PA 1 HESI questions

which intervention should the nurse plan to implement when caring for a client who has just undergone a right above the knee amputation?

Place a large tourniquet at the clients bedside.

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO prn, for a client with CKD who is complaining of indigestion. What intervention should the nurse implement?

Question the HCP's prescription

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

Serosanguineous nasal drainage

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A) 15 minutes before and 15 minutes after the next dose. B) One hour before and one hour after the next dose. C) 5 minutes before and 30 minutes after the next dose. D) 30 minutes before and 30 minutes after the next dose.

5 minutes before and 30 minutes after next dose.

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?

"Change your tampon frequently" Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority?

A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse?

A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately. Options B, C, and D are also findings that require intervention by the nurse but are of less priority than option A. Option B may indicate a hypertensive condition but is not as acute a condition as peritonitis. Option C is an expected finding in clients with small bowel obstruction and may require medication. Option D indicates probable fluid volume deficit, which requires fluid volume replacement.

Small bowel obstruction is a condition characterized by which finding? A) Severe fluid and electrolyte imbalances. B) Metabolic acidosis. C) Ribbon-like stools. D) Intermittent lower abdominal cramping.

A) Severe fluid and electrolyte imbalances.

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? A) Vasodilators and hormones. B) Analgesics and sedatives. C) Anticoagulants and expectorants. D) Bronchodilators and steroids.

Bronchodilators and steroids

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger.

C) Purulent sputum.

a client who is receiving chemotherapy asks the nurse "why is so much of my hair falling out each day?" which response by the nurse best explains the reason for alopecia?

Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?

Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg. Which action should the nurse implement? A) Position the head of the bed (HOB) flat. B) Withhold intravenous fluids. C) Administer a bolus of IV fluids. D) Give an antihypertensive medications.

D) Give an antihypertensive medications.

A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?

Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?

Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first?

Increase oxygen flow rate. Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication?

Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?

Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately take to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?

Positive electrode is placed on the client's mid-chest to the right of the sternum, negative electrode is placed on the upper left part of chest. Ground placement is placed on lower left portion of the chest.

The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?

Presence of a U wave. Rationale: A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia

A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? A) Release the traction q4h to provide skin care. B) Turn the client for back care while suspending traction. C) Provide back and skin care while maintaining the traction. D) Give back care after the client is released from traction.

Provide back and skin care while maintaining the traction.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?

Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A) Sodium. B) Antidiuretic hormone. C) Potassium. D) Glucose.

Sodium

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?

The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the TV. Which nursing intervention should the nurse implement?

Turn off the television and darken the room.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? A) Place HIV positive clients in strict isolation and limit visitors. B) Wear gloves when coming in contact with the blood or body fluids of any client. C) Conduct mandatory HIV testing of those who work with AIDS clients. D) Freeze HIV blood specimens at -70° F to kill the virus.

Wear gloves when coming in contact with the blood or body fluids of any client.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?

Willingness of client to learn injection sites

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?

With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

The nurse is assessing a client with CKD. which finding is most important for the nurse to respond to first? a. K+ 6.0 b. Uremic fetor c.Peripheral neuropathy d. daily urine output of 400ml

a. K+ 6.0

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A) Fluid and electrolyte balance. B) Prevention of water toxicity. C) Reduced glucose in the urine. D) Adequate cellular nourishment.

adequate cellular nourishment

which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

cherry red color to the mucous membranes

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A) Limit the client's intake of oral fluids and food. B) Evaluate the effectiveness of narcotic analgesics. C) Encourage the client to ambulate as tolerated. D) Teach the client about prevention of crises.

evaluate the effectiveness of narcotic analgesics

a client is admitted to the emergency after being lost for four days while hiking in a national forest. upon review of lab results, the nurse determines the clients serum level for TSH is elevated. which additional assessment should the nurse make?

exposure to cold environmental temperatures

The nurse is caring for a client after a transurethral resection of the prostate and determines the clients urinary catheter is not draining. What should the nurse implement?

irrigate the catheter.

in planning care for a client with an acute stroke resulting in right sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning?

left lateral, supine, brief periods on the right side, prone

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis.

nocturia

A 67 year old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?

osteoporosis resulting from hormonal changes

A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client? A) Avoid high carbohydrate foods. B) Decrease intake of fat soluble vitamins. C) Decrease caloric intake. D) Restrict salt and fluid intake.

restrict salt and fluid intake

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function?

A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?

A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate intervention by the nurse?

A unilateral pupil that is dilated and nonreactive to light. Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the health care provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A) He visits his diabetic brother who just had surgery to amputate an infected foot. B) He is provided with the most current information about the dangers of untreated diabetes. C) He comments on the community service announcements about preventing complications associated with diabetes. D) His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.

A) He visits his diabetic brother who just had surgery to amputate an infected foot.

In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) A) Set the infusion pump to infuse the albumin within four hours. B) Compare the client's blood type with the label on the albumin. C) Assign a UAP to monitor blood pressure q15 minutes. D) Administer through a large gauge catheter. E) Monitor hemoglobin and hematocrit levels. F) Assess for increased bleeding after administration.

