HESI practie test #2

A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?

"I have known many clients with depression who have felt better after several weeks of treatment." -Stating the observation that others have recovered can give a client hope. Telling a person to stop negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the client's feelings and does not provide the same degree of hope.

During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond?

"Tell me about the drugs you use now." -Open-ended questioning allows the client provide specific information without probing. Asking the person to explain what drugs they are taking is critical of the client's descriptors and does not encourage further dialog. Asking about legal vs. illegal drugs or "kind of drugs" both are close-ended questions that require one word responses, and stop further exploration with the client.

The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions?

1. Clamp the drainage tubing. 2. Label the urine specimen. 3. Place in a biohazard bag. 4. Document the procedure. -The drainage tubing should be clamped before obtaining the specimen. After withdrawing the urine specimen, the specimen is labeled, and then the container is placed in a biohazard bag for transport to the laboratory. Documentation should be completed after the specimen is labeled and transported to the laboratory.

The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented?

1. Measure the client's vital signs. 2. Review medications client is taking. 3. Notify the healthcare provider. 4. Complete an incident report. -Cardizem is a calcium channel blocker that decreases blood pressure, and slows SA or AV node conduction, which can cause bradycardia or cardiac arrhythmias, so the client's vital signs should be measured first to determine the client's reaction to the medication error. The client's current medications should be reviewed before notifying the healthcare provider, and then the incident report completed.

The nurse is preparing to perform oral care for an unconscious client.In what order should the nurse implement the nursing actions?

1. Raise bed to a comfortable working height. 2. Lower the side rail between the nurse and the client. 3. Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin. -To ensure client and nurse safety when performing oral care for an unconscious client, first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin.

A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.)

1. Airway and breathing. 2. Pain management. 3. Sleep and rest. 4. Definitive therapy. -First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies.

A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the GTPAL system?

4-1-2-0-4. - Using the GPTAL system is the correct record of gravity and parity. G reflects the total number of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number of pregnancies carried to term, not the number of deliveries at term; she has had only one pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation. A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies the number of children born that are currently living.

The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit?

A client scheduled for a femoro-popliteal bypass surgery tomorrow. -The client with an elective surgical procedure can be rescheduled for a later date so is considered stable enough to be discharged. A client with a recent biopsy is not stable for discharge as the procedure can result in bleeding due to the high vascularity of the liver. A client with acute pancreatitis is unstable, in acute pain, and at risk for rupture of diverticula. A client with rhythm irregularities has a life-threatening condition because of the risk for ventricular tachycardia.

The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN?

A client with an epidural infusion reports lower extremity parasthesia. -Assessment of possible adverse effects of an epidural infusion should be performed by the RN, who has the expertise to evaluate the significance of the assessment data. The other options are skills that can be delegated to the PN.

A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?

A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?

A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client?

A private room on a medical unit. -To protect others from contamination, the nurse should assign this client to a private room. Isolation room is not indicated(A) is an isolation room used for clients with TB. (B) should not be assigned because of the possibility of cross-contamination by the infected client. (C) should not be assigned because the OB unit is considered "clean."

When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents?

A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. -A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs.

The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer?

A teacher who seeks information about her disease and wants to continue teaching. -Those who seek information about their disease while attempting to carry on with their lives as best they can are likely to handle the diagnosis of cancer best. Those who use repression to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support, especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations is used to being in control, and control over a life-threatening diagnosis is not always possible.

A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client?

A terminally ill and depressed client with cancer. -A nurse who believes in the sanctity of life may find it difficult to relate to individuals who do not place the same high level of value on life. Clients with cancer, who have not made a conscious decision to end their lives, are most likely to be easily understood by this nurse.

Which client requires the most immediate intervention by the nurse?

A young adult who is reporting an anaphylactic response to an antibiotic. - An anaphylactic response is a severe allergic reaction that may result in airway constriction and shock, so the nurse should first respond to this potentially life-threatening situation.

A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented?

Acetylcysteine (Mucomyst) 140 mg/kg. -Mucomyst is the antidote for acute acetaminophen (Tylenol) poisoning and is the treatment of choice for an overdose.

When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use?

