaceutical pain relief measures.

A. Instructions about how much fluid the child to drink daily

Which nursing intervention is most important when caring for a client with alcohol withdrawal delirium?

A. Maintain a quiet, non-stimulating environment

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multiple-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

A. Maintain strict intake and output

Older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation.? Select all that apply. A) Place a bedside commode next to bed. B) Measure neurological bagel signs every four hours. C) Play classical music in room while client is awake. D) Section oral cavity every four hours. E) Encourage family to participate in the clients care.

A. Place a bedside commode next to bed E. Encourage family to participate in the client's care

A client with unilateral hearing loss is admitted for a schedule surgery. Which technique should the nurse use to provide education about pain relief options?

A. Speak directly facing the client

HISTORY AND PHYSICAL The client is a 49-year old male who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED) last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. Which 2 orders should the nurse complete first? A. Sputum culture B. Start oxygen 3 L/minute via nasal cannula C. Place the client on a cardiorespiratory monitor. D. Chest x-ray E. Acetaminophen 350mg PO every 6 hours for temperature F. Run 0.9% sodium chloride IV infusion at 150 mL/hour G. Start a peripheral IV H. NPO

A. Sputum Culture B. Start oxygen 3 L/minute via nasal canula E. Acetaminophen 350mg PO every 6 hours for temperature greater than F. Run 0.9% sodium chloride IV infusion at 150 ml/hr H. NPO

1300 Orders: -Admit to the surgical unit -Vital signs every 4 hours -Advance diet as tolerated -Administer Lactated Ringers IV at 85 ml/hr -Ibuprofen 800 mg PO every 8 hours PRN for pain The nurse would anticipate which of the following could be affecting the client's current condition? SATA A. stress B. medication C. Anemia D. Fever E. Hypothermia F. Hypertension G. Pain

A. Stress B. Medication G. Pain

Chest xray: Left lower lobe consolidations consistent with pneumonia The client has an oxygen saturation of 96% on 8 L/minute via simple face mask. The nurse assess the client and he is feeling less restless and anxious. His heart rate is now 79 beats/minute, respiratory rate 24 breaths/minute, and blood pressure 119/73 mm Hg. Which are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge? A. The client will report pain less than 3 on a pain scale of 1-10. B. The client will remain free of skin breakdown. C. The client will maintain oxygen saturation of 96% with out a mask D. The client will have quit smoking E. The client will be afebrile for 24 hours.

A. The client will report pain less than 3 on a pain scale of 1-10. C. The client will maintain oxygen saturation of 96% without mask E. The client will be afebrile for 24 hours.

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

A. Turn on overhead lights while giving instructions

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation should the nurse provide this client? SATA A. Use a residual limb shrinker B. Inspect skin for redness C. Apply alcohol to the residual limb after bathing. D. Wash the residual limb with soap and water E. Avoid range of motion exercises.

A. Use a residual limb shrinker B. Inspect skin for redness D. Wash the residual limb with soap and water

The nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to be unlicensed assistive personnel? SATA. A) Weigh the client and report any weight gain. B) Note and report the clients food and liquid intake during meals and snacks. C) Assess the client for weakness and fatigue. D) Evaluate the client for sleep disturbances. E) Report any client mention of pain or discomfort.

A. Weigh the client and report any weight gain C. Assess the client for weakness and fatigue E. Report any client mention of pain or discomfort

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) Widen stance while working near the sink. B) Leans forward to pull a pan from a high shelf. C) Tenths from the waist to pick trash off the floor. D) Brings a heavy can close to body before lifting. E) Lots knees while preparing food on the counter.

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

1930 -Admit to the medical floor -Vital signs every 4 hours -Regular diet -Out of bed with assist

Actions to take: -ask the client for a nutrition history -Encourage the client to drink Potential condition: -Malnutrition

NGN: For newborn baby. which actions are appropriate for the nurse to take at this time? SATA A) Keep infant in warmer with Billirubin lights to maintain temp. B) Continue to monitor glucose levels. C) Observe for signs of respiratory distress and monitor oxygen. D) Tell the mother that she will need to discuss any concerns. E) Explain to the mother that the babies respiratory rate needs. F) Monitor temperature. G) Informed the mother that the baby is stable enough to take.

