HESI Review Question Combined Pt. 3
A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client
A) A 79 year-old malnourished client on bed rest
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents
A) Abdominal x-ray
An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A) Administer a daily dose of lisinopril as scheduled. B) Assess the client for postural hypotension. C) Notify the healthcare provider immediately D) Provide a PRN dose of acetaminophen for headache E) Withhold the next scheduled daily dose of warfarin
A) Administer a daily dose of lisinopril as scheduled. D) Provide a PRN dose of acetaminophen for headache
A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins
A) An infant who has been identified to have botulism
To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion
A) Apply suction for no more than 10 seconds
The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance
A) Avoid chocolate and cheese
A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness
A) Can predispose to dysrhythmias
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones
A) Exercise doing weight bearing activities
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88
A) FHT 168 beats/min
The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube
A) Hold the tube feeding and notify the provider
A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.
A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.
A client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate of intravenous fluid infusion D) Withhold next dose of corticosteroid E) Initiate fall risk precuations
A) Measure capillary glucose level B) Monitor cardiac telemetry pattern E) Initiate fall risk precuations
An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bedside commode next to the bed C) Suction oral cavity every 4 hours D) Encourage family to participate in the client's care E) Play classical music in room while client is awake
A) Measure neurological vital signs every 4 hours D) Encourage family to participate in the client's care E) Play classical music in room while client is awake
A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered PRN medication D) Reassess the foot in fifteen minutes
A) Notify the health care provider
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asksthe nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light D) A medication is used to induce sleep during the procedure E) These medications assist in obstructing client ́s vision during the surgery
A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs
A) Orthostatic hypotension is a common side effect
To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A) Practice relaxation exercises B) Limit fluids to avoid bladder distention C) Space activities to allow for rest periods D) Avoid persons with infections E) Take warm baths before starting exercise
A) Practice relaxation exercises C) Space activities to allow for rest periods D) Avoid persons with infections
A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem
A) Protamine
The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2
A) S3 ventricular gallop
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees
A) Side-lying on the left with the head elevated 10 degrees
61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding C) Maintain sequential compression devices while in bed D) Administer low molecular weight heparin as prescribed E) Assess pain level and medicate PRN as prescribed
A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding
A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are inyour ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as youfeel up to it. The stitches generally dissolve in seven to ten days. D)The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.
A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."
B) "I have been coughing up foul-tasting, brown, thick sputum."
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."
B) "Our child should brush and floss carefully after every meal."
The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children or adults."
B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"
B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis
B) A positive purified protein derivative with an abnormal chest x-ray
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention isto A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake
B) Administer acetaminophen as ordered as this is normal at this time
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication
B) Assess for dyspnea or stridor
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses
B) Assess for post operative arrhythmias
The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision
B) Assist client to turn, deep breathe, and cough
An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids
B) Check the client's gag reflex
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour
B) Continuously
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids
B) Decreased sodium and potassium
When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises
B) Deep breathing and coughing
The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness
B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output
B) Have the client turn to the left side
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets
B) Hemoglobin and hematocrit
A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B) It is critical to report promptly to your health care provider any findings of peptic ulcers c) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine
B) It is critical to report promptly to your health care provider any findings of peptic ulcers
59. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles
B) Jugular vein distention
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation
B) Leukopenia
A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) A) Protect medication from exposure to light B) Monitor for changes in level of consciousness C) Observe for onset of generalized bruising or bleeding D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes
B) Monitor for changes in level of consciousness D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes
What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements
B) Oozing liquid stool
The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator
B) Perform a quick assessment of the client's condition
A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin
B) Potassium
A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses
B) Pupils fixed and dilated
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Take an additional dose for signs of hyperglycemia B) Recognize signs and symptoms of hypoglycemia C) Report persist polyuria to the healthcare provider D) Use sliding scale insulin for finger stick glucose elevation E) Take Glucophage with the morning and evening meal.
B) Recognize signs and symptoms of hypoglycemia C) Report persist polyuria to the healthcare provider E) Take Glucophage with the morning and evening meal.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion
B) Sore throat, fever
Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended
B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
B) The client has a right to know about the prescribed medications
Which of these observations made by the nurse during an excretory urogram indicates a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."
B) The client's entire body turns a bright red color
When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays in normal sinus rhythm, but he has no spontaneous respirations, and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Observed for swelling at the fracture site B. Begin chest compressions at 100/minute C. Analyze the cardiac rhythm in another lead D. Obtain a 12-lead electrocardiogram
B. Begin chest compressions at 100/minute
After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."
C) "He is scared and taking it out on you. Let's talk to figure out what to do."