Adjust the diopters. -The diopter corresponds to the magnification power of the ophthalmoscope's lens, which is adjusted to bring the retina into focus when a client's error of refraction, such as myopia or hyperopia, causes a change in the eyeball shape. Using a red-free filter produces a green beam for examination of the optic disc for pallor and recognition of retinal hemorrhages. The direct wide-beam light is used to examine the anterior eye. The application of an ophthalmic mydriatic should be instilled prior to extended fundoscopic visualization.

The charge nurse, along with another RN and a practical nurse (PN) are caring for clients on a medical/surgical unit. Which nursing action should be assigned to the PN?

Administer a bolus tube feeding through a gastrostomy tube. -Administration of a bolus tube feeding through a gastrostomy tube is a skill that can be safely performed by the PN. Looking at a stoma for the first time requires support from the RN, who has greater expertise in client teaching and emotional support than the PN. Accessing an implanted port is beyond the scope of practice of the PN. The PN can reinforce initial teaching presented by the RN, but should not be assigned to develop a teaching plan.

Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)?

An older client with intestinal obstruction and septic shock. -High risk clients vulnerable for MODS include older clients with decreased organ reserve, comorbidities, and massive inflammatory or immune dysfunction, such as septic shock, or clients who have experienced various ischemia-reperfusion events related to trauma or surgical complications. Although acute respiratory failure, respiratory arrest, or myocardial infarction may be precursors to MODS, additional complications usually precipitate the pathological cascade of hypermetabolism and excessive production of inflammatory and biochemical mediators that cause widespread organ damage. An adolescent with autoimmune disease is at risk for MODS only if complications such as massive infection, respiratory failure, or cardiac arrest occur.

When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?

Apply a sterile lubricant to the end of the catheter. -After testing the balloon for patency, the nurse should next lubricate the end of the catheter. The sterile drape should already be positioned under the client's buttocks. The client is instructed in breathing just prior to insertion.

When culturing a wound, the nurse should obtain the sample from which part of the wound?

Areas containing purulent or pooled exudates. -To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions, then return the swab to the culturette tube, cap the tube, and crush the inner ampoule so that the medium for the organism growth coats the swab.

Which action should the nurse implement when implementing a physical assessment of an older client?

Arrange the exam sequence to minimizes position changes. -Adaptations of the physical examination sequence that limits the amount of position changes during the exam are often useful for an older adult who may have age-related problems, such as decreased mobility, limited energy, or perceptual changes.

An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first?

Ask if she is going to the bathroom frequently. -The nurse should ask questions directed toward symptoms of diabetes. Recurrent vaginal and urinary tract infections are often an early sign of diabetes.

The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement?

Assess and document skin condition around the incision and IV site at each shift. -Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented during each shift.

A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question?

Atropine sulfate 0.4 mg IM on call to operating room. -Many ophthalmic agents used to reduce intraocular pressure (IOP) in glaucoma cause miosis, which increases the outflow of aqueous humor. Atropine is an anticholinergic agent that causes mydriasis, which can increase IOP and counteracts the action of β-blocking agents, so Atropine prescription should be brought to the attention of the healthcare provider.

Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first?

Attempt to arouse the client to stimulate respirations. -The nurse should first attempt to stimulate respirations by arousing the client. This measure is noninvasive and may produce an immediate increase in respiratory rate. If this action is unsuccessful, the nurse should then implement the other options listed.

The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first?

Auscultate heart and lungs. - The sequence for physical examination in a quiet child begins with auscultation of heart and lungs to enable the nurse to hear the breath and heart sounds clearly.

An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids?

Begin wearing the aids in quiet environments to experiment with adjustments.\ -Initially, the use of hearing aids should be restricted to quiet situations in the home. As adjustments occur, the client should gradually be exposed to conditions with background noise and the outdoors. Time restriction is not necessary.

The new parents express concern that they did not have the opportunity to hold and bond with their infant immediately after birth because the mother received anesthesia during an emergency cesarean delivery. What information should the nurse provide?

Bonding is a process that occurs over time and begins with the first parent-newborn contact. -Bonding is a gradual emotional process and begins when the parents first make contact with the infant. It does not have to begin in the first minutes after birth. Telling the parents not to worry since their child is healthy dismisses their concerns. The time immediately after birth is not a critical period for human attachment, but telling the parents otherwise is not indicated and may increase their anxiety.