B) Continue to monitor glucose levels. C) Observe for signs of respiratory distress and monitor oxygen. F) Monitor temperature.

The nurse enters a clients room to administer oral medication's and find an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A) Determine why the UAP did not notify the nurse of the change in the clients condition. B) Advised the UAP to stop providing care so the nurse can assess the clients condition. C) Explain to the UAP that changes in a clients condition should be reported immediately. D) Ask for UAP to position the client so the oral medication's can be administered.

B. Advise the UAP to stop providing care so the nurse can assess the client's condition

Nurse is caring for a client with a sexually transmitted infections syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

B. Answer questions directly and correct any misinformation

A client arrives at the emergency department (ED) describing chest pain that began three hours earlier which has not subsided. To assess the quality of the client's chest pain, which approach should the nurse use?

B. Ask the client to describe the pain

Client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000. Which intervention is most important for the nurse to include in the clients plan of care?

B. Assess urine and stool for occult blood

The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

B. Auscultate for irregular heart rate

1300 Orders: -Admit to the surgical unit -Vital signs every 4 hours -Advance diet as tolerated -Administer Lactated Ringers IV at 85 ml/hr -Ibuprofen 800 mg PO every 8 hours PRN for pain 1310 -Start supplemental oxygen at 2 What diagnostic test would be appropriate for this client? A. Doppler B Blood gases C. Blood culture D. Complete blood count E. Urinalysis F. Chest radiograph E. Echocardiogram

B. Blood gases D. Complete blood count F. Chest radiograph

A client with an acute myocardial infarction is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

B. Cardiac tracing shows 1.2mm wide Q waves half the height of the comlex

A client who is receiving zidovudine reports the appearance of pinpoint, red, brown spots on the skin. Which result should the nurse report to the healthcare provider? A) Skin biopsy. B) Complete blood count. C) Allergy test. D) Electromyography.

B. Complete blood count

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nure take?

B. Finish the prodedure

HISTORY AND PHYSICAL The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? SATA A. Have the client remove any sharp objects from the home. B. Have the client sign a no-suicide contract C. Help the client enlist the help of friends and family. D. Make the client feel too guilty to commit suicide E. Place the client in a locked unit. F. Refer the client for cognitive behavioral therapy.

B. Have the client sign a no-suicide contract. C. Help the client enlist the help of friends and family. F. Refer the client for cognitive behavioral therapy.

The older adult client who has difficulty hearing is being discharged from the day surgeries following a cataract extraction and lens in plantation. Which intervention is most important for the nurse to implement to help ensure the client compliant with self-care?

B. Have the client vocalize the instructions provided.

A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client? A) Inhaled short acting beta two agonists. B) Inhaled corticosteroids. C) Anti-cholinergics. D) Leukotriene modifiers.

B. Inhaled corticosteroids

A client is being urgently transported to radiology for a CT scan after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube of 20 cm section. Which action is most important for the nurse to take?

B. Keep chest tube container below the site of insertion

What nursing intervention is particularly indicated for the second stage of labor? A) Assessing the fetal heart rate and patterns for signs of fetal distress. B) Monitoring effects of oxytocin administration to help achieve cervical dilation. C) Providing pain medication to increase the clients tolerance of labor pains. D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.

B. Maintaining effects of oxytocin administration to help achieve cervical dilation

Client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

B. Plan volume-controlled, evenly-spaced meals throughout the day

NGN: NURSES NOTES saturation is low. Noted cyanosis in the clients lips. Healthcare provider made aware. 1310 pain rating for on a pain scale of 0 to 10. Temperature elevation noted. The client is anxious and using accessory muscles to breathe. Alerted the surgeon about the client status. New orders noted. What does the nurse need to document at 1330? SATA A) urine output. B) Respiratory rate. C) Blood pressure. D) Pain. E) Temperature. F) Flow rate of oxygen. G) Oxygen saturation.

B. Respiratory rate C. Blood pressure D. Pain E. Temperature G. Oxygen saturation

The nurse is managing 4 clients in the ICU who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding?