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."
C) "The medication must be continued so the fluid problem is controlled."
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea
C) A cold, pale lower leg
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time
C) Activated PTT
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again
C) Assist him to stand by the side of the bed to void
The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.
C) Children are not to share hats, scarves and combs.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms
C) Dyspnea
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room
C) Irrigate and redress a leg wound
The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks
C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent
A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently
C) Keep conversations short
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs
C) Lower the oxygen rate
After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness
C) Palpate pulses
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive
C) Participate with the compressions or breathing
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h
C) Place in respiratory/secretion precautions
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision
C) Reinforce the dressing and elevate the leg
A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors should wear gloves if they touch the client
C) Visitors should wash their hands before and after touching the client
A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure
C) improved respiratory status and increased urinary output
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter
C) minimal drainage into the urinary collection bag
A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. What action should the nurse implement? A. Notify the radiation department to withhold the treatments for now B. Determine if the client wishes to cancel further radiation treatments C. Ask the client about his expected goals for this hospitalization D. Explain that palliative care measures can be provided at home
C. Ask the client about his expected goals for this hospitalization
A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the streptococcus bacteria? A. High, protracted fever B. Flaky, peeling skin C. White coating on the tongue D. Red bumps across chest
C. White coating on the tongue
The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."
D) "I always make sure to shake the NPH bottle hard to mix it well."
A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) "I knew this would happen. I've been eating too much red meat lately." B) "I really enjoyed my fishing trip yesterday. I caught 2 fish." C) "I have really been working hard practicing with the debate team at school." D) "I went to the health care provider last week for a cold and I have gotten worse."
D) "I went to the health care provider last week for a cold and I have gotten worse."
Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen
D) A young adult in the second day of treatment for an overdose of acetometaphen
Which of these nursing diagnoses of 4 elderly clients would place 1 client at thegreatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia
D) Altered patterns of urinary elimination related to nocturia
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides
D) Application of pediculicides
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene
D) Assist with oral hygiene
The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato
D) Baked potato
Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall
D) Bed in lowest position, wheels locked, place bed against wall
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact
D) Contact
A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage
D) Continue to monitor the rate of drainage
A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.
D) Fibroids that cause no problems still need to be taken out.
A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube
D) Flush adequately with water before and after using the tube
As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss
D) Hair loss
A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces
D) Have gloves on while handling bedpans with feces
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client's written consent before I release any information to you.
D) I need to get the client's written consent before I release any information to you.
Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.
D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.
Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days
D) No bowel movement for 3 days
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings
D) Pale, thin arms and legs, uninterested in surroundings
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation
D) prevent the drug from tissue irritation
A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness
D) restlessness
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight
D) weekly weight
An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 b. 0800, 1200, 1600, 2000 c. Administer with meals and a bedtime snack d. Given equally divided doses during waking hours
a. 1000, 1600, 2200, 0400
Four hours after the nurse administers interferon alpha subcutaneously into a client, the client develops a headache, muscle aches and a fever of 101.8 degrees Fahrenheit. What action should the nurse implement? a. Administer prescribed PRN dose of acetaminophen for these side effects b. Explain that an antihistamine may be needed in response to this allergic reaction c. Document these findings as an idiosyncratic response to this medication d. Observed the site where the medication was injected for signs of local reaction
a. Administer prescribed PRN dose of acetaminophen for these side effects
A client with chronic kidney disease is admitted in heart failure and is complaining of shortness of breath and a headache. Assessment findings include blood pressure 180/90 mmHg, heart rate 130 beats/minute, oxygen saturation 89%, and a temperature of 100 degrees Fahrenheit. A temporary dialysis catheter is inserted for immediate hemodialysis and the client is scheduled for replacement of an arterial venous fistula in the left arm. Which action should the nurse implement? a. Avoid using the left arm for IV access b. Initiate oxygen at 110% per face mask c. Give the PRN dose of enalapril d. Administer PRN antipyretic prescription
a. Avoid using the left arm for IV access
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include heart rate of 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? a. Bilateral diffuse wheezing b. Temperature of 100.5 c. Yellow expectorated sputum d. Shortness of breath on exertion
a. Bilateral diffuse wheezing
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Blood transfusion b. Bone marrow transplantation c. Immunosuppressive therapy d. Chemotherapy
a. Blood transfusion
A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first? a. Determine the clients vital signs b. Administer prescribed pain medication c. Apply warm blankets d. Assess the surgical site
a. Determine the clients vital signs
The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? a. Difficulty breathing b. Increased blood pressure c. Chills and tremors d. Nausea and vomiting
a. Difficulty breathing