What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.)

Border irregularity Lesion with color variations. -ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion; B for irregular border; C for color, usually dark; D for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of the characteristics of ABCDE should be evaluated by a healthcare provider. Lesions that lack the color variable, are raised, dome-shaped, or benign clusters of blood vessels that do not require treatment. Lesions of 3 to 5 mm diameter are small and may be monitored instead of treated.

A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action?

Call for emergency assistance -Stridor upon exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema postoperatively. In life-threatening complications, such as respiratory obstruction or bleeding, a call for emergency assistance should be made first in the event intubation is required. Extending the clients neck is contraindicated. Although documentation is necessary, a stridor or voice change are indicators of early airway compromise.

The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective?

Cleans perianal area with mild soap and water after each diarrhea stool. -To remove bacteria, provide comfort, stimulate circulation, and prevent skin breakdown, the client is demonstrating effective perianal care when the perianal area is cleansed after each bowel movement with mild soap and warm water, and then dried thoroughly

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?

Close the demographic screen on the computer. - The priority is for the charge nurse to close the computer screen, so the health information stored in computerized systems is secured because it is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act).

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take?

Complete an adverse occurrence report and submit it to the nurse-manager. -A medication error occurred, so an adverse occurrence report should be completed and submitted to the nurse-manager for evaluation of the situation, so that measures can be implemented to prevent a repeat of the occurrence.

The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful." Which term should the nurse document to best describe the client's response?

Confabulation -Confabulation describes the client's story that is made-up to fill in the gaps of memory when one is unable to remember something that might have happened.

Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa?

Consume at least 50% of all meals. -An outcome statement should be measurable and provide observable behaviors that indicate the client's problem is resolving. Self-starvation is the major problem associated with anorexia nervosa, so stating the person should consuming 50% of diet should be included in this client's plan of care. "Improve bosy perception" is vague and not measurable. Adolescents with anorexia nervosa often obsessively exercise to lose additional weight, so defining exercise time limits may be excessive. Clients with anorexia have an increased risk for hypokalemia, so decreasing serum potassium levels is an inappropriate goal for this client.

During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement?

Contact the client's healthcare provider to report the assessment findings. -Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of aspirin that the client is taking. The healthcare provider should be notified of the symptoms to determine further treatment. The other choices will likely increase the client's symptoms of toxicity.

While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take?

Continue the interview process and record the findings. -The nurse should accept these behaviors as culturally determined and continue with the interview. These behaviors are common in the Chinese culture where people are members of strong, cohesive groups that focus on the group rather than the individual.

While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first?

Current hair care practices. -Dry and brittle hair may be a result of hair treatments such as hair dyes, rinses, permanents, straighteners, or frequent blow-drying. Although an unexplained weight gain could be related to hypothyroidism, which causes hair to become dry and brittle, assessing current hair care practices should be determined first because of the prevalent use of cosmetic products. Next, a family history of alopecia and absence of axillary hair should be assessed to identify other problems contributing to hair abnormalities, such as nutritional deficiencies, endocrine dysfunction, or genetic predisposition.

The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement?

Defibrillate at 200 joules. -After confirming ventricular fibrillation, rapid defibrillation is critical in re-establishing cardiac output and preserving vital organ function. After CPR is initiated and defibrillation attempted, airway intubation and intravenous access are indicated for successful resuscitation. Arterial blood gases are obtained during or after resuscitation to determine medical management for metabolic acidosis which occurs secondary to anaerobic glycolysis during VF or cardiac arrest.

Which responsibility best describes the role of a nurse as manager?

Delivery of client care while meeting agency goals. -The nurse manager is accountable for organizing direct and indirect client care functions that necessitate delegation and assignment to competent unit staff, personnel management, quality improvement of client care, and system coordination to achieve agency goals. The other options are all components of professional nursing practice.

A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first?

Describe the placement and rationale for care of the catheter. -A client's anxiety or fear about a treatment or procedure is commonly the result of a lack of knowledge, so providing information, such as drawings or pictures, and explanations about the catheter, may help the client understand the catheter's function and decrease his anxiety regarding its presence.

To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication?

Determine if the client has ever had a hypersensitivity reaction to penicillins. -Most individuals who have an allergy to penicillins are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Ceclor) dose.

Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.)

Economics. -Economics affects the health of the company and its workforce productivity, in terms of profitability, growth, and expansion. Technology adds to an industry's capacity to develop and implement new or improved work processes. Legislation/regulation in the workplace, such as the blood-borne pathogen standard, affects the workforce in terms of requirements, administration, and control strategies. Occupational safety programs are built around the workforce to strive for maximum internal productivity. Interventions are internal environmental influences of an occupational health and safety program. Socio-economic status is a demographic variable commonly used in epidemiology.

A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement?

Encourage family members to bring foods from home. -Encouraging the parents to bring familiar foods from home that the child likes should increase the child's likelihood to eat. Although selecting nutritious food from the menu gives a 6-year-old control in the selection of foods that are preferred, an adult should provide direction to ensure nutritious variation, instead of any snack or "junk" food that can curb the appetite. Children should be served smaller portions to prevent feeling overwhelmed by large portions that may be refused.

A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?

Encourage the student to associate with non-smokers only while attempting to stop smoking. - It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers.

Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting?

Ensure that all enrolled children have been immunized for Hepatitis A. -The CDC recommended immunization schedule for children includes the hepatitis A vaccine (HAV), so follow-up of enrolled children's immunization status with HAV or human-immune gamma globulin should be implemented. Preschoolers should be taught the importance of hygiene practices, such as keeping themselves clean or correct handwashing technique, but hepatitis A is transmitted via the fecal-oral route and immunization provides the best universal protection. Hepatitis A is not transmitted through blood contact.

What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane?

Enzyme release from lysosomes. -Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes intracellularly and the cell is destroyed.Inadequate ATP production and defective protein synthesis lead to cell death either as the result of defective chromosomes or production of defective integral proteins.

A client who has been taking a diuretic and ACE inhibitor for hypertension has a blood pressure of 160/90. Today a new drug, carvedilol (Coreg), is prescribed, and the client expresses concern about receiving so many different medications. What action should the nurse implement?

Explain the rationale for the administration of all three medications to the client. -Treatment of hypertension may require a combination of several different medications, so the nurse should explain the rationale for the use of three different types of medications, thus addressing the client's expressed concern. Since the client's BP is elevated, there is no indication that any of the prescribed medications should be withheld. The client has expressed concern, not refusal to comply with treatment.

Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult?

Functional abilities. -The focus of a geriatric assessment is to determine the older client's functional abilities, so appropriate interventions can be planned and implemented to maintain and enhance independence.

When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement?

Gather the supplies needed to discontinue the IV fluid. -An IV infusion stops when pressure is placed on the skin above the tip of the catheter, but will continue to flow into the subcutaneous tissue if there is infiltration, which requires removal of the IV. The other options will not resolve the infiltration.

An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide

Get up and walk around frequently during the day. -Edema and swelling in the lower extremities results from gravitational pooling of blood and are common after extended periods of standing or sitting. Walking is a common recommendation to stimulate circulation, venous return, and to reduce swelling. Although limiting salt intake is a common heart-healthy life-style modification, the client's sedentary hours predispose to venous stasis and distal swelling. Recommending a daily vitamin with minerals is not a common remedy for the client's complaint. Elevating the feet at night may be helpful, but the best information is to consider the cause and get up and move around.

Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide?

Give the toddler nutritious snacks. -At approximately 18 months of age, most toddlers manifest lower nutritional need and decreased appetite, a phenomenon known as "physiologic anorexia" which is often manifested as a picky, fussy eater with strong taste preferences, and erratic eating patterns. Toddlers are learning to differentiate self and social boundaries and may be disruptive while sitting at the table, so offering nutritious finger foods is a good way to ensure proper nutrition during this stage.

Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional?

I don't talk about things like that anymore." -When the client states that she doesn't want to talk about things like that anymore, she is likely less delusional, because when a client begins to question the delusional belief or stops talking about it, the client is becoming less delusional.

A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload?

Increase in size. -Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart by increasing afterload which requires an increase in the force of contraction to pump blood out of the heart. Myocardial hypertrophy results because the cells increase in surface area or size by increasing the amount of contractile proteins, but the quantity of fibers remain constant. As myocardial hypertrophy progresses, the heart becomes ineffective as a pump because the ventricular wall cannot develop enough tension to cause effective contraction, which causes myocardial irritability due to hypoxia.

