HESI NCLEX Live Review

The nurse assigned to the women's health unit received the morning report. Which client should the nurse assess first? A. A 49-year-old client 1 day post vaginal hysterectomy who is saturating pads every 3 hours B. A 34-year-old client post uterine artery embolization who has not voided since her indwelling catheter was removed 4 hours ago C. A 52-year-old client who is 2 days post abdominal hysterectomy requesting oral analgesics instead of the PCA pump D. A 67-year-old client 1 day post anterior and posterior repair who is refusing to ambulate with the unlicensed assistive personnel

A. A 49-year-old client 1 day post vaginal hysterectomy who is saturating pads every 3 hours

A client is admitted to the acute care unit with stable angina. At 7 AM the client had stable vital signs and is on 2 L nasal cannula. At 10 AM the client reports chet pain 6/10, is slightly diaphoretic and pale, BP 100/52 and respiratory rate is 24. Which action will the nurse implement? A. Apply 4 L of oxygen as ordered B. Administer a fluid bolus of 0.9 NS C. Administer the prescribed opioid for pain control D. Obtain a full set of vital signs including temperature

A. Apply 4 L of oxygen as ordered Rationale: ONAM and when in distress do not assess!

The nurse reviews the medication record of a 2-month old and notes that the infant was given a scheduled dose of digoxin with a documented apical pulse of 76 bpm. What action should the nurse take first? A. Assess the current apical pulse rate B. Observe for the onset of diarrhea C. Complete and adverse occurrence report D. Determine the serum potassium level

A. Assess the current apical pulse rate Rationale: Data came from 3rd party source so you must do your own assessment

The nurse is caring for a client when they suddenly become unconscious. The nurse identifies the following rhythm on the monitor (v tach). Which action is highest priority? A. Check for carotid pulse B. Begin chest compressions C. Administer epi 1;10,000 IV D. Initiate bag-valve mask ventilations

A. Check for carotid pulse Rationale: info came from 3rd party source so you have to assess

The charge nurse is planning client assignments for the unit which consists of an RN, LPN, and UAP. Which clients should be assigned to the RN? (Select all that apply.) A. Client pending a blood transfusion for GI bleeding with an Hgb 70 B. Client with pernicious anemia who is awaiting a vitamin B12 injection C. Client with resolving sickle cell crisis pending IV fluid conversion to saline lock D. Client with a pressure ulcer who has been prescribed negative pressure wound vac care E. Client who received two blood transfusions yesterday and needs AM care

A. Client pending a blood transfusion for GI bleeding with an Hgb 70 C. Client with resolving sickle cell crisis pending IV fluid conversion to saline lock Rationale: unstable and need ongoing assessments

A parent is preparing a 5-year-old for kindergarten. The child has not received any immunizations. What vaccines will be given to start school? (Select all that apply). A. DTaP B. Inactivated polio virus C. Varicella D. Pneuomococcal conjugate vaccine E. Influenza

A. DTaP B. Inactivated polio virus C. Varicella

The nurse is monitoring a client in the first stage of labor who is being induced. The RN identifies a fetal heart rate pattern of decelerations occurring after the onset of each contraction and a return to the baseline well after the contraction is over. Which actions should the nurse take? (Select all that apply). A. Discontinue the oxytocin infusion B. Document as a reassuring finding C. Give a bolus of 750 mL D5LR D. Assess uterine activity pattern E. Administer maternal oxygen F. Assess baseline variability

A. Discontinue the oxytocin infusion D. Assess uterine activity pattern E. Administer maternal oxygen Rationale: Late decelerations indicate an issue with the placenta = PROD (pitocin off, ..., oxygen, get doctor)

The nurse receives shift reports on four postpartum clients. Which cient should the nurse assess first? A. G3P3 is 7 hours after forceps delivery who complains of pain and perineal pressure unrelieved by analgesics B. G1P1 is 8 hours after c section delivery who is receiving IV oxytocin and complains of cramping with increased lochia when sitting C. G2P2 is 5 hours after vaginal delivery who complains of abdominal pain when the infant breastfeeds D. G7P6 is 6 hours after vaginal delivery of twins who reports saturating one pad in a 3-hour period

A. G3P3 is 7 hours after forceps delivery who complains of pain and perineal pressure unrelieved by analgesics Rationale: Sign of a complication when pain meds don't work

A child who is diagnosed with hydrocephalus is 1 day post-op for revision of a ventriculoatrial shunt. Which finding is most important? A. Increased blood pressure B. Increased temperature C. Increased serum glucose D. Increased hematocrit

A. Increased blood pressure Rationale: Increased ICP

The nurse is completing discharge teaching to the parent of a 2-year-ld child diagnosed with active TB. Which instructions should the nurse provide the family member? (Select all that apply). A. Inform the family that bodily fluids may turn an orange-red color B. Stress the importance of adequate nap and sleep time C. Advise the family to wear gloves when cleansing the child's face and nose D. Place the child in home isolation until medications are completed E. Avoid contact with other individuals, except family members, for at least six months

A. Inform the family that bodily fluids may turn an orange-red color B. Stress the importance of adequate nap and sleep time C. Advise the family to wear gloves when cleansing the child's face and nose

The nurse is planning a class on stroke prevention for clients with hypertension. What information reflects accurate prevention measures that clients can undertake? (Select all that apply). A. Limit salt intake to 1500 mg/day or less B. Eliminate tobacco products C. Initiate a program of walking one mile per day D. Achieve a BMI of 26.2 E. Schedule routine health assessments biannually

A. Limit salt intake to 1500 mg/day or less B. Eliminate tobacco products C. Initiate a program of walking one mile per day

The mental health RN is assigned to five clients. Which client should be assessed first? A. Newly diagnosed client with major depression whose assessment is complete B. Client diagnosed with schizophrenia who is having auditory hallucinations of an infant crying C. Client recently diagnosed client who has a 5-year history of daily consuming two 6-packs of beer D. A client diagnosed with bulimia having difficulty attending group E. A client who has been taking benzodiazepines off and on daily for the last 2 years

A. Newly diagnosed client with major depression whose assessment is complete Rationale: Newly diagnosed depressed client is at risk for suicide

The nurse is caring for a client who is 24 hours post-procedure for a hemicolectomy with a temporary colostomy placement. The nurse assesses the client's stoma, which is dry and dark blue. What action should the nurse take based on this finding? A. Notify the health care provider of the finding B. Document the finding in the client record C. Replace the pouch system over the stoma D. Place petrolatum gauze dressing on stoma

A. Notify the health care provider of the finding Rationale: this is a complication requiring immediate surgical intervention

A postmenopausal woman with BMI 19 has come to the clinic for her annual well-woman exam. Which teaching plan topic is most important for the nurse to prepare for this high-risk client? A. Osteoporosis B. Obesity C. Anorexia D. Breast cancer

