MED Important hesi

a nurse is caring for a client with diabetes insipidus (DI). which data warrants the most immediate intervention by the nurse?

serum sodium of 185 mEq/L (185 mmol/L)

a client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. which prescribed medication should the nurse administer first?

sodium polystyrene sulfonate 15 grams by mouth

the healthcare provider prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia?

sputum culture and sensitivity

a client with chronic kidney disease is started on hemodialysis. during the final dialysis treatment, the client's blood pressure drops from 150/90 mmHg to 80/30 mmHg. which action should the nurse take first?

stop the dialysis treatment

a client is recovering from an episode of urinary tract calculi. during discharge teaching, the client asks about dietary restrictions. in discussing fluid intake, the nurse should include which type of fluid limitation?

tea and hot chocolate

the nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. which outcome should the nurse include in the plan of care for this client?

the client will record episodes of angina and self management for one week

the nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. which outcome should the nurse include in the plan of care for this client?

the client's daily blood pressure will be less than 140/80 mmHg this month

a client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. on which information should the nurse's response be based?

the procedure is performed with the client in an upright position

the nurse is obtaining the admission history for a client with suspected peptic ulcer diseased (PUD). which subjective data reported by the client supports this medical diagnosis?

upper mid-abdominal pain described as gnawing and burning

while caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. before reporting this finding to the healthcare provider, the nurse should review which of the clients laboratory values?

white blood cell (WBC) count

after teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. which food choices eliminated by the client indicate to the nurse that teaching has been successful?

whole milk and daily servings of ice cream

a hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. which statement by the client indicates to the nurse that learning has occurred?

"I can use a mirror to check the bottoms of my feet for any signs of breakdown"

the nurse prepares a teaching plan for an adult client with metabolic syndrome. which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (SATA)

-abdominal obesity -increased triglyceride levels -blood pressure of 150/96 mmHg -hyperglycemia

a client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dl (18 mmol/L SI). the client describes to the nurse of not understanding why the blood glucose level continues to be out of control. which interventions should the nurse implement? (SATA)

-have the client describe a typical day at work, home, and social activities -have the client demonstrate technique used to monitor blood glucose levels

to reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), which interventions should the nurse implement? (SATA)

-perform chest physiotherapy -teach the client breathing exercises -encourage the use of incentive spirometer

the nurse is caring for a client who is postoperative for a femoral head fracture repair. which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis? (SATA)

-pneumatic compression devices -calf-pump exercises -prescribed anticoagulant therapy

an older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complication? (SATA)

-sensation in feet and legs -skin condition of lower extremities -visual acuity

a client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). the nurse determines that the client's distal pulses are diminished in the left foot. which interventions should the nurse implement? (SATA)

-verify pedal pulses using a doppler pulse device -evaluate the application of the splint to the left leg -monitor left leg for pain, pallor, paraesthesia, paralysis, pressure

the healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. the available vial is labeled, "penicillin 500,000 units/mL". how many mL should the nurse administer to this client?

0.4`

the healthcare provider prescribes diazepam 8 mg IM every 4 hours PRN muscle spasms for a client with a fractured femur. the available vial is labeled, diazepam injection, USP 10mg/2 mL. how many mL should the nurse administer to this client?

1.6

a client receives a prescription for 1 liter of lactated ringer's intravenously to be infused over 6 hours. how many mL/hr should the nurse program the infusion pump to deliver?

167

the healthcare provider prescribes regular insulin 6 units/hr intravenously (IV). the IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. how many mL/hr should the nurse program the infusion pump?

6

a client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. this client states, "I just had a little case of the sniffles and a bit of a sore throat and wham! suddenly I couldn't get out of bed or do anything." which response is best for the nurse to provide this client?

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the nurse is performing stomal care with a client. while cleaning around the stoma, the nurse notices blood on the washcloth. which action should the nurse take next? VIDEO

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after three days of persistent epigastric pain, a female client presents to the clinic. she has been taking oral antacids without relief. her vital signs are heart rate of 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmHg. the nurse obtains a 12-lead electrocardiogram (ECG). which assessment finding is most critical?

ST elevation in three leads

which client has the highest risk for developing skin cancer?

a 65-year-old fair-skinned client who is a construction worker

the family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency (HIV) positive. which symptom confirms their suspicions?

a change has recently occurred in his handwriting

during a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. which information is most useful in determining the possible cause of the symptoms?

a grandson and his new dog recently visited

the nurse is caring for a client who had a cholecystectomy two days ago. the client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. the nurse reviews the client's serum amylase and lipase level results which are twice the normal value. based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?

acute pancreatitis

a client receives prescriptions for a multi-drug regimen for the treatment of tuberculosis. which information should the nurse prioritize?

adherence to the regimen imperative

a client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. in reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120 g/L) and the hematocrit is 35% (0.35). which action should the nurse prepare to take?

administer 1,000 mL (1 L) normal saline

an adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. what is the priority nursing action?

administer IV antibiotics as prescribed

a client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. when performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. which intervention should the nurse implement?