B. Restrained and restless with a low volume alarm sounding

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

B. Sitting up and leaning forward

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA. A) Location of the initial IV site. B) Swollen lymph nodes in the groin. C) Red blood cell count. D) White blood cell count. E) Core body temperature.

B. Swollen lymph nodes in the groin D. White blood cell count E. Core body temperature

ORDERS -Diagnosis: depression and post-traumatic stress disorder -Diphenhydramine 12.5mg PO every night at sleep (HS) -Buspirone hydrochloride 7.5 mg PO twice a day After the examination by the physician, the client was diagnosed with depression and post-traumatic stress disorder. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnosis and medications. How can the nurse build a therapeutic relationship with the client? SATA A. The nurse can show no emotion when talking to the client B. The nurse can be open, honest, and sincere. C. The nurse can talk as much as needed to get the client to talk D. The nurse can focus energy on the client. E. The nurse can communicate acceptance of the client as si F. The nurse can establish a meaningful connection

B. The nurse can be open, honest, and sincere. D. The nurse can focus energy on the client E. The nurse can communicate acceptance of the client as stated D. The nurse can establish a meaningful connection.

The healthcare provider prescribed furosemide for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? Reference range: BUN 5 to 18 Urine specific gravity 1.005 ot 1.03

B. Urinary output decrease of 5 mL/hour

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which non-pharmacological intervention should the nurse implement?

B. Use distraction and therapeutic communication skills

The charge nurse is making assignments for one practical nurse(PN) and three registered nurses(RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

B. Viral meningitis whose temperature changed from 101 to 102F.

When preparing to administer a prescribed medication to a homeless client at a community psychiatric clinic, the client tells the nurse that the usual dosage taken is different from the dose the nurse is giving. Which action should the nurse take?

B. Withhold the medication until the dosage can be confirmed

Client should the nurse assess frequently because of the risk for overflow incontinence? A) a client with hematuria and decreasing hemoglobin and hematocrit levels. B) A client who has been fast, with increased serum creatinine levels. C) A client who is confused and frequently forgets to go to the bathroom. D) A client who has a history of frequent urinary tract infections.

C. A client who is confused and frequently forgets to use the bathroom.

The nurse completed teh diet teaching of a client who is being discharged following the treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

C. A tuna fish sandwich with chips and ice cream.

Which instruction should the nurse delegate to an unlicensed assistive personnel? A) Call the pharmacy to obtain clients new antibiotic dose. B) Observe the clients gate to determine the need for assistance. C) Bring a sterile chest drainage unit from central supply to the unit. D) Evaluate a clients urinary catheter for proper drainage.

C. Bring a sterile chest drainage unit from central supply to the unit

The nurse leading the care team on a medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which activity should the nurse assigned to the UAP?

C. Empty and measure drainage from closed wound containers

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?

C. Excessive concave curvature fo the lumbar spine

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?

C. High pitched or fine crackles

Four hours after surgery, a client reports nausea and begins to vomit. The nurse knows that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

C. Notify the client's healthcare provider of the vomiting

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A) IV administration of benztropine. B) IV administration of isotonic crystalloid fluid. C) PO administration of lorazepam. D) PO administration of divalproex.

C. PO administration of Lorazepam

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instructions should the nurse include in the teaching?

C. Practice using muscle relaxation techniques.

The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

C. Self-reported glucose levels 120-150 mg/dL

A client with diabetes insipidus has an average urinary output of 500 ML of dilute urine every hour for the past four hours. Which laboratory test is most important for the nurse to monitor?

C. Serum sodium

The nurse is administering multiple prescribe vaccines to a toddler. Which strategy should the nurse prioritized to reduce the duration of pain? A) Supine positioning. B) Verbal reassurance. C) Simultaneous injections. D) Physical soothing.

C. Simultaneous injections

The nurse on a medical surgical unit receives a report from a post anesthesia care unit nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, the client has an IV infusion of 1000 mL of lactated ringers infusing at 125 mL per hour into the left wrist with 300 mL remaining. Prescriptions and food morphine sulfate 2 mg IV every 2 to 4 hours for pain. Last administer 30 minutes ago, and aspirin 4 mg IV every eight hours for nausea, last administered 15 minutes ago. Which additional information is most important for the nurse to obtain in the report?