A. Osteoporosis

The nurse is reviewing the current medication list of a client, newly diagnosed with type 1 diabetes, who will be prescribed insulin. Which medications should the RN discuss with the healthcare provider? (Select all that apply). A. Prednisone B. Atenolol C. Clarithromycin D. Acetaminophen E. Ibuprofen F. Pantoprazole sodium

A. Prednisone B. Atenolol C. Clarithromycin

The nurse is facilitating a support group for stress management. During the initial phase, a female group member who has a master's degree states that her educational background makes it easier to help the other group members. How should the nurse respond? A. Reiterate the purpose for the support group sessions B. Ask the group to identify the various stressful problems C. Obtain ideas from the members about strategies for stressful situations D. Terminate the meeting and evaluate the situation

A. Reiterate the purpose for the support group sessions

A pregnant client tells the nurse that she smokes only a few cigarettes a day. What information should the nurse provide the client about the effects of smoking during pregnancy? A. Smoking causes vasoconstriction and decreases placental perfusion B. Smoking decreases the lecithin: sphingomyelin ratio contributing to lung immaturity C. Smoking causes vasodilation and increased fluid overload for the fetus D. Smoking during pregnancy places the fetus at risk for lung cancer

A. Smoking causes vasoconstriction and decreases placental perfusion

A client at 36-weeks gestation is placed in lithotomy position. She suddenly complains of feeling breathless and lightheaded and shows marked pallor. What action should the nurse take first? A. Turn to lateral positon B. Place in Trendelenburg C. Obtain VS and pulse ox D. Initiate distraction techniques

A. Turn to lateral positon Rationale: For women in labor the least invasive intervention is positioning

The emergency department nurse is assessing a client with a vesicular rash as a result suspected smallpox exposure. Which of the following transmission precautions would be appropriate for this client? (Select all that apply). A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

Airborne, contact, droplet, standard

A 13-month child diagnosed with a congenital heart defect is presscirbed digoxin. The maintenance dosage ordered by the HCP is 50 mcg/kg/day and the child weighs 10 kg. The HCP prescribes the digxon to be given twice daily. The nurse prepares how much dig to administer at each dose?

Answer= 250 mcg/dose

The nurse directs the UAP to play with a 4-year-old child on bedrest. Which activities should the nurse recommend? (Select all that apply). A. Monopoly B. Checkers C. 50-piece puzzle D. Hand puppets E. Coloring book

B. Checkers D. Hand puppets E. Coloring book

The nurse is caring for a 3-month old diagnosed with congestive heart failure. Which sign or symptom most clearly relates to a side effect of furosemide? A. Increased skin turgor B. Decreased urine output C. Bulging fontanels D. Peripheral edema

B. Decreased urine output

The nurse performs a vaginal exam for a client who is in labor. The RN determines that the cervix is dilated 4 cm with 60% effacement, and the presenting part is at the -2 station. 30 minutes later, the client tells the RN that she thinks her water just broke. Which action has the highest priority? A. Call in results to HCP B. Evaluate FHR C. Help the client to the bathroom D. Perform nitrazine and fern tests

B. Evaluate FHR Rationale: Mother is 3rd party data source for her baby so you need to assess the baby

Four births will occur at once. Which birth should the nursery charge nurse assign a newly licensed nurse as her first solo birth admission? A. G1P0 at 39 weeks who will give birth vaginally after a 15-hour induced labor. The mother has been on magnesium sulfate for preeclampsia throughout the labor B. G5P4 at 38 weeks who will give birth vaginally after a 5-hour un-medicated labor. Mild to moderate variable decelerations have been occurring for the last 15 minutes C. G3P1 at 34 weeks who will give birth by C-section for a non-reassuring FHR pattern. The client has a history of cocaine use and has symptoms of abruptio placentae D. G2P1 at 42 weeks who will give birth vaginally after induced labor. The client has been pushing for 2 hours and forceps will be used

B. G5P4 at 38 weeks who will give birth vaginally after a 5-hour un-medicated labor. Mild to moderate variable decelerations have been occurring for the last 15 minutes Rationale: Least amount of complications

A client who is 72-hours post c-section delivery is preparing to go home. She shares that she cannot get the baby's diaper on right. Which action should the nurse take? A. Demonstrate how to correctly place the diaper on the baby B. Observe the client diapering the baby while offering praise and hints C. Call the social worker for long-term follow up D. Reassure the client that she knows how to take care of her baby

B. Observe the client diapering the baby while offering praise and hints

While receiving IV antibiotics for sepsis, a 2-month old is crying inconsolably despite the mother's presence. The nurse recognizes that the infant is exhibiting symptoms related to which condition? A. Allergic reaction to antibiotics B. Pain related to IV infiltration C. Separation anxiety from the mother D. Hunger and thirst

B. Pain related to IV infiltration Rationale: Match subjective data with subjective data

A 7-year-old is to have a painful procedure. Which statement by the nurse best prepares the child to cope with this? A. It feels like burning pain B. Sometimes this feels like pushing C. There is nothing wrong when you have pain D. You will get ice cream after the procedure

B. Sometimes this feels like pushing Rationale: Use descriptive words without saying "pain"

A client who has gestational diabetes asks the nurse to explain the reason her baby is at risk for macrosomia. Which explanation should the nurse offer? A. The placenta receives decreased maternal blood flow during pregnancy because of vascular constriction B. The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth C. Infants of diabetic mothers are post-mature, which allows the fetus extra time to grow D. Rapid fetal growth contributes to congenital anomalies, which are more common in infants of diabetic mothers

B. The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth

A client's suspected pregnancy is confirmed. The client tells the nurse that she also had one pregnancy that she delivered at 39 weeks, twins delivered at 34 weeks, single gestation delivered at 35 weeks. Using GTPAL notation, how should the nurse record the client's gravidity and parity? A. 3-0-3-0-3 B. 3-1-1-1-3 C. 4-1-2-0-4 D. 4-2-1-0-3

C. 4-1-2-0-4 Rationale: Knowing how many living children there are gives you the last number and can narrow down some choices

The nurse an UAP take a group of mental health clients to a baseball game. During the game, a client begins to complain of SOB and dizziness. Which intervention should the nurse implement first? A. Have the UAP escort the client back to the unit B. Request the client to describe his or her current feelings C. Accompany the client to a quiet area D. Ask the client if anything untoward occurred

C. Accompany the client to a quiet area Rationale: Remove them from the stimulus

The LPN is assigned by the RN charge nurse to care for a 3-year-old with Reye's syndrome. The child's temperature is 39.1 (102) and the LPN is preparing to administer aspirin PO. What action should the charge nurse implement? A. Direct LPN to assess gag reflex and LOC B. Advise to wait until fever is higher C. Advise to hold all aspirin containing meds D. ...

