Hesi study Test A

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond?

"Listening to the news seems to be frightening you."

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents?

Warm the child with an electric blanket prior to getting the child out of bed. Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first

Take the vital signs to determine the client's response for a potential blood loss

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff?

Team 1: RN team leader, PN; team 2, PN team leader, UAP

Which physiologic finding in an older adult contributes to an adverse drug reaction?

Reduced renal excretion

Prior to administering an oral suspension, which intervention is most important for the nurse to implement?

A.Assess the client's ability to swallow liquids

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic?

"Tell me more about how you're feeling."

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction?

"When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel."

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis?

Has your child had an ear infection recently?" Osteomyelitis can be caused by internal infections, such as otitis media (A). (B and C) are normal developmental findings for a 2-year-old. Osteomyelitis is caused by a bacterial infection, so (D) is not relevant.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting?

Inability to flex the chin to the chest Rationale:Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)?

Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma?

Pain scale measurement Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience?

. A client who is 2 days postoperative with a right total knee replacement

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members?

. Assign the UAPs to take vital signs and obtain daily weights Rationale:A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment?

. Immunization history

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include?

. Instruct the client to grasp the overhead trapeze bar. The client will gain upper body strength and independence by using the overhead trapeze bar for positioning

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.)

1) Report lithium level of 2.0 mEq/L to the primary health care provider. 2) Maintain consistent salt levels in the diet when client is taking lithium. 3) Assess the client's nutritional and hydration status. A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C).

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse?

50 mg/dL

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults?

A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? Rationale

A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol)

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse?

A multiparous client who is dilated 5 cm and 50% effaced

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?

Assist the client with toileting

A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids?

Breath sounds Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last.A. Gently insert the catheter without suction using sterile technique.B. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB).C. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg.D. Apply suction intermittently while withdrawing the catheter.

C, B, A, D

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?

Check the client's blood pressure.

A nurse is planning patient care and wants to verify the steps for a specific client procedure. Which action should the nurse take?

Consult the agency's policies and procedures manual and follow the guidelines.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart?

Cover one eye while reading the chart with the other.

A child is having a generalized tonic-clonic seizure. Which action should the nurse take?

Move objects out of the child's immediate area.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented?

Serum potassium level is 2.5 mEq/L Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image?

The spouse has never seen the client naked.

The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min?

Use the following calculation (B):20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had a appendectomy. The IV tubing being using delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.)

Use the following calculation (B):Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client?

With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother?

"Did your daughter also start her menstrual period at 12 years of age? Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma?

"Does anyone in your family have glaucoma?"

The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse?

"I take aspirin for my pain."

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly?

Help the client dangle his legs.

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary?

"Swimming can begin on the tenth postoperative day.

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP?

A woman who had a hip replacement and may be transferred to the home care unit

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide?

A client with normal vision can read at 100 feet what this client reads at 20 feet.

Which client is best to assign to a graduate PN who is being oriented to a renal unit?

A client with renal calculi whose urine needs to be strained

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable?

A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.)

A.Hourly urine output B.Bladder distention D.Intraoperative bladder decompression Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.)

A.Increase in T3 and T4 E.Decrease in periorbital edema Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.)

A.Monitor maternal vital signs for hemorrhage B.Instruct the woman to report any contractions D.Monitor fetal heart rate for 1 hour after the procedure.

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36-month-old child? (Select all that apply.)

A.Record wet diapers. C.Examine skin turgor. D.Observe mucous membranes. All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, and D), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.)

A.Shave the area where the TENS will be placed. C.Place the TENS unit directly over or near the site of pain. E.Describe the use of TENS for postoperative procedures such as dressing changes. The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next?

Allow the client to sit on the side of the bed for a few minutes before transferring.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement?

Ask about scrotal pain or blood in the semen Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results?

Assess the client for pain and administer pain medication as prescribed.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital. "C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery. "D. "Would you like to make a change in his pharmacologic regimen?"

B, C, A, D SBAR: S = Situation and includes introduction of the nurse and client/setting (B). B = Background and includes the presenting complaint and relevant history (C). A = Assessment and includes current vital signs and other information (A). R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (D).