A, D, E, F

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement first?

Add 5 cm positive end-expiratory pressure (PEEP). Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take?

Administer the medication at scheduled time. The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?

All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?

All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? A) A history of obesity. B) An allergy to sulfa drugs. C) Cessation of smoking three years ago. D) Numbness in the soles of the feet.

An allergy to sulfa drugs

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question?

Anticholinergic with side effect of pupillary dilation. Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?

Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.

A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?

CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement?

Call HCP for new order. The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met?

Changes in pulse and feelings of dizziness. Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?

Confusion and Tachycardia The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?

Continue with shift report and discuss at another time. Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?

Cross country skiing. Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide? A) Diagnosis of AIDS is made when you have 2 positive ELISA test results. B) Diagnosis is made when both the ELISA and the Western Blot tests are positive. C) I can tell that you are afraid of being diagnosed with AIDS. Would you like for me to call your minister? D) AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual.

Diagnosis of AIDS is made when you have 2 positive ELISA test results.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

Difficulty in handwriting.

A client who is admitted to the coronary care unit with a MI begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement?

Notify healthcare provider.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement?

Return the solution to the pharmacy. Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administeredReturn the solution to the pharmacy.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the clients lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action?

Determine the time the client last voided.

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? A) Diabetes mellitus. B) Hypothyroidism. C) Parkinson's disease. D) Recurring pneumonia.

Diabetes mellitus

During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the clients stoma is dry and dark red in color. what action should the nurse implement?

Document the assessment.

a client is admitted to the medical intensive care unit with a diagnosis of MI. The clients history indicates the infarction occurred ten hours ago. Which lab test results would the nurse expect this client to exhibit?

Elevated CK-MB

A client has undergone insertion of a permanent pacemaker. when developing a discharge teaching plan, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? a.feelings of dizziness b. facial flushing c. pounding headache d. fever

Feelings of dizziness

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the HCP?

Fingerstick glucose of 300

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?

Follow exposure precautions. Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? a. cyanosis, fever, classic signs of shock b. headache, diaphoresis, palpitations c. numbness, tingling, cramps in extremities d. nausea, vomiting, muscular weakness

Headache, diaphoresis, palpitations

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A) Jewish European ancestry. B) H. pylori bowel infection. C) Family history of irritable bowel syndrome. D) Age between 25 and 55 years.

Jewish european ancestry

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?

Just prior to tube feeding. Rationale: The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

A nurse is preparing to insert an IV catheter after applying an eutetic mixture of lidocaine and prilocaine, a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect?

Leave the cream on the skin for 1-2 hours before the procedure

a client is admitted to the hospital with a diagnosis of severe acute diverticulitis. which assessment finding should the nurse expect this client to exhibit?

Lower left quadrant pain and low grade fever

The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include?

Maintain a fluid intake 3-4L per day.

The nurse is preparing an adult client for an upper GI series. Which information should the nurse include in the teaching plan?

Nothing by mouth is allowed for 6-8 hrs before the study.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?

Notify HCP Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?

Oral temp of 102. Rationale: Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion? A) Pain in the calf awakening him from a sound sleep. B) Calf pain on exertion which stops when standing in one place. C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D) Pain upon arising in the morning which is relieved after some stretching and exercise.

Pain in the calf upon exertion which is relieved by rest and elevating the extremity

A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. what information shoulder the nurse communicate?

Parenteral abx for 4-8 weeks, oral abx 4-8 weeks.

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?

RR:12, O2 sat-85% Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A) Losing weight. B) Decreasing caffeine intake. C) Avoiding large meals. D) Raising the head of the bed on blocks.

Raising the head of the bed on blocks.

A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?

Reassign the PN until the resident can be assessed more completely for reality orientation. Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted.

An adult is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?

Regenerative function of the skin is absent because the dermal layer has been destroyed.

A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period?

Regular insulin subcutaneously only. Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?

Risk for infection. The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing option A, B, or D, these problems are not the primary reason for the provision of frequent oral care.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client?

Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome?

Serum calcium of 5mg

A 46-year old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?

Serum creatinine

A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? A) Start an IV nitroglycerin infusion. B) Nasogastric lavage with cool saline. C) Increase the vasopressin infusion. D) Prepare for endotracheal intubation.

Start an IV nitroglycerin infusion.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone?

Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching?

Tell the client to carry a medical alert card that explains his condition. Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A) Tinnitus, vertigo, and hearing difficulties. B) Sudden, stabbing, severe pain over the lip and chin. C) Facial weakness and paralysis. D) Difficulty in chewing, talking, and swallowing.

sudden, stabbing, severe pain over the lip and chin

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?

The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?

The level of consciousness (LOC) should be established immediately when a head injury has occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be assessed after LOC has been established by assessing eye opening.

The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?

The outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration. A 14-year-old client may or may not follow through with option A, and there is no measurement of learning. Option B may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In option C, the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client?

This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time

A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation?

This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of option A, which does not exacerbate the ectopy. Option C could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.

Which nursing action is necessary for the client with a flail chest?

Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?

Turn off the feeding. A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

the nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess?

Upper chest subcutaneous emphysema