C. Advise to hold all aspirin containing meds

The nurse is planning to teach client strategies for coping with anxiety. The nurse finds the client in the client's room compulsively hand washing. What action should the nurse take next? A. While the client is hand washing introduce alternative to handwashing B. Ask the client to immediately stop hand washing then begin teaching C. Allow client to complete hand washing then begin teaching D. Ask client to describe events that precipitated the handwashing

C. Allow client to complete hand washing then begin teaching Rationale: Don't interrupt the activity that is relieving their anxiety

A hospitalized client reports to the nurse that they have not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes B. Notify the healthcare provider and request a prescription stool softener C. Assess the medical record to determine the client's normal bowel pattern D. Instruct the caregiver to increase the client's fluids to five 8-oz glasses per day

C. Assess the client's medical record to determine the client's normal bowel pattern

A school-aged child with history of nephrotic syndrome has just received hemodialysis. What assessment is most important to obtain after hemodialysis? A. Pain assessment B. Capillary refill C. Urine ketones D. Daily weight

D. Daily weight Rationale: Weight before and after dialysis

A nurse is caring for a 6-year-old child who had a tonsillectomy 2 hours ago. Which sign or symptom most likely relates to a complication? A. Apical rate 90 bpm B. BP 96/50 C. Frequent swallowing D. Nasal congestion

C. Frequent swallowing Rationale: Sign of bleeding

A woman who is in labor becomes nauseated, starts hiccupping, and tells her partner to leave her alone. The partner asks the nurse what he did to make this happen. How should the nurse respond? A. In active labor, it is quite common for women to react this way. It's nothing you did B. I don't know what you did, but stop, because she is quite sensitive right now C. I'll come and examine her. The reaction is common during the transition phase of labor D. Early labor can be very frustrating. I'm sure she doesn't mean to take it out on you

C. I'll come and examine her. The reaction is common during the transition phase of labor

A client diagnosed with borderline personality disorder returns after a weekend pass with lacerations to both wrists. The client complains about how the nurse is performing the dressing change. The nurse's response should be: A. Distant B. Concerned C. Matter of fact D. Empathetic

C. Matter of fact

A client who has a history of bulimia is admitted to the mental health unit. What intervention is most important for the nurse to include in the treatment plan? A. Observe the client after meals for purging B. Assess daily weight and vital signs C. Monitor serum potassium and calcium D. Provide a structured environment at mealtimes

C. Monitor serum potassium and calcium Rationale: Electrolytes are really important in bulimia

The nurse is teaching the school-age child and parent about the administration of inhaled beclomethasone dipropionate and ipratropium bromide for the treatment of asthma. Which statement by the parent indicates that the teaching has been effective? A. I'll keep the inhalers in the refrigerator B. My child only needs to use inhalers when the peak flow numbers are in red C. My child will take the bronchodilator first, then the corticosteroid D. My child will take the corticosteroid first, wait a few minutes, then take the bronchodilator

C. My child will take the bronchodilator first, then the corticosteroid

The nurse is caring for a 16-year-old client with down syndrome who has a mental age of 5 in the acute care hospital. Which priority nursing action should be included in the client's plan of care? A. Monitoring for hearing loss B. Monitoring I+O C. Providing a dependable routine D. Providing small puzzles

C. Providing a dependable routine

During the second stage of labor, the nurse notes a pattern of fetal heart rate decelerations between 80 and 100 from a baseline of 160. The decelerations are unrelated to the contractions, and moderate long-term baseline variability is present. Place the interventions for these findings in order, starting with highest priority first. A. Administer oxygen B. Change maternal position C. Document the finding D. Notify the primary provider

Change maternal position, administer oxygen, notify provider, document finding

An adult client is admitted to the inpatient mental health unit with a diagnosis of severe depression. As the client begins to recover the develops rapport with the nurse. After being discharged from the hospital the client and the nurse happen to meet in the coffee shop. The client asks the nurse if they can schedule future meetings at the coffee shop. Which response by the nurse is the best? A. I'll contact the nurse supervisor about this B. Let's not plan to meet however we may see each other inadvertently C. I am off duty and can't discuss care D. A client patient relationship is inappropriate

D. A client patient relationship is inappropriate

A client at 33 weeks gestation who has been diagnosed with pregnancy-induced hypertension is admitted to the labor and delivery area. She is obviously nervous and expresses concern for the health of her baby. How should the nurse respond? A. You have the best doctor on the staff, so don't worry about a thing B. Your anxiety is contributing to your condition and may be the reason for your admission C. This is a minor problem that is easily controlled, and everything will be all right D. As I assess you and your baby I will explain the plan for your care and answer your questions

D. As I assess you and your baby I will explain the plan for your care and answer your questions

A client at 15 weeks of gestation is admitted for an inevitable abortion. 30 minutes after returning from surgery her vital signs are stable. Which intervention has the highest priority? A. Ask the client if she would like to talk about losing her baby B. Place cold cabbage leaves on the client's breasts to decrease breast engorgement C. Send a referral to the grief counselor for at-home follow-up D. Confirm client's Rh and Coombs' status and administer RhoGAM if indicated

D. Confirm client's Rh and Coombs' status and administer RhoGAM if indicated Rationale: 72 hour window for RhoGAM

A client with a history of alcohol abuse is admitted to the medical unit for GI bleeding and pancreatitis. His admission data includes BP 156/96, pulse 92, temp 99.2. Which is most important for the nurse to implement? A. Provide a quiet, low-stimulus environment B. Initiate seizure precautions C. Administer prn lorazepam as prescribed D. Determine the time and quantity of the client's last alcohol intake

D. Determine the time and quantity of the client's last alcohol intake Rationale: Determine if they are in window of withdrawal or withdrawal delirium

Which nursing action has the highest priority for an infant immediately after birth? A. Place the infant's head in the sniff position and give oxygen via face mask B. Perform a bedside glucose test and feed the infant glucose water as needed C. Assess the heart rate and perform chest compressions if rate is less than 60 bpm D. Dry the infant and place under a radiant warmer or skin-to-skin with the mother

D. Dry the infant and place under a radiant warmer or skin-to-skin with the mother Rationale: Temperature is priority above ABCs for infants

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states "don't blame me, nobody likes this idea." What is the charge nurse's priority action? A. Confront the other staff members involved in the change of unit policy B. Call a unit meeting to review the reasons the change was made C. Develop a written unit policy for the expression of complaints D. Encourage the nurse to be accountable for the nurse's own behavior

D. Encourage the nurse to be accountable for the nurse's own behavior Rationale: you don't want to involve any outside parties in the conversation

A 4-year-old is brought to the clinic with a fever of 103, sore throat, moderate respiratory distress caused by a suspected bacterial infection. What is contraindicating a swab? A. Tonsillitis B. Strep C. Bronchiolitis D. Epiglottitis

D. Epiglottitis Rationale: Medical emergency of tight/blocked airway

A 2-year-old is prescribed furosemide, digoxin, and captopril for congestive heart failure. Which value should the nurse verify with the lab? A. Increased serum calcium level B. Reduced serum sodium level C. Low hemoglobin level D. Low serum potassium level