administer narcotic antagonist

the nurse is caring for a client who had an appendectomy 4 hours ago. which finding requires immediate action by the nurse?

apical heart rate of 100 to 110 beats/minute

the nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. which client action about skin care indicates a need for further teaching?

applies prescribed lotions to the radiation site

four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. which action should the nurse implement first?

assess pulse with a vascular doppler

an older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. the client is anxious and is complaining of a dry mouth. which intervention should the nurse implement?

assist client to an upright position

the nurse is planning care for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. which postoperative pain intervention should the nurse implement first?

attempt to obtain a self-report of pain level from the client

a client with liver disease and esophageal varices is admitted for an episode of hematemesis. which client teaching should the nurse provide prior to discharge?

avoid lifting heavy objects

a client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. the client asks the nurse for an alternative way to manage sleep apnea. which recommendation should the nurse provide?

begin a weight loss program

the nurse is assessing a client who has a left ventricular heart failure. which assessment finding is this client most likely to exhibit?

bilateral basilar crackles

a client with type 2 diabetes mellitus and hyperlipidemia is admitted to the medical unit with influenza and a blood glucose level of 320 mg/dL (17.8 mmol/L). which finding requires immediate follow-up by the nurse?

blood pressure 130/80 mmHg

which admission assessment findings should the nurse document related to a client who has been diagnosed of cushing's syndrome?

central-type obesity, with thin extremities

a postoperative client reports incisional pain.the client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. before selecting which medication to administer, which action should the nurse implement?

compare the client's pain scale rating with the prescribed dosing

a client with rheumatoid arthritis has an elevated serum rheumatoid factor. which interpretation of this finding should the nurse make?

confirmation of the autoimmune disease process

while completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. the client reports joint pain and trouble twisting a door knob due to weakness. which action should the nurse take in response to these findings?

consult with the occupational therapist for a functional assessment

following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothroax. two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. which action should the nurse implement?

continue to monitor the drainage system

the home health nurse provides teaching about insulin self-injection to a client who was recently diagnosed with diabetes mellitus. when the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide?

continue with the insulin injection

an older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. which assessment finding indicates progress toward the desired effect of this treatment plan?

decreased abdominal girth

when planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing problem of, "visual sensory/perceptual alterations". this problem is based on which etiology?

decreased peripheral vision

an older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. the client's family expresses concern about the client's nutritional status. how should the nurse respond to the family's concern?

demonstrate the use of visual scanning during meals to the client and family

a client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. which finding is most important for the nurse to report to the healthcare provider?

distended, hard, and rigid abdomen

a healthcare worker with no known exposure to tuberculosis has received a mantoux tuberculosis skin test. the nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. which is the best initial nursing action?

document negative results in the client's medical record

a client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. the nurse observes the area of inflammation extends about the ankle area. the client receives prescriptions for colchicine and indomethacin. which instruction should the nurse include in the discharge teaching?

drink at least 8 cups (1920 mL) of water per day

when conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

eat a high-fiber diet and increase fluid intake

the nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. to help the client manage the pain, which assessment data is most important for the nurse to obtain?

eating patterns and dietary intake

the nurse is obtaining a health history from a new client who has a history of kidney stones. which statement by the client indicates an increased risk for renal calculi?

eats a vegetarian diet with cheese 2 to 3 times a day

the nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral tissues. which is the best initial nursing action?

encourage frequent mouth care

a client with chronic syndrome of inappropriate anti-diuretic hormone (SIADH) reports to the nurse that they feel constantly thirsty. which action should the nurse take?

encourage the client to use hard candy frequently to help relieve thirst

the nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. the client has expressive aphasia and often becomes frustrated with the nursing staff. which intervention should the nurse implement?

encourage the client's use of picture charts

the nurse is assessing a client's arteriovenous (AV) fistula. which finding provides evidence of its normal function?

enlarged vein

an adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. when conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?

excessive physical exertion and respiratory tract infections

a client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. when notifying the healthcare provider, which information should the nurse provide first using the SBAR (situation, background, assessment, and recommendation) process?

explain specific reason for urgent notification

the nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. which information should the nurse provide?

family members can help with regular foot exams

the nurse is preparing an older client for a magnetic resonance imaging (MRI) with contrast. which laboratory value should the nurse report to the healthcare provider before the scan is performed?

fasting blood sugar of 200 mg/dL (11.1 mmol/L)

which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet?

fortified milk and cereals

a client with metastatic cancer reports of a pain level of a 10 on a pain scale of 0 to 10. twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. which intervention is most important for the nurse to include in this client's plan of care?

frequently evaluate the client's pain

the nurse obtains a fingerstick blood glucose level utilizing bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. the meter indicates 56 mg/dL (3.12 mmol/L). at this time, which intervention should the nurse implement first?

give the client six ounces of non-diet carbonated soda and instruct client to drink it entirely

an obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity tolerance. oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. which information is most important for the nurse to emphasize in the discharge teaching plan?

guidelines for oxygen use

the nurse is assessing a client who has herpes zoster. which question will allow the nurse to gather further information about this condition?