The healthcare provider prescribes a placebo instead of pain medication. What intervention should the nurse implement? a. Discuss ethical concerns about placebo use with the health care provider b. Administer the placebo as prescribed when the client complaints of pain c. Tell the charge nurse about the prescribed placebo and refuse to administer it d. Inform the client that the provider prescribed a placebo instead of pain medication
a. Discuss ethical concerns about placebo use with the health care provider
An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 milliliters of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of bed b. Complete focus assessment c. Offer PRN pain medication d. Send emesis sample to the lab
a. Elevate the head of bed c. Offer PRN pain medication b. Complete focus assessment d. Send emesis sample to the lab
The nurse notes that a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a. Engage the client in non-threatening conversations b. Encourage the client to participate in group activities c. Encourage the clients family to visit more often d. Schedule a daily conference with the social worker
a. Engage the client in non-threatening conversations
An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus is admitted to the telemetry unit for sudden onset of dizziness with palpitations and a burning sensation in her chest. Which intervention should the nurse implement first? a. Evaluate telemetry cardiac rhythm b. Administer an oral antacid c. Assess blood glucose level d. Review clients last meal choices
a. Evaluate telemetry cardiac rhythm
A client with chronic kidney disease (CKD) is discharged with a prescription for epoetin alpha subcutaneously. In teaching the client about the medication, the nurse should emphasize the benefit of increasing which food product in the diet? a. Iron rich foods b. High fiber foods c. Citrus fruits and vegetables d. Dairy products
a. Iron rich foods
A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply. a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions
a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs e. Initiate contact transmission precautions
An adult male is brought into the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?a. Nausea with projectile vomiting b. Rebound abdominal tenderness c. Diminished bilateral breath sounds d. Rib pain with deep inspiration
a. Nausea with projectile vomiting
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate that the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Observe aspiration site b. Monitor skin elasticity c. Measure urinary output d. Assess body temperature
a. Observe aspiration site
The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. Plumb line test indicates fetal position curvature c. Babinski tests that reveals fanning out of toes d. Moro test precipitating a startle response
a. Ortolani maneuver causing a click at the hip joint
While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavio
a. State it is unacceptable to undress during interview
The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the clients discharge teaching plan? Select all that apply. a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting d. Crossed legs at knee but not at ankle e. Maintain the bed flat while sleeping
a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? a. "How do you cope with the voices?" b. "What are the voices saying?" c. "Which medication works best?" d. "When do you hear voices?"
b. "What are the voices saying?"
The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. Which intervention has the highest priority for this client? a. Administer prescribed PRN sleep medications b. Administer prescribed stool softener c. Encourage use of prescribed analgesic perennial sprays d. Encourage breastfeeding to promote uterine involution
b. Administer prescribed stool softener
Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis
b. Allergic rhinitis d. Contact dermatitis
Oxygen at 5 L/minute per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? a. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs b. Avoid administration of oxygen at high levels for extended periods c. Oxygen is less toxic when it is humidified with a hydration source d. Increase oxygen rate during sleep to compensate for slower respiratory rate
b. Avoid administration of oxygen at high levels for extended periods
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Continued development of the brain lesion determines the child's outcome b. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation
b. Brain damage with CP is not progressive but it does have variable course
A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? a. Administer and non-steroidal anti-inflammatory drug for pain b. Check neurovascular status of the distal digits c. Change the dressing if drainage increases d. Position the arm in a sling for discharge
b. Check neurovascular status of the distal digits
An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? a. Prepare for emergent oral intubation b. Clarify end of life desires c. Offer sips of favorite beverages d. Initiate comfort measures
b. Clarify end of life desires
A male client who is experiencing musculoskeletal pain is discharged with instructions to take ibuprofen, on non-steroidal anti-inflammatory drug by mouth BID. After receiving discharge teaching, the client states he plans to take the medication twice daily, with breakfast and dinner. How should the nurse respond? a. Review the need to limit intake of leafy, green vegetables such as spinach b. Confirm that the client has an effective plan for when to take the medication c. Explain the need to take the medication before meals to increase absorption d. Remind the client to increase fluid intake while taking the medication
b. Confirm that the client has an effective plan for when to take the medication
A client at 28 weeks' gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? a. Recount the heart rate manually to confirm a monitor malfunction b. Contact the health care provider after initiating oxygen per face mask c. Explain that there is no indication the fetal heart rate is due to trauma d. Evaluate the presence of preterm labor by performing a vaginal examination
b. Contact the health care provider after initiating oxygen per face mask
A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number
b. Determine type of chemical exposure
An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she's sick or stressed. How should the nurse respond? a. Describe the use of the vaccination to treat herpes simplex type 2 b. Explain the use of the vaccination to reduce risk for herpes zoster c. Confirm that consent form is signed before administering the vaccination d. Arrange for skin testing to evaluate if the client is a candidate for the vaccine
b. Explain the use of the vaccination to reduce risk for herpes zoster
A seriously ill male client is transferred to the health care facility in a different state. Included in his records are advanced directive and a physician orders for life sustaining treatment. However, the state to which he is transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? a. Request that the new health care provider cosine the POLST document b. Implement the clients wishes as described in his advanced directive c. Ask the clients family to make life sustaining treatment decisions d. Attached an advance directive copy to a medical record prescription page
b. Implement the clients wishes as described in his advanced directive ??