D. Low serum potassium level

A female client who is 5-year breast cancer survivor received confirmation that she has a recurrence of breast cancer. She informs her family that the biopsy was negative. Which action should the nurse take? A. Tell the client's family to consult the HCP B. Ask the client to restate what the HCP told her C. Encourage the client to inform her family about the results D. Suggest the client talk to the nurse about her fears

D. Suggest the client talk to the nurse about her fears Rationale: Allow them to be in denial

pH 7.33 pCO2 50 HCO3 29

Partially compensated respiratory acidosis

pH 7.55 pCO2 32 HCO3 29

Partially compensated respiratory alkalosis

A client is seen in the clinic for the first time since being newly diagnosed with diabetes. Which findings should the nurse associate as a complication of diabetes? Select all that apply. A. burning sensation in the client's toes B. visual acuity 60/20 C. protein in the client's urine D. blood pressure 110/60 E. a sore on the client's foot that is not healing

A. burning sensation in the client's toes C. protein in the client's urine E. a sore on the client's foot that is not healing

An elderly man comes to the ED complaining of SOB. The HCP determines he has pneumonia. The client's condition deteriorates in the ED and the client now has impending respiratory failure. Which set of ABG values demonstrate acute respiratory failure? A. pH 7.30 pCO2 52 PO2 56 HCO3 26 B. pH 7.35 pCO2 44 PO2 86 HCO3 22 C. ... D. ...

A. pH 7.30 pCO2 52 PO2 56 HCO3 26 Rationale: Oxygen is low and body is not compensating

Which client must be assessed first? A. 20-year-old female whose GCS is 8 and unchanged from last assessment B. 45-year-old male with a left-sided CVA who refuses his morning care C. 38-year-old male who is increasing stuporous after an aneurysm repair D. 29-year-old female post MVA whose GCS was 9 an hour before and is now 10

C. 38-year-old male who is increasing stuporous after an aneurysm repair

The nurse is monitoring the status of a client recovering from a myocardial infarction. Which symptom indicates an evolving problem? A. Steady pulse of 88 bpm B. Rising systolic pressure from 110 to 120 mmHg C. Three premature ventricular contractions/min D. Central venous pressure of 8 mmHg

C. Three premature ventricular contractions/min Rationale: All others are normal range

The charge nurse is assigning rooms for four new clients. Only one private room is available on the oncology unit. Which client should be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intracavity radiation

D. The client with cervical cancer who is receiving intracavity radiation Rationale: limiting exposure

A family member of a client who is in a Posey vest restraint (safety reminder device) asks why the restraint was applied. How should the nurse respond? A. The restraint was prescribed by the healthcare provider B. There are not enough staff to keep the client safe all the time C. The other patients are upset when the client wanders at night D. The client's actions place the client at high risk of harm to self

D. The client's actions place the client at high risk of harm to self Rationale: safety!

pH 7.32 pCO2 50 HCO3 25

Respiratory acidosis

Which laboratory result for a preoperative client would prompt the nurse to contact the HCP? A. Platelet count 151,000 B. WBC count 8,500 C. Serum potassium level 2.8 D. Urine specific gravity 1.031

C. Serum potassium level 2.8

The nurse is teaching an 86-year-old client who has glaucoma and bilateral hearing loss. Which intervention should the nurse implement? A. Maintain constant eye contact B. Stand on the side unaffected by glaucoma C. Speak in a lower tone of voice D. Keep the environment dimly lit

C. Speak in a lower tone of voice Rationale: Older adults with hearing impairment have a hard time with high-pitch noises

Which situation warrants a variance (incident) report by the nurse? A. Refusal by a client to take prescribed medication B. Improved status before completion of the course of medication C. A client has an allergic reaction to a prescribed medication D. A client received medication prescribed for another client

D. A client received medication prescribed for another client Rationale: safety!

Which client should the nurse assess first? A. Client diagnosed with hyperthyroidism exhibiting exophthalmos B. Client with type 1 diabetes who has an inflamed foot ulcer C. Client with Cushing's disease exhibiting moon face D. Addison's disease with tremors and diaphoresis

D. Addison's disease with tremors and diaphoresis All others are expected findings and non life-threatening

A client has an order for hydromorphone IV push 1 mg q3h. It is available as 4 mg/mL. How many mL should the nurse administer?

0.25 mL

In the elevator, the newly licensed nurse overhears two nurses talking about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed nurse should be implemented first? A. Monitor the nurses closely for further occurrences B. Advise them to cease their communication C. Inform the nurse manager of the conversation D. Submit an occurrence or variance report

B. Advise them to cease their communication Rationale: you don't want to involve anyone else in the conversation

Healthcare provider prescribes a loading dose of Amicar IV 5 g to be infused in 250 mL D5W over 1 hour. The tubing drop factor is 15 drops/mL. How many drops per minute would the nurse set for the IV rate?

63 drops per minute

A client is receiving an infusion of dobutamine hydrochloride. The order reads infuse dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hr.

9.75 mL/hr

A charge nurse is making assignments for 5 five clients. The nursing team has an RN, LPN, and two UAPs. Which clients would be assigned to the RN? (Select all that apply). A. A client from the previous shift with unstable angina B. A client with a stage 3 pressure ulcer who needs a bed bath C. A client with an enteral feeding absorbing at 30 mL/hr D. A cardiotomy client who is day 2 post-op and who has chest tubes E. A client with quadriplegia for whom urinary catheterization is prescribed

A. A client from the previous shift with unstable angina D. A cardiotomy client who is day 2 post-op and who has chest tubes Rationale: RN needs to do ongoing assessments for unstable patients. UAP can give bed baths, LPN can do foley caths

The cardiac monitor alarms nad the nurse arrives to find the 59-year-old client slumped in the chair. Place the nurse's actions in order of priority for this client from first to last. A. Activate the code team and obtain defibrillator B. Determine unresponsiveness C. Assess cardiac rhythm using the "quick look" paddles D. Assess for a pulse (carotid) E. Open airway and give two rescue breaths by bag valve mask F. Move the client to a flat position in bed or on the floor G. Begin compressions

B, A, D, F, G, E, C Rationale: determine responsive first then call for help then ONAM

The charge nurse is planning client assingments for the shift. The care team includes an RN, an LPN, and UAP on the care team. Which clients should be assigned to the PN? (Select all that apply). A. A client scheduled for a STAT CT xray after a fall on his hip B. A client receiving IV vancomycin through a PICC line C. A client with sickle cell crisis who was transferred from the ICU to the acute care area and who is receiving hydromorphone via PCA pump D. A client with a pressure ulcer who was prescribed negative pressure wound vac care E. A post-operative client who has been prescribed 2 units of packed red blood cells

A. A client scheduled for a STAT CT xray after a fall on his hip B. A client receiving IV vancomycin through a PICC line D. A client with a pressure ulcer who was prescribed negative pressure wound vac care Rationale: LPN can do wound care, hang IV meds but CANNOT give ongoing assessments or give blood