C. Soft abdomen, absent bowel sounds, no bleeding on dressing

The client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge IV catheter with 0.9% sodium chloride is infusing at a rate of 150 mL per hour. Which intervention should the nurse implement first? A) Discontinue the 24 gauge IV. B) Establish a second IV site. C) Stop the 0.9% sodium chloride infusion. D) Assess the IV for blood return.

C. Stop the 0.9% sodium chloride infusion

He states "I am feeling extremely anxious right now." The client has decreased breath sounds in the left lower lobe. His mucous membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is 4 seconds. Vital signs -Temp 100.2 orally -Heart rate 101 beats/minute -Respiratory rate 28 breaths/minute -Blood pressure 145/89 mm Hg -Oxygen saturation 90% on room air

Cardiovascular: -Capillary refill 4 seconds -Blood pressure 145/89 mm Hg Neurological -Anxious -Restless Respiratory -Oxygen saturation 90% on room air -Respiratory rate 28 breaths/minute

Well making rounds, the charge nurse notices that a young adult client with asthma who has admitted yesterday is sitting on the side of the bed and leaning over the side table. The client is currently receiving oxygen at 2 L per minute via nasal cannula. The client is wheezing and is using per slip breathing. Which intervention should the nurse implement?

D. Administer a nebulizer treatment

The nurse is assessing the feet of a client with type 1 diabetes mellitus. Which finding requires immediate intervention by the nurse?

D. Decreased response to pain discrimination on dorsal surface of foot.

After receiving report on an inpatient acute care unit, which client should the nurse assess first ?

D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

A client with heart failure become short of breath, anxious, and has audible reasoning with pink frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one time dose of morphine sulfate IV. Which action should the nurse take? A. Administer the dose of morphine sulfate as prescribed B. Consult with the charge nurse regarding the morphine prescription C. Review the need for the prescription with the healthcare provider D. Withhold the morphine until the client's dyspnea resolves

D. Withhold the morphine until the client's dyspnea

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Previously, the owund was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

D. request a culture and sensitivity of the wound

NGN: NURSES NOTES 1800: the client is a female neonate born at 37 weeks of gestation to a gravida to party one mother, who was diagnosed with gestational diabetes following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 8 lbs. 9 oz. and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30.... The nurse recognizes that the infant of a diabetic mother is at risk for __________________, _________________________, and ___________________________.

Hyperbilirubinemia Respiratory distress syndrome Cardiomyopathy

HISTORY AND PHYSICAL The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. The client is exhibiting symptoms of

Post-traumatic stress disorder related to experiencing a life-threatening event and losing a loved one.

NGN: Match the activity with the most appropriate person to do the activity. Provide mouth care.- Document changes in respiratory status.- Set up the oxygen administration system.-Change the gauze under the nasal cannula.

Provide mouth care-UAP Document changes in respiratory status-RN/Respiratory therapist Set up the oxygen administration system-RN/Respiratory therapist Change the gauze under the nasal cannula-UAP

The nurse is preparing a four-year-old client with a serum bilirubin level of 19 for discharge from the hospital when teaching the parents about home phototherapy which instruction should the nurse include in the discharge teaching plan?

Reposition every two hours

1300 Vital signs -Heart rate 104 beats/minute -Respiratory rate 31 breaths/minute

The client is experiencing Tachypnea and Tachycardia

HISTORY AND PHYSICAL The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression. Findings:

The client states that she avoids driving altogether and takes the bus----Ineffective The client states she feels numb when thinking about the crash---Ineffective The client states she feels less jumpy and more relaxed----Effective The client reports sleeping 6 to 7 hours per night---Effective The client talks to her father and her best friend when she starts---Effective

An older adult client with Alzheimer disease is confused and asking the nurse to call their mother who is deceased which pharmacological intervention should the nurse implement?

Use distraction and therapeutic communication skills

HISTORY AND PHYSICAL The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated "I feel so sad that I can't seem to feel anything at all." in addition to her father, the client has a large family and friend support system. She denies alcohol or drug use. The client states, "I don't want to kill myself, but I sometimes wish I had died in the crash."

parasuicidal behavior and should be followed up with an assessment of risk factors for suicide.