The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow?

Inject air until no air is auscultated over the larynx during a deep breath. -To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the cuff) during inhalation. At the point when sounds of air movement cease, inflation is stopped, indicating that the cuff is sealed against the tracheal wall.

A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority?

Intensity of pain -The hallmark sign of pancreatitis is severe abdominal pain due to autodigestion of the pancreas by the enzymes amylase and lipase.

The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

MAP is calculated by adding the systolic pressure to twice the diastolic pressure and dividing by 3. 152 + 180 = 332 3 = 110.66 = 111 mm Hg

A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first?

Massage the fundus. -The initial management for uterine atony is fundal massage to prevent postpartum hemorrhage.

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan?

Method used to aspirate medication from a vial. -To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration. The other options are teaching topics, but are not components of maintaining sterile technique while administering an injection.

A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first?

Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. -Comfort and pain management using an effective analgesic-sedative such as morphine, is the most important standard of care therapy in hospice home care to ensure comfort and enhance the quality of life for a client with a life expectancy of less than six months, as in this case. Adjunct therapy that promotes a sense of well-being, including prednisone, and provides adequate oxygenation work to supplement morphine in easing a client's discomfort, associated shortness of breath, and anxiety during a terminal illness.

Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6 F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take?

Notify the healthcare provider of the client's status. -The healthcare provider should be notified so that medications can be prescribed to prevent seizures. Grand mal seizures sometimes occur during barbiturate withdrawal, and pronounced muscle twitching can herald seizure activity.

A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as February 14, what expected date of birth (EDB) should the nurse calculate?

November 21. -N gele'srule for calculation of EDB is determined by adding 7 days to the first day of the LMP and then subtracting 3 months.

The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first?

Observe the UAP performing blood pressure measurements. -The charge nurse should first observe the UAP's performance to determine if the UAP is performing the task appropriately. If the UAP needs education, the charge nurse can provide instruction real time.

The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged?

Observe the client while demonstrating crutch walking. -To evaluate a client's ability to crutch walk, the nurse should observe the client perform the skill. It is not necessary to check the client's serum calcium level. Crutches should be two to three inches from the axilla to prevent brachial plexus damage. Living alone should not be a problem because the client can use the three point gait with the crutches to perform self-care.

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction?

Obstruction at the urinary bladder neck. -Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed.

A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement?

Offer the child a popsicle and allow him to pick the flavor he prefers -Fluids in popsicle form are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. Manipulation should be avoided and the nurse must be careful not to make promises that may not be possible.

Which type of management style is a case management model for nursing care delivery?

Patient focused and primary nursing. -A client classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet patient needs. Case management is patient focused and provides primary nursing. Clinically- and business-oriented is a business model of organizational decision making. Centralized and decentralized systems models are management strategies or models of organizational decision making, such as shared governance which is a decentralized model. Clinical pathways are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for clients with a particular diagnosis, procedure, or symptoms.

Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis?

Peripheral edema. -Four types of cirrhosis include alcoholic, post-necrotic, biliary, and cardiac cirrhosis, which are associated with severe right-sided heart failure (HF), so peripheral edema is most consistent with right-sided HF. Although jaundice and vomiting can occur in all types of cirrhosis, the most defining characteristic of cardiac cirrhosis is related to HF. Hepatic engorgement can occur in a client with HF or cirrhosis and cause right upper quadrant pain, not left sided quadrant pain.

A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first?

Place the client in mechanical restraints until calm. -This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to or have the ability to verbalize his feelings

A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction. What action should the nurse implement at this time?

Place the client on her left side. - A sharp drop in the FHR from the baseline that returns quickly to the FHR baseline is a variable deceleration. Variable deceleration occurs when the umbilical cord is being compressed, so the nurse should change the client's position to determine if this resolves the cord compression.

A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information?

Presence of genetic disorders. -Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal, genetic, and metabolic disorders. Amniocentesis in the third trimester assesses fetal lung maturity by evaluating the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks ) are found.

The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use?

Prioritize tasks with the most crucial needs first. -Planning care for a client with numerous treatments should be prioritized with the most crucial client needs first to the least. Delegating to others or reporting displace the nurse's responsibility to provide care. Starting with easiest is an inefficient utilization of time in meeting critical client needs.