The nurse is orienting a graduate nurse caring for a client dependent on the ventilator. Which action by the GN demonstrates understanding of the VAP bundle of care? (Select all that apply). A. Administers a proton pump inhibitor as prescribed B. Rinses the client's oral cavity with Chlohexidine q2h C. Elevates HOB 60 degrees D. Implements spontaneous breathing trial E. Performs hand hygiene before care

A. Administers a proton pump inhibitor as prescribed B. Rinses the client's oral cavity with Chlohexidine q2h D. Implements spontaneous breathing trial E. Performs hand hygiene before care Rationale: HOB 60 is too high, should be 30-45

During the evaluation, which assessments indicate an early sign of increased ICP for a client newly diagnosed with a CVA? (Select all that apply). A. Alteration in the ability to respond to questions B. Change in the ability to respond to verbal stimuli C. Consensual response of pupils D. Heart rate 50, BP 192/60 E. Drooping of the mouth on one side

A. Alteration in the ability to respond to questions B. Change in the ability to respond to verbal stimuli

A 52-year-old client who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation about women's health screening examinations should the nurse offer? A. Continue the annual pap smear and mammogram, annual clinical breast exams, monthly breast self-exams B. Pap smear is no longer necessary, but continue ... C. ... D. ...

A. Continue the annual pap smear and mammogram, annual clinical breast exams, monthly breast self-exams

A client who has a history of myasthenia gravis presents with a heart rate of 112 bpm, respiratory rate 24 with accessory muscle use, anxiety, restlessness. Which of these interventions demonstrates best practice? (Select all that apply). A. Elevate the head of the bed to 45 degrees B. Prepare to administer Lasix 40 mg IV C. Administer 2 L oxygen per prescription D. Teach the importance of wearing a medical ID bracelet

A. Elevate the head of the bed to 45 degrees C. Administer 2 L oxygen per prescription Rationale: Myasthenia gravis affects the respiratory system

After hemodialysis, the nurse is evaluating the blood results for a client who has end-stage renal disease. Which value should the nurse verify with the laboratory? A. Elevated serum potassium B. Increase in serum calcium C. Low hemoglobin D. Reduction in serum sodium

A. Elevated serum potassium Rationale: This is why they are in dialysis in the first place

While obtaining the health history of a client and reviewing the medical records, which data will alert the nurse that the client has an increased risk of developing peptic ulcer disease? (Select all that apply). A. Excess of gastric acid or a decrease in the natural ability of GI mucosa to protect itself from acid and pepsin B. Invasion of stomach by H pylori C. Viral infection, allergies to foods, immune factors, psychosomatic D. Certain drugs, corticosteroids, anti-inflammatory medications E. Allergies to gluten

A. Excess of gastric acid or a decrease in the natural ability of GI mucosa to protect itself from acid and pepsin B. Invasion of stomach by H pylori D. Certain drugs, corticosteroids, anti-inflammatory medications

A client is receiving pancreatic enzyme replacement therapy for chronic pancreatitis. Which statement by the client indicates a need for more effective teaching? A. I will need to mix the enzyme with a protein food B. I will take the enzyme with each meal C. My stools will decrease in number and frequency D. My abdominal pain may lessen

A. I will need to mix the enzyme with a protein food Rationale: with liver damage avoid protein (makes liver work harder)

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply). A. Limit alcohol and stop smoking B. Suggest supplementing the diet with vitamin E C. Promote regular weight-bearing exercise D. Implement a home safety plan to prevent falls E. Propose a regular sleep pattern of 8 hours nightly

A. Limit alcohol and stop smoking C. Promote regular weight-bearing exercise D. Implement a home safety plan to prevent falls

The graduate nurse is teaching a client about Crohn's disease. The new nurse is correct in identifying which complications as being the result of cobblestone lesions of the small intestines? A. Malabsorption of nutrients B. Severe diarrhea of 15 to 20 stools per day C. A high probability of developing intestinal cancer D. An inability of the body to absorb water

A. Malabsorption of nutrients

A 60-year-old client who has a history of hypertension, heart failure, and sleep apnea is admitted to the acute care unit. Which findings would relate most directly to a diagnosis of acute decompensated heart failure? (Select all that apply). A. Respiratory rate of 25 B. Orthopnea C. S3 heart sound D. Dry non-productive cough E. Heart rate 69 and irregular

A. Respiratory rate of 25 B. Orthopnea C. S3 heart sound Rationale: symptoms of left-sided heart failure

After stopping hormone replacement therapy (HRT) a 76-year-old client reports that she is experiencing increased vaginal discomfort during intercourse. What action should the nurse take? A. Suggest the use of vaginal cream or lubricant B. Recommend that the client abstain from sexual intercourse C. Teach the client to perform Kegel exercises daily D. Instruct the client to resume HRT

A. Suggest the use of vaginal cream or lubricant

Which clinical manifestations would the nurse expect to see in a patient experiencing Graves' Disease? (Select all that apply). A. Tachycardia B. Decreased sweating C. Insomnia D. Increased respirations E. Muscle aches and pain

A. Tachycardia C. Insomnia D. Increased respirations Rationale: Hyperthyroidism

An LPN is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observations should the LPN immediately report to the RN? (Select all that apply). A. The client complains of incisional pain, rating it an 8/10 B. The client has had a change in orientation to person but not to time or place C. Swelling and redness have developed in the client's lower left leg D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain E. The client's last set of vital signs was temp 37.9 (100.2), pulse 87, respirations 12, BP 108/74, and O2 sat 93%

A. The client complains of incisional pain, rating it an 8/10 B. The client has had a change in orientation to person but not to time or place C. Swelling and redness have developed in the client's lower left leg E. The client's last set of vital signs was temp 37.9 (100.2), pulse 87, respirations 12, BP 108/74, and O2 sat 93% Rationale: RN needs to know any symptom/change in condition, watch for post-op complications

A client is currently in the oliguric phase of acute kidney injury. Which findings would the nurse expect to assess on the client? (Select all that apply). A. 450 mL urine output in 24 hours B. Potassium of 6.2 C. Serum sodium 155 D. Metabolic alkalosis E. Weight gain

B. Potassium of 6.2 E. Weight gain Rationale: Oliguric phase is when kidneys are holding onto stuff/stop working

The nurse is the first responder at the scene of a mass casualty incident. The nurse is tasked to triage the victims from highest to lowest priority. Please arrange the victims from highest to lowest priority. A. Victim A is an older adult with agonal respirations and an open head injury B. Victim B is a confused adult with bright red blood pulsating from a leg wound C. Victim C is a young adult with multiple compound fractures of the arms and legs D. Victim D is an adult with multiple shrapnel wounds of the face and arms and complaining of abdominal pain E. Victim E is a sobbing adult with several minor lacerations on the face, arms, legs

B (red tag), D (red tag), C (yellow tag), E (green tag), A (black tag)