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.)

B.Mood changes from depressed to happy C.Begins giving away possessions

The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained?

Blood pressure of 90/56 mm Hg Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications?

Blood urea nitrogen >25 mg/dL Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.)

C.Explain the benefits of remaining in the hospital. E.Provide the client with names of local support groups. F.Notify the health care provider of the client's intention.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement?

Call for the charge nurse to check the advanced directive while continuing to assess the client.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take?

Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take?

Continue to monitor the client. The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client

The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time?

Continue with current assignments until more instructions are received.

The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose?

Guaiac-positive stool Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority?

Health care-associated infection (HAI) transmission of infectious diarrhea is prevented.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization?

Encourage as much independence in decision making as possible. Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible (C) helps reduce stress experienced with repeated hospitalization.

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff?

Encourage staff to participate in online in-service education.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity?

Encourage the client to ambulate every 3 hours.

After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority?

Ensure that the client receives breakfast within 30 minutes.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform?

Examine for clamp closures. Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps (A) first. The CVC should be flushed with normal saline (D) or a diluted solution of heparin (10-100 U/mL) after (A) is completed, if necessary.

An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client?

Face the client and speak in a normal tone of voice.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test?

Failure to collect all urine specimens during the period of the study will invalidate the test. Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time?

Hypotension During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension (B). (A) is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not (C). (D) is characteristic of chronic renal failure with multiple body system involvement.

The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved?

Increased oxygen saturation

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program?

Individuals interested in having children

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make?

Inform the client that the scheduled Pap test cannot be done today.

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement?

Leave the room and discuss the incident privately with the staff member.

A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first?

Notify the health care provider of the change in mental status.

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement?

Obtain a stool specimen for culture and sensitivity. Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen (C)

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP?

Offer the client emotional support.

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation?

Offer to develop an alternate solution so that the residents can continue to watch television.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)?

Old medical records are kept in a locked file cabinet in the department.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client?

Oral hygiene should be performed before the medication

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement?

Place trochanter rolls on the lateral aspects of the client's thighs. Rationale: Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board (A) provides increased back support, especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP?

Position the client who has vomited on his side and obtain vital signs. The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement?

Rest in bed with the head of the bed elevated 20 degrees and flex the knees.

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide?

Save the next urine sample.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit?

Sending medical records to health care providers via the Internet

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client?

Serum sodium level of 137 mEq/L Rationale:Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client?

Sitting upright and forward with both arms supported on an over the bed table Sitting upright and forward with both arms supported on an over the bed table

When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement?

Speak privately with the nurse.

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.)

Use lanolin to moisturize the tops and bottoms of the feet. Wash feet daily and dry well, particularly between the toes. Wear leather shoes that fit properly

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level?

The client's renal function has affected his potassium level.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain?

The client's usual sleeping pattern

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse?

The color of the dialysate outflow is opaque yellow. Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia

A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol). How should the nurse respond to this client's statement?

The drug is hepatotoxic and contraindicated.

A male client with Parkinson's disease has been taking the antiparkinsonian agent amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The medicine doesn't seem to be working anymore." Which information should the nurse provide to this client?

The effects of this drug tend to decrease after 3 months. The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time and then resumed at a higher dosage, and although (A) is partially correct, (D) is more correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an adjunct, but (C) would have little effect.

Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective?

The oral mucosa is pink and intact.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations?

The ventilator setting for respiratory rate and the client-initiated respirations The nurse should count the client's respirations, and document both the respiratory rate set by the ventilator and the client's independent respiratory rate (D). Never rely strictly on the respiratory settings on the ventilator

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide?

This sensation occurs as breast milk moves to the nipple.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide?

Those are Mongolian spots and will gradually fade in 1 or 2 years. Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned babies.

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child?

Toasted oat cereal and low-fat milk A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet.

The nurse should encourage a laboring client to begin pushing at which point?

When the cervix is completely dilated Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson's reflex)

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.)

left HF: A.Confusion C.Crackles in the lungs D. Dyspnea Right HF: B.Peripheral edema E. Distended neck veins