The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles?

QRS interval of 0.14 second. -The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates an electrical anomaly in the ventricles. The T wave is normally 0.16 seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be 0.31 to 0.38 secon

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take?

Record these findings in the client's record. -These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention. Dehiscence is separation of a surgical incision, and there is no indication that this is a possibility at this time.

A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement?

Refer for further diagnostic evaluation. -The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in a homeless environment. Although productive prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be implemented. A dormant form that neither causes disease nor is communicable.

What instrument should the nurse use to determine the presence of deep tendon reflexes?

Reflex hammer. - Deep tendon reflexes are assessed using a reflex hammer. A goniometer is used to assess the degree of joint flexion and extension. A Wood's lamp determines the presence of fungi. Transilluminator is a light source that helps detect the presence of fluid in the sinus cavities.

The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression?

Renal function. -MODS includes the immediate consequences of posttraumatic pulmonary failure, thermal injuries, acute tubular necrosis, or invasive infections. Acute renal failure is a common manifestation of MODS, so the client's renal function should be monitored closely because the kidneys are highly vulnerable to reperfusion injury.

A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding?

Respirations of 10 - With respirations less than 12, the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours (or 25 ml/hour) (D) and absent reflexes. Reflexes of 1+ are hypoactive but present. A client with preeclampsia can seize with blood pressures lower than 140/90. Magnesium sulfate is not an antihypertensive.

A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2 F, chills, pelvic pain, and uterine tenderness. What action should the nurse take?

Review the complete blood count. -This client is exhibiting symptoms of endometritis, and an elevated white blood count suggests infection. The breast milk is not contaminated, so a breast pump should be provided to maintain lactation. Collection of a 24-hour urine specimen is not indicated for a client with endometritis. Infant safety is jeopardized by a client exhibiting these symptoms, so rooming-in should be discouraged.

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which priority nursing diagnosis should the nurse include in the plan of care?

Risk for Infection -Risk for Infection related to altered immune mechanisms caused by disease and effects of steroids is the priority. The other nursing diagnoses are not priority for a child with nephrotic syndrome who is receiving prednisone.

Which action should the nurse implement when using the confrontation technique during a vision exam?

Sit facing the client and while look directly at the client's face, move an object inward from the periphery. -Confrontation technique during a vision exam is used to determine peripheral vision, sodirectly facing the client and moving an object inward allows the client to state when the object enters the nasal, temporal, superior, and inferior fields of vision. Using an ophthalmoscope determines pupillary reactivity. Standing behind the client and asking them to identify when an object enters peripheral fields does not allow the examiner to determine if the client's eyes stay centered when testing the peripheral fields. Having client look at cards with different size of printing evaluates the client's visual acuity.

The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? Sinus bradycardia at 50 beats per minute.

SpO2 is 88% with shallow, slow respirations. -Bradypnea, ineffective gas exchange, and low SpO2 (D) should be reported to the healthcare provider because a client with a C7 spinal cord injury is likely to deteriorate due to post-injury spinal cord edema that may extend to cervical innervation of the diaphragm. Bradycardia and hypotension occur after spinal cord injury above T6 due to autonomic nervous system dysfunction. Flaccid paralysis is consistent with spinal shock which occurs after injury and resolves in varying degrees and time frames. Although fluid resuscitation may be prescribed to ensure tissue perfusion, hypotension may persist with peripheral vasodilation that results from loss of sympathetic function.

Which biological practices are federally regulated for healthcare workers? (Select all that apply.)

Standard precautions. N-95 tuberculosis standard. Blood-borne pathogen standard. Droplet precautions -Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration (OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks when caring for a client who is positive for tuberculosis, and required annual updates for healthcare workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee rights.

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next?

Start the first transfusion of blood. -The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started. Rechecking labs should be obtained after the client is transfused to evaluate its effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in the plan of care, but is not as essential as giving the transfusion at this time.

A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response?

Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. -Epoetin alfa is a biological response modifier that is used to stimulate the formation of red blood cells. Accelerating neutrophil production describes agents, such as filgrastim, used to decrease the risk for infection in clients with chemotherapy-induced neutropenia

A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide?