Four clients arrive in the ED after an explosion at an apartment complex. In which order should they be assessed? A. 70-year-old who is complaining of pain level rated 8/10 from a hand burn B. 35-year-old with partial thickness and full thickness burns to the anterior and posterior chest C. 25-year -old with superficial burns to the right anterior arm and lateral chest D. 42-year-old with partial thickness burn to the anterior lower extremity and lateral chest

B, D, A, C Rationale: Who is most unstable, will die first

A 72-year old client returned from surgery 6 hours ago. The client received hydromorphine 2 mg IV 30 minutes ago for pain rating 8/10. The family member requests her father be checked immediately. On arrival to the room you find the client difficult to arouse, with a respiration rate of 6. What is the priority nursing action? A. Elevate the head of the bed B. Administer naloxone 0.4 mg IV C. Assess breath sounds D. Check vital signs and pulse oximetry

B. Administer naloxone 0.4 mg IV

The nurse is administering 0900 medications to three clients on a tele unit when the UAP reports that another client is complaining of a sudden onset of substernal discomfort. What action should the nurse take? A. Ask the UAP to obtain vital signs B. Assess the discomfort C. Advise to rest in bed D. Observe the client's ECG pattern

B. Assess the discomfort Rationale: Assessment came from third party source so you need to get your own data

A client who is 1 day post-op from a left pneumonectomy is lying on his right side with the HOB elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A. Further elevate the HOB B. Assist the client into the supine position C. Measure the client's O2 saturation D. Administer IV prn morphine

B. Assist the client into the supine position Rationale: Pt just had left lung removed and are lying on the right side, compressing the one lung they have left

The CBC results for a client receiving chemotherapy are hemoglobin 8.5, hematocrit 32%, WBC 6,500. Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

B. Broiled steak, whole wheat rolls, spinach salad, coffee Rationale: low hemoglobin means low iron so you want iron rich foods. Fresh fruits and veggies are typically avoided in patients on chemo

A client with burn injuries has lost a significant amount of body fluid. An IV of LR is infusing at 200 mL/hr and the urine output for the past 8 hours is 400 mL. Which sign or symptom relates to early distributive shock? A. Change in BP from 118/60 to 102/68 B. Change in level of consciousness from awake to restless C. Decrease in O2 sat from 98% to 93% D. Decrease in urine output over 8 hours from 400 to 240 mL

B. Change in level of consciousness from awake to restless

The charge nurse is planning client assignments for the unit. The collaborative care team consists of an RN, LPN, and UAP. Which clients should be assigned to the LPN? (Select all that apply). A. Client with a history of heart failure who has had no urinary output for the past 2 hours B. Client with a history of angina who requires morning medications C. Client recently admitted and anticipating oral antibiotics for cellulitis D. Client with history of Raynaud syndrome who is pending a dressing change E. Client with an acute deep vein thrombosis who requires a heparin hourly infusion

B. Client with a history of angina who requires morning medications C. Client recently admitted and anticipating oral antibiotics for cellulitis D. Client with history of Raynaud syndrome who is pending a dressing change

The RN assigns the LPN a client diagnosed with diabetes. Which findings should the RN instruct the LPN to report immediately? (Select all that apply). A. Fingerstick BG 247 B. Cold clammy skin C. Crackles at the end of inspiration D. Numbness in the fingertips and toes E. Unsteady gait, slurred speech

B. Cold clammy skin E. Unsteady gait, slurred speech Rationale: Indicates an acute change in condition, others are normal or expected

The nurse is caring for a client hospitalized with Guillain-Barre syndrome. Which information would be most important for the nurse to report to the primary healthcare provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status C. Blurred vision and sensation changes D. Persistent unilateral headache

B. Decrease in cognitive status

A 36-year-old married man with a BMI of 33 states that he wants to lose weight. In addition to dietary intake and level of physical activity, what data are most necessary for the nurse to collect before planning care? A. Draw blood for determination of resting metabolic rate B. Determine who prepares the meals C. Identify the client's educational level D. Ascertain the client's smoking history

B. Determine who prepares the meals

A 22-year old client is admitted through the ED with a 2-day history of cough, fever, and fatigue. The medical history is positive for type 1 diabetes and recent upper respiratory infection. Vital signs are heart rate 109, BP 102/58, respiratory rate 24, temperature 104, O2 sat 92% on 2 L nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large bore IV access B. Draw two sets of blood cultures C. Administer the ordered IV antibiotics D. Draw serum lactate and glucose levels

B. Draw two sets of blood cultures Rationale: before administering antibiotics for sepsis you want blood cultures from at least two different sites

The nurse suspects a postoperative thyroidectomy client may have had an inadvertent removal of the parathyroid when the client begins to experience which symptoms? (Select all that apply). A. Hematoma formation B. Harsh, vibratory sounds on inspiration C. Tingling of lips, hands, toes D. Positive Chvostek's sign E. Sensation of fullness at the incision site

B. Harsh, vibratory sounds on inspiration C. Tingling of lips, hands, toes D. Positive Chvostek's sign Rationale: low calcium, laryngeal stridor associated with tetany from low calcium

A client who had a vaginal hysterectomy the previous day is saturating perineal pads with blood and requires frequent changes during the night. What is the nurse's priority action? A. Provide iron-rich foods on each dietary tray B. Monitor the client's vital signs every 2 hours C. Administer IV fluids at the prescribed rate D. Encourage postoperative leg exercises

B. Monitor the client's vital signs every 2 hours Rationale: patient is expected to saturate only 1 pad every 3 hours

A client with a 20-year history of type 1 diabetes is having renal function tests because of recent fatigue, weakness, BUN 8.5, and serum creatinine of 146. What other early symptoms of renal insufficiency might the nurse expect? A. Dyspnea B. Nocturia C. Confusion D. Stomatitis

B. Nocturia Rationale: Dyspnea and confusion are late signs of renal dysfunction

A client with a history of uterine fibroids has a C-section 12 hours earlier and delivered healthy twin girls. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which action has the highest priority? A. Assess the client's temperature B. Notify the healthcare provider C. Clean the blood from the incision site D. Draw labs for PT, PTT, CBC, fibrinogen

B. Notify the healthcare provider Rationale: Medical emergency, change in condition, when in distress do not assess!

The nurse observes an older male client with glaucoma administer eye drops by tilting his head back, instilling each drop to the close to the inner canthus, and keeping his eye closed for 15 seconds. What action should the nurse take first? A. Ask the client whether a family member is available to administer the drops B. Review the correct steps of the procedure with the client C. Administer the eye drops correctly in the other eye to demonstrate the technique D. Discuss the importance of correct eye drop administration for persons with glaucoma

B. Review the correct steps of the procedure with the client Rationale: teach while encouraging; eyedrops should be instilled onto middle of eye not inner part of eye

After the change of shift report, the nurse reviews her assignments. Which client should the RN assess first? A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48-hours post-op for a colectomy and who is reported to be having nausea and vomiting C. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours D. The client who is 2 days post-op for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory rate of 12 breaths/min

B. The adult client who is 48-hours post-op for a colectomy and who is reported to be having nausea and vomiting Rationale: this patient will die before others because they are experiencing a post-op complication