has everyone at home already had varicella?

the nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. which additional information about the client would be important for the nurse to tell the healthcare provider?

hematocrit and blood pressure

the nurse is assessing client's in an outpatient diabetic clinic. which entry provides the best indication that the client is adhering to the prescribed diabetic regimen?

hemoglobin A1C of 6.2%

a client with gram-negative bacterial infection develops disseminated intravascular coagulation (DIC). which intervention should the nurse prioritize in the client's plan of care?

hold heparin infusion when a new bleeding site occurs

the nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. which mechanism contributes to edema and ascites in clients with cirrhosis?

hypoalbuminemia that results in a decreased colloidal oncotic pressure

a client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). which information should the nurse provide?

increase physical activity

a client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. which action is most important for the nurse to instruct the client about self care?

increase the daily intake of fluids to liquefy secretions

the nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). what is the best initial nursing action?

increase the flow of the bladder irrigation

during spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. which intervention is the most important for the nurse to implement first?

initiate isolation precautions

a client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. after obtaining vital sign measurements, which prescription should the nurse implement first?

insert a nasogastric tube (NGT) and attach to low intermittent suction

a client taking antibiotics for three days to treat a streptococcal throat infection returns to the clinic reporting a fine itchy rash across the chest and arms. the nurse auscultates pulmonary wheezing and an elevated heart rate. which action should the nurse implement?

instruct client to stop taking the antibiotics

a client with cushing's syndrome is recovering from an elective laparoscopic procedure. which assessment finding warrants intervention by the nurse?

irregular apical pulse

two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. the nurse obtains a nasal swab to test for COVID-19. which action is most important for the nurse to take?

isolate the client from other clients, family, and healthcare workers not wearing proper PPE

a client is admitted to the medical unit during an exacerbation of systemic lupus erythematous (SLE). it is most important to report which assessment finding to the healthcare provider?

low grade fever

an adult woman with grave's disease is admitted with severe dehydration and malnutrition. she is currently restless and refusing to eat. which action is most important for the nurse to implement?

maintain a patent intravenous site

an adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." the client expresses great concern about going blind. which nursing instruction is most important for the nurse to provide this client?

maintain prescribed eye drop regimen

a client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. when the client tells the nurse the need to urinate, which intervention should the nurse implement?

maintain traction while the client uses a urinal

the nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. the nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. which intervention is most important for the nurse to implement?

medicate for pain and monitor vital signs according to protocol

a client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. the nurse recognizes the client is exhibiting symptoms of which condition?

meningococcal meningitis

a client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). which information should the nurse include in the discharge instructions?

monitor urinary stream for decrease in output

a client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. a triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark pink-tinged outflow with blood clots in the tubing and collection bag. which action should the nurse take?

monitoring catheter drainage

the nurse observes that a client with parkinson's disease (PD) has a mask-like face. which follow-up assessment is most important for the nurse to implement?

note frequency of drooling

the nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. the client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. during the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. what is the priority nursing action?

notify the healthcare provider of the client's medication history

while completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. the operating team is preparing to take the client to surgery. which intervention should the nurse implement immediately?

notify the surgical team to cancel the surgery

the nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. based on this finding, which action should the nurse include in the client's plan of care?

obtain a prescription for artificial tear drops

a client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. which action should the nurse implement?

obtain a specimen of urethral drainage for culture

a client with herpes zoster (shingles) on the thorax tells the nurse of having difficulty sleeping. which is the probable etiology of this problem?

pain

a client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. which assessment finding should the nurse expect this client to exhibit?

pain and a burning sensation upon urination and hematuria

a client is hospitalized with heart failure (HF). which interventions should the nurse implement to improve ventilation and reduce venous return?

place the client in high fowler's position

a male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. the client reports his feet feel uncomfortably cool at night, preventing him falling asleep. which action should the nurse implement?

place warm blankets next to the client's feet

the nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. which laboratory result should the nurse review?

platelet count

a client with chronic kidney disease (CKD) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. vital signs are temperature 100.4 F (38 C), heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. the client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. which laboratory result should the nurse report to the healthcare provider immediately?

potassium 6.5 mEq/L (6.5 mmol/L)

a client in the operating room received succinylcholine. the client is experiencing muscle rigidity and has an extremely high temperature. which action should the nurse implement?

prepare ice packs for placement in the client's axillary area

the nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. which instructions regarding skin care of the portal site should the nurse provide?

protect the skin of the radiation portal site from sunlight exposure

the nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. which symptom should the nurse tell the client to report to the healthcare provider?

rapid weight gain

2. a client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. the nurse observes the area of inflammation extends about the ankle area. the client receives prescriptions for colchicine and indomethacin. which instruction should the nurse include in the discharge teaching?

return for periodic liver function studies

2. while caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. before reporting this finding to the healthcare provider, the nurse should review which of the clients laboratory values?

serum albumin

an adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. the healthcare provider prescribes ferrous sulfate 325 PO daily. which laboratory values should the nurse monitor?

serum iron and ferritin