Stool is eventually expelled through the rectum. - An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually indicated.

A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first?

Stop the irrigation flow. -The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped to prevent severe bladder distention. The next action is to check the external system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 ml of normal saline using a large piston syringe. If the obstruction is not resolved, then the healthcare provider should be implemented.

A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject?

Storing nitroglycerin. - Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with air can be avoided, and keeping it in a pants pocket exposes it to body heat, which can reduce its effectiveness. The client should keep the medication in a jacket pocket, which would reduce direct body contact with the bottle. He should also check the expiration date on the bottle (it is good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people experience a headache when taking nitroglycerin, due to the vasodilatation effect.

While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take?

Suction the client's endotracheal tube and auscultate following suctioning. -Suctioning the ET tube clears secretions and will usually eliminate the coarse snorous sounds. Respiratory therapy usually provides treatments when airways are edematous, not for secretions. Changing the tidal volume will not clear the airways. Clients on a ventilator will have sounds of the ventilator working, however the ventilator should not be stopped for auscultation of breath sounds.

Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding?

Survivors of violence that occurred at least 5 years ago. - Vulnerable populations are those groups who have an increased risk of developing adverse health outcomes. Survivors of violence, even though the violence occurred more than 5 years ago, have an increased risk for adverse health outcomes. The other options just describe demographic groups.

A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action?

Take the client's vital signs. -After the client is transferred from the PACU stretcher to the hospital bed and the PACU nurse reports the client's condition, the client's vital signs should be obtained first, so a change in the client's status can be determined. Vital sign changes are a primary indicator of cardiopulmonary complications and bleeding in the first hours postoperatively.

What is the most effective way to implement a teaching plan?

Teach the information that the client wants to learn first. -Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something.

A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide?

Tell the HCP that both of you should talk to the supervisor now -Conflict resolution between staff and HCP is best resolved with a mediator who can address facts, not emotional reactions. Walking away or stating it is not their client ignores the conflict, which may escalate. Giving the medication is unsafe practice.

The nurse is assessing an older adult client's living arrangements and care. Which situation should the nurse identify as contributing the most to the client's vulnerability for elder abuse?

The caregiver's stress level is overwhelming. -The intensity and complexity of caregiving places a caregiver at risk for high levels of stress which contribute to being overwhelmed (A), invoking feelings of inadequacy, powerlessness, depression, or anger, and may be displaced to the older client.

A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something is not right". Which finding should the nurse assess further?

The cervix is effacing and dilated to 2 cm. - Cervical changes, such as shortened endocervical length, effacement, and dilation accompanied by regular contractions indicate labor at any gestation period, so the client should be monitored for pre-term labor. Estriol is a form of estrogen found in plasma at 9-weeks gestation, and increased levels of salivary estriol have been shown to occur before preterm birth. The presence of fetal fibronectin in vaginal secretions, between 24 and 36 weeks of gestation has a 20% to 40% positive predictive value for preterm labor. Irregular mild contractions that do not cause cervical change indicate Braxton Hicks contractions or false labor.

A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond?

The healthcare team must honor the written wishes of the client. -The client is the ultimate decision-maker regarding treatment or refusal of treatment. The client's ethical right to autonomy and legal right to give informed consent for treatment are recognized in both legally created special directives and living wills. Although family members are very important in the care and support of the client, the nurse, and healthcare provider must respect the legal document that the client created to direct the course of treatment.

Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)?

Type 1 DM and retinopathy and mild vision loss. -Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop nephropathy and CKD. The client with hemoglobin A1C of 3.5% is demonstrating compliance with therapy (H-A1c target level is no greater than 7%), which indicates tight glucose control and reduces the risk for microvascular complications. The client with controlled hypertension is less likely to develop CKD, although metoprolol, a beta adrenergic receptor antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk for complications associated with chronic obesity.

Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells?

Vital signs. -Baseline vital signs are essential to obtain prior to administering a blood transfusion, so that vital signs measured during the transfusion administration can be compared to the baseline to assess for the onset of a transfusion reaction. The other assessments provide less significant data immediately prior to the administration of the transfusion.

The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase

urine output to 55 ml/hr. -The expected outcome of this treatment is an increase in urine output due to increased renal perfusion. Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is indicated in a critically ill client who is hypotensive.