A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? a. Maintain head of bed at 45 degrees b. Infuse 0.9% sodium chloride 500 ml bolus c. Insert nasogastric tube to intermittent suction d. Document strict and intake and output
b. Infuse 0.9% sodium chloride 500 ml bolus
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility b. Names 3 home safety hazards to be resolved immediately c. States 4 risk factors for the development of osteoporosis d. Lists five calcium rich foods to be added to her daily diet
b. Names 3 home safety hazards to be resolved immediately
The nurse is caring for a client with a suspected diagnosis of osteomyelitis. Which diagnostic test should the nurse prepare the client to expect the health care provider to prescribe? a. Radiographs b. Radionuclide bone scan c. C reactive protein tests d. Erythrocytes sedimentation rate
b. Radionuclide bone scan
The nurse on a pediatric unit of a healthcare facility observes a colleague leaving and open client electronic health record unattended while taking a lunch break. Which action should the nurse take? a. Close the computer and complete the day's assignments b. Remind the colleague of information security principles c. Comment about the action on a staff discussion board d. Discuss the incident with the facilities risk manager
b. Remind the colleague of information security principles
The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? a. Collect a sputum specimen immediately b. Request a consultation to confirm dysphasia c. Offer the client additional clear liquids frequently d. Encourage the client to do deep breathing exercises daily
b. Request a consultation to confirm dysphasia
A male client with hypertension, who is receiving a new antihypertensive prescription at his last visit returns to the clinic 2 weeks later to evaluate his blood pressure. His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad." In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Heart block due to myocardial damage b. Stroke secondary to hemorrhage c. Acute kidney injury due to glomerular damage d. Blindness secondary to cataracts
b. Stroke secondary to hemorrhage
Following breakfast, the nurse is preparing to administer 0900 medications to the clients on the medical floor. Which medication should be held until a later time? a. The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease b. The antifungal nystatin suspension, for a client who has just brushed his teeth c. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour d. The loop diuretic furosemide, for a client with a serum potassium level of 4.2 meq/L
b. The antifungal nystatin suspension, for a client who has just brushed his teeth
A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30-second periods of apnea, the healthcare provider is notified, and STAT arterial blood gases are drawn. What ABG results should the nurse anticipate? a. Compensated respiratory acidosis b. Uncompensated respiratory acidosis c. Uncompensated metabolic acidosis d. Compensated metabolic acidosis
b. Uncompensated respiratory acidosis
When should intimate partner violence screening occur? a. Once the clinician confirms a history of abuse b. Only when a client presents with an unexplained injury c. As a routine part of each healthcare encounter d. As soon as the clinician suspects a problem
c. As a routine part of each healthcare encounter
For the second time in four months, and overweight client is seen in the clinic because of vulvovaginitis resulting from a candida infection. Which intervention should the nurse implement first? a. Determine the client's typical menstrual cycle b. Obtain the client's blood glucose level c. Ask the client about recent sexual activity d. Review the client results for a complete blood count
c. Ask the client about recent sexual activity
A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Obtain the infants vital signs b. Observe the instant latching on to the breast c. Place the ID bands on the infant and mother d. Administer vitamin K injection
c. Place the ID bands on the infant and mother
The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? a. Remove pillows and soft toys from the crib at bedtime b. Keep a bulb syringe accessible for use for an infant c. Position the infant in a supine position while sleeping d. Do not prop bottles for an infant during naps and bedtime
c. Position the infant in a supine position while sleeping
The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asked the nurse for information about the scheduled procedure. What action should the nurse implement? a. Reassure the client that whatever the outcome, he will be able to cope with the results b. Encourage the client to take deep breaths in to avoid thinking negative thoughts c. Repeat the client teaching and leave written instructions for the client d. Remind the client of the instructions that were provided an hour ago
c. Repeat the client teaching and leave written instructions for the client
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider?a. Serum ph of 7.45 b. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c. Serum potassium of 3.0 mg/dl d. Gastric output of 100 ml in the last 8 hours
c. Serum potassium of 3.0 mg/dl
A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? Select all that apply. a. Arrange in service training through the education department b. Obtain informed consent from clients who will receive care c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee
c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee
A middle-aged man in the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide? a. Keep the infected area covered until the infection is resolved b. Use a fine-tooth comb to remove any knits observed on the scalp c. Take your medication with a glass of water two hours after meals d. Wash your bed linens and hot water after starting the medication