An awake, alert client with impending pulmonary edema is brought to the ED. The client provides the nurse with a copy of a living will that states that no invasive medical procedures should be used to keep the client alive. The healthcare team is questioning whether the client should be intubated. What information should guide the team's decision? A. The living will removes the obligation to the client in any medical decision making B. The client is awake and alert, which makes the living will irrelevant and non-binding C. Lifesaving measures do not need to be explained to the client because of the signed living will D. The family should be notified for decision making

B. The client is awake and alert, which makes the living will irrelevant and non-binding Rationale: advanced directives should not be looked at until the pt cannot make decisions for themselves

The nurse is precepting a nurse orientee caring for a client with a chest tube who is 12 hours post-op from a left partial pneumectomy. Which assessment will the nurse advice be reported to the HCP immediately? (Select all that apply). A. Pain level 6/10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of 50 mL in the last hour D. Oxygen saturation of 90% on 2 L/min E. Vigorous bubbling in the suction chamber

B. Tracheal deviation toward the right side D. Oxygen saturation of 90% on 2 L/min E. Vigorous bubbling in the suction chamber Rationale: Change in condition, others are expected

A client who is diagnosed with an obstruction of the common bile duct caused by cholelithiasis passes clay-colored stools containing streaks of fat. What action should the nurse take? A. Auscultate for diminished bowel sounds B. Send a stool specimen to the lab C. Document the assessment in the chart D. Notify the healthcare provider

C. Document the assessment in the chart Rationale: this is an expected finding in blockage of bile duct (stool contains bilirubin)

A 62-year-old client who has a history of coronary heart disease was admitted to the acute care unit 2 days ago for management of angina. During the assessment, the client states "I feel like I have indigestion." In what order should the nurse implement care? A. Notify the rapid response team B. Administer prn nitroglycerin prescription C. Check pulse, respirations, blood pressure, oxygen sat D. document assessment on EMR E. provide 2 L oxygen

C, E, B, A, D Rationale: Assess first if responsive, then ONAM, then call for help

A client who has type 1 diabetes returns to the clinic for follow-up after dietary counseling. The client states that he has been managing his diabetes very closely. Which lab result indicates that the client is maintaining tight control of the diabetes? A. Fasting BS changes from 7.5 to 6 B. Self-monitoring of BG at bedtime changes from 2.5 to 5 C. A1C change from 9% to 6% D. Urine ketones change from 0 to 3

C. A1C change from 9% to 6% Rationale: A1C reflects long term control

Which action by the UAP requires immediate follow-up by the nurse? A. Positioning a client who is 12 hours post-op from an above the knee amputation with the residual limb elevated B. Assisting a client with ambulation while the client uses a cane on the unaffected side C. Accompanying a client who has lupus to sit outside in the sun during a break D. Helping a client with rheumatoid arthritis to the bathroom after the client receives Celebrex

C. Accompanying a client who has lupus to sit outside in the sun during a break Rationale: Sunlight potentiates lupus

Which client should the nurse assess first? A. The client receiving oxygen per nasal cannula who is dyspneic on mild exertion and has hgb of 7 B. Client receiving IV aminoglycosides per CVC who complains of nausea and has trough level below therapeutic levels C. Client with a chest tube that drained 150 mL in the last hour D. The client receiving chemo whose temperature is 37.2 (98.9) and who has a WBC count of 2,500

C. Client with a chest tube that drained 150 mL in the last hour Rationale: Notify HCP about chest tube drainage > 70-100 mL

Which client should be assigned to a graduate nurse orienting to the neuro unit? A. Client with a head injury who has a GCS score of 6 B. Client who developed autonomic dysreflexia after T6 spinal cord injury C. Client with multiple sclerosis who needs the first dose of interferon D. Client diagnosed with Guillain-Barre syndrome

C. Client with multiple sclerosis who needs the first dose of interferon

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A. Reassure the client that this admission is only for a limited amount of time B. Offer the client and family the opportunity to share their feelings about the admission C. Determine the behaviors that resulted in the need for admission D. Advise the client about the legal rights of all hospitalized clients

C. Determine the behaviors that resulted in the need for admission Rationale: safety!

A nurse is preparing for change of shift. Which action by the nurse is characteristic of ineffective handoff communication? A. The nurse states to the nurse coming on duty "the client is anxious about his pain after surgery, review the information I gave him about use of incentive spirometer" B. The nurse refers to the EMR to review the client's medication administration record C. During rounds the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client D. Before giving report, the nurse performs rounds on her assigned clients so that there is less likelihood of interruption during handoff

C. During rounds the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client

A client who is receiving a transfusion of packed red blood cells has an inflamed IV site. Which action should the nurse take? A. Double-check the blood type of the transfusing unit of blood with another nurse B. Discontinue the transfusion and send the remaining blood and tubing to the lab C. Immediately start a new IV at another site and resume the transfusion at the new site D. Continue to monitor the site for signs of infection and notify the healthcare provider

C. Immediately start a new IV at another site and resume the transfusion at the new site Rationale: blood reaction is systemic, these symptoms indicate a local reaction at the IV site

The nurse palpates a crackling sensation of the skin around the insertion site of a chest tube in a client who has had thoracic surgery. What action should the nurse take? A. Return the client to surgery B. Prepare for insertion of a larger chest tube C. Increase the water seal suction pressure D. Continue to monitor the insertion site

C. Increase the water seal suction pressure

In completing a client's perioperative routine, the RN finds that the consent has not been signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next? A. Witness the client's signature on the consent B. Answer the client's questions about surgery C. Inform the healthcare provider that the client has questions about the surgery D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered

C. Inform the healthcare provider that the client has questions about the surgery Rationale: scope of practice

What adaptation of the environment is most important for the nurse to include in the plan of care for a client diagnosed with myxedema? A. Reduce environmental stimuli B. Prevent direct sunlight from entering the room C. Maintain a warm room temperature D. Minimize exposure to visitors

C. Maintain a warm room temperature Rationale: hypothyroidism

A client who is diagnosed with advanced cirrhosis of the liver has an acute exacerbation of hepatic encephalopathy. What type of food might be limited in his diet? A. Fruits B. Vegetables C. Meats D. Bread

C. Meats Rationale: In liver damage avoid meats (protein causes liver to work harder)

The nurse is planning a class on stroke prevention for clients with hypertension. What is most important to include? A. Salt restriction diet B. Weight reduction C. Medication compliance D. Risk for stroke

C. Medication compliance Rationale: The biggest reason people with hypertension have strokes is due to medication non-compliance

A client who was recently prescribed metformin calls the clinic to discuss symptoms of bloating, nausea, cramping, and diarrhea. Which instructions should the nurse provide the client? (Select all that apply). A. Discontinue the medication immediately B. Increase fiber and fluids in the die C. Monitor symptoms D. Continue to take the metformin as prescribed E. Seek immediate emergency medical care