c. Take your medication with a glass of water two hours after meals
An adult client is admitted to the psychiatric unit with a diagnosis of major depression. After two weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving personal belongings away to visitors, and is in a better mood. Which intervention is best for the nurse to implement? a. Tell the client to keep one's belongings because they will be needed at discharge b. Support the client by validating the progress that has been made c. Reassure the client that the antidepressant drugs are apparently effective d. Ask the client if there are any recent thoughts of harming self
d. Ask the client if there are any recent thoughts of harming self
The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? a. Remind the UAP to wash hands frequently while in the room b. Help the UAP reposition the gown sleeve over the glove edges c. Confirm that the gown is tide securely at the neck and waist d. Assist the UAP with application of a face mask or face shield
d. Assist the UAP with application of a face mask or face shield
The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated blood pressure in a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Measure ankle circumference b. Monitor daily sodium intake c. Record usual eating patterns d. Auscultate for irregular heart rate
d. Auscultate for irregular heart rate
A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. What teaching should the nurse provide? a. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals b. Multivitamins are contraindicated during treatment with weight control medications such as Orlistat c. Following a well-balanced diet is a much healthier approach to a good nutrition than depending on a multivitamin d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness
d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are being taken so often. Which response by the nurse is most accurate? a. Hypertension leading to sudden shock can develop at any time b. Blood pressure fluctuations means that the condition has become chronic c. Sodium intake with meals and snacks affects the blood pressure d. Elevated blood pressure must be anticipated and identified quickly
d. Elevated blood pressure must be anticipated and identified quickly
The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? a. Importance of recording daily weights b. Adherence to a high fiber low fat diet c. Need to check temperature daily d. Events requiring steroid dosage adjustments
d. Events requiring steroid dosage adjustments
What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with and HIV infection? a. Increase ability to carry out activities of daily living b. Promote a feeling of general well-being c. Prevent spread of infection to others d. Improve function of the immune system
d. Improve function of the immune system
The nurse inserts and indwelling urinary catheter as seen in the video. What action should the nurse take next? a. Remove the catheter and insert into urethra opening b. Insert the catheter further and observe her discomfort c. Observe for urine flow and then inflate the balloon d. Leave the catheter in place and obtain a sterile catheter
d. Leave the catheter in place and obtain a sterile catheter
A client who is hypotensive is receiving dopamine, and adrenergic agonist IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a. Initiate seizure precautions b. Assess pupillary response to light hourly c. Monitor serum potassium frequently d. Measure urinary output every hour
d. Measure urinary output every hour
A client is receiving a hypertonic solution for bladder irrigation in as at risk for dilutional hyponatremia. The nurse should plan to observe for which common sign of hyponatremia?a. Irregular heartbeats b. Bradycardia c. Muscle spasms d. Mental status changes
d. Mental status changes
The father of a four-year-old has been battling metastatic lung cancer for the past two years. After discussing the remaining options with his health care provider, the client request that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Provide the client written information about end-of-life care b. Reassure the client that his child would be allowed to visit c. Mark the chart with the clients request for no heroic measures d. Obtain a detailed report from the nurse transferring the client
d. Obtain a detailed report from the nurse transferring the client
A client with a history of upper respiratory symptoms is admitted with chest tightness, productive cough, and difficulty breathing period the client's arterial blood gases indicate respiratory acidosis. An increase in which laboratory test result supports this finding? a. HCO3 b. Arterial pH c. PaO2 d. PaCO2
d. PaCO2
A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement? a. Using analgesic spray to the perennial area to reduce pain b. Apply an ice pack to the perineum for the first 24 hours c. Teach the client how to practice kegel exercises d. Review the use of sitz bath equipment with the client
d. Review the use of sitz bath equipment with the client
When teaching a group of school age children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? a. Wash hands frequently b. Avoid drinking lake water c. Do not share personal products d. Wear long sleeves and pants
d. Wear long sleeves and pants
The healthcare provider prescribes an antibiotic cefdinir 300 mg PO Every 12 hours for a client with a postoperative wound infection. Which food should the nurse encourage this client to eat?a. Avocados and cheese b. Green leafy vegetables c. Fresh fruits d. Yogurt or buttermilk
d. Yogurt or buttermilk