C. Monitor symptoms D. Continue to take the metformin as prescribed Rationale: These are normal side effects of metformin that should go away over time

The nurse is assessing a client who is scheduled for surgical fixation of a compound fracture of the right ulna. Which finding should the nurse report to the healthcare provider? A. Ecchymosis around the fracture site B. Crepitus at the fracture site C. Paresthesia distal to fracture D. Diminished range of motion

C. Paresthesia distal to fracture Rationale: 5 P's associated with fractures

The charge nurse is making assignments for each of four staff members, including an RN, an LPN, and two UAPs. Which task is best to assign to the LPN? A. Maintain a 24-hour urine collection B. Wean a client from a mechanical ventilator C. Perform sterile wound irrigation D. Obtain scheduled vital signs

C. Perform sterile wound irrigation Rationale: LPNs can do wound care, PO meds, foleys

A client is admitted to the hospital with a diagnosis of Addison's crisis. The nurse places a peripheral saline lock. Regarding which prescriptions should the nurse question the healthcare provider? (Select all that apply). A. IV D5NS at 300 mL/hr for 3 hrs B. Hydrocortisone sodium succinate 100 mg IV push C. Potassium 20 mEq in 100 mL saline IV over 60 minutes D. 50% dextrose intravenous push E. 10% calcium chloride 5 mL intravenously over 10 minutes

C. Potassium 20 mEq in 100 mL saline IV over 60 minutes E. 10% calcium chloride 5 mL intravenously over 10 minutes

A client with COPD is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. What action should the RN take first? A. Call the healthcare provider B. Obtain a bedside pulse oximeter C. Raise the head of the bed higher D. Assess the client's vital signs

C. Raise the head of the bed higher Rationale: if the client is in distress you don't assess (dyspnea is a symptom that indicates a change in condition)

The nurse is caring for a client with peritonitis. Which information should the nurse report immediately to the healthcare provider? A. BP 92/64, 110/70, and 100/68 over the past hour B. Urine output of 300 mL over the past 8 hours C. Rebound tenderness and pain and the client rates as 7/10 D. Dry mucous membranes and nausea

C. Rebound tenderness and pain and the client rates as 7/10 Rationale: GI symptoms for GI condition indicate change in condition

A client recovering from ARDS is awake and alert, has residual fatigue and generalized weakness. His current vital signs are heart rate 83, BP 104/64, respiratory rate 25, O2 sat 92% on 2 L/min nasal cannula. Which vital sign value should the unlicensed assistive personnel report immediately to the nurse? A. Heart rate 88 bpm B. BP 104/64 C. Respiratory rate 25 breaths per min D. O2 sat 92%

C. Respiratory rate 25 breaths per min Rationale: affects respiratory system, HR and BP are normal, expect low oxygen sat with ARDS

Which assignment should the nurse delegate to a UAP in an acute care setting? A. Checking blood glucose hourly for a client with a continuous insulin drip B. Giving PO medications left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humeral and left tibial fractures D. Replacing a client's pressure ulcer dressing that has been soiled by incontinence

C. Taking vital signs for an older client with left humeral and left tibial fractures Rationale: UAPs do vitals and bed baths

The client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3-4 months. What would be the nurse's best response? A. To determine the progression of the disease B. To evaluate the enzyme-linked immunosorbent assay (ELISA) C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine

C. To monitor the effectiveness of the treatment

Which dysrhythmias would defibrillation be more appropriate for? (Select all that apply). A. Asystole B. Pulseless electrical activity C. V fib D. Pulseless v tach E. V tach F. A fib

C. V fib D. Pulseless v tach Rationale: asystole starts CPR, PEA is not a problem with the heart but an underlying issue, v tach with a pulse can be cardioverted, a fib gets cardiovert or medication

A client who has hyperparathyroidsim is scheduled to receive a dose of oral phosphate. The RN notes that the client's serum calcium is 12.5 mg/dL. What action should the nurse take? A. Hold the phosphate and notify the HCP B. Review the client's serum parathyroid hormone level C. Give prn dose of IV calcium per protocol D. Administer the dose of oral phosphate

D. Administer the dose of oral phosphate Rationale: phosphate is given to lower serum calcium levels

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code? A. Client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. Client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18 C. Client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. Client with an open wound to the abdomen, a deformed right femur, a pulse of 125, delayed capillary refill, and respiratory rate of 32, who is moaning

D. Client with an open wound to the abdomen, a deformed right femur, a pulse of 125, delayed capillary refill, and respiratory rate of 32, who is moaning Rationale: Will die first, actively bleeding out

The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the nurse to ask the client? A. When did the surgeon explain the procedure to you? B. Is any member of your family going to be here during your surgery? C. Have you been instructed in postoperative activities and restrictions? D. Have you received any preoperative pain medication?

D. Have you received any preoperative pain medication? Rationale: pre-op meds will affect getting consent due to mind-altering effects

A client in shock develops a MAP of 60 mmHg and a heart rate of 110 bpm. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow B. Obtain arterial blood gas results C. Insert an indwelling urinary catheter D. Increase the rate of IV fluids

D. Increase the rate of IV fluids Rationale: MAP is low so you want to increase blood flow/volume

The nurse is preparing to administer a PPD test to a client who is entering nursing school. Which action by the nurse is of highest priority? A. Prepare 0.1 mL solution for tuberculin syringe B. Assess the skin condition on the forearm C. Teach the client about positive findings D. Inquire about bacillus calmette-guerin (BCG) vaccine history

D. Inquire about bacillus calmette-guerin (BCG) vaccine history Rationale: Contraindicates PPD test due to reaction/scarring

The charge nurse is making assignments on the renal unit. Which client should the nurse assign to a practical nurse who is new to the unit? A. Older client who has thick, dark red drainage in a urinary catheter one day after a transurethral prostatic resection B. Middle-aged client admitted with diagnosis of acute renal failure secondary to IVP dye C. Older client who has end-stage renal disease and complains of nausea after receiving digoxin D. Middle aged client who receives hemodialysis and is prescribed epogen subcutaneously

D. Middle aged client who receives hemodialysis and is prescribed epogen subcutaneously Rationale: All other patients are unstable

Which change in status of a client being treated for increased intracranial pressure warrants immediate action of the nurse? A. Urinary output changes from 20-50 mL/hr B. CO2 changes from 40-30 mmHg C. GCS score changes from 5-7 D. Pulse changes from 88-68 bpm

D. Pulse changes from 88-68 bpm

The nurse is performing a respiratory physical assessment on a client. In what order should the nurse assess this client? A. Percussion B. Palpation C. Inspection D. Auscultation

Inspection, Palpation, Percussion, Auscultation Rationale: IPPA unless abdominal system vs clinical: Look, listen, feel

pH 7.28 pCO2 35 HCO3 18

Metabolic acidosis

pH 7.56 pCO2 44 HCO3 38

Metabolic alkalosis

pH 7.43 pCO2 40 HCO3 24

Normal