266 HESI lots of questions

redo sterile setup

trach care video question ?

B. Place the client in high Fowler's position.

A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? A. Perform passive range of motion exercises B. Place the client in high Fowler's position. C. Administer oxygen per nasal cannula D. Increase the client's activity level.

d. Measure her temperature and pulse rate.

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? a. Palpate the right flank for tenderness. b. Test her urine for the presence of hematuria c. Evaluate the urine for a strong odor. d. Measure her temperature and pulse rate.

B. Obtain a specimen of urethral drainage for culture

A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with someone he casually met. Which action should the nurse implement? A. Identify all sexual partners in the last four days B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Observe the perineal areas for a chancroid-like lesion

A. Pain

A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough

c. ST elevation in three leads Remember STEMI

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 122 beats/min. respiration 16 breaths/min. oxygen saturation 96%, and blood pressure 116/70 mmhg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most crucial? a. Irregular pulse rate b. Bile colored emesis c. ST elevation in three leads d. Complaint of radiating jaw pain

A. Serum iron and ferritin

An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg PO daily. Which laboratory values should the nurse monitor? A. Serum iron and ferritin B. Platelet count and hematocrit C. Neutrophils and eosinophils D. Serum electrolytes.

- A Hypovolemia and electrocardiogram (ECG) changes.

Question 20 of 55 A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? - A Hypovolemia and electrocardiogram (ECG) changes. - B Side effects of total parental nutrition (TP) and Intralipids. - C Uremic irritation of mucous membranes and skin surfaces. - D Elevated creatinine and blood urea nitrogen (BUN).

D. Initiate isolation precautions This could be meningitis, which requires isolation and droplet precautions to prevent the spread of infection. droplet precautions - think PIMP: Pertusus, Influenza, Meningitis, and Pneumonia

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. What is the most important for the nurse to implement first? A. Administer an antipyretic B. Draw blood cultures C. Prepare for a lumbar puncture D. Initiate isolation precautions

c. Assess pulses with a vascular Doppler.

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? a. Wrap the feet with warmed blankets. b. Elevate extremities on pillows. c. Assess pulses with a vascular Doppler. d. Evaluate edema for pitting

c. Eat a high-fiber diet and increase fluid intake. so that intestinal contents are bulked up by fiber washed down by fluid without getting suck in the pouches in the intestinal lining caused by the diverticulosis, which would lead to diverticulitis.

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals. b. Eat a bland diet and avoid spicy foods. c. Eat a high-fiber diet and increase fluid intake. d. Eat a soft diet with increased intake of milk and milk products

c. Ensure oral suction is available.

When providing care for an unconscious client who has seizures. Which nursing intervention is most essential? a. Maintain the client in a semi-Fowler's position. b. Keep the room at a comfortable temperature. c. Ensure oral suction is available. d. Provide frequent mouth care

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

Which client has the highest risk for developing skin cancer? A. a 70-year-old fair-skinned client who works as a secretary. B. a 65-year-old fair-skinned client, who is a construction worker. C. A 16-year-old, dark-skinned client who tans in tanning beds once a week. D. a 25-year-old, dark-skinned client whose mother had skin cancer.

b. Fortified milk and cereal

Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Citrus fruits and juices b. Fortified milk and cereal c. Red meals and eggs d. Green leafy vegetables

b. Weakened cough effort.

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Inappropriate laughter. b. Weakened cough effort. c. Asymmetrical weakness. d. Increasing anxiety.

Question about dry feet - not sure

apply lotion to prevent cracks?

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply) A. Perform chest physiotherapy B. Teach the client breathing exercises C. Initiate passive range of motion exercises D. Establish a regular bladder routine. E. Encourage use of incentive spirometer

A. Perform chest physiotherapy B. Teach the client breathing exercises E. Encourage use of incentive spirometer

- D Enjoys fat-free yogurt as an occasional snack food.

Question 1 of 55 The nurse is evaluating a client's understanding about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? - A Uses only lactose-free dairy products. - B Carefully cleans and peels all fresh fruit and vegetables. - C No longer incudes grains in daily diet. - D Enjoys fat-free yogurt as an occasional snack food.

- A Family members can help with regular foot exams.

Question 10 of 55 The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? - A Family members can help with regular foot exams. - B Heating pads are useful if on the lowest setting. - C Shoes should be worn outside the house, but it is fine to be barefoot inside. - D Aching feet may be soaked in lukewarm water for one hour or more.

- D Platelet count.

Question 9 of 55 The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? - A Red blood cell count. - B Hemoglobin levels. - C White blood cell count. - D Platelet count.

c. hematocrit and blood pressure The nurse should inform the healthcare provider about the client's hematocrit and blood pressure. Hematocrit is a measure of the proportion of red blood cells in the blood, which can indicate if there's internal bleeding, a possible complication of an AAA. Blood pressure is also crucial as high blood pressure can cause the aneurysm to rupture. The other options (white blood cell count, pulse, serum amylase, level of consciousness, calcium level, skin condition) are less directly related to the condition and symptoms of an AAA.

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is complaining of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider? a. White blood cell count and pulse rate b. Serum amylase and level of consciousness c. Hematocrit and blood pressure d. Calcium level and skin condition

C. Upper mid-abdominal pain described as gnawing and burning

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? A. Frequent use of chewable and liquid antacids for indigestion B. Severe abdominal cramps and diarrhea after eating spicy foods. C. Upper mid-abdominal pain described as gnawing and burning D. Marked loss of weight and appetite over the last 3 or 4 months

d. Frequent premature beats auscultated at apical site The presence of a pulse deficit indicates that there may be an issue with cardiac function or efficiency. When a pulse deficit is detected, it means that the volume of blood pumped from the heart may not be sufficient to meet the needs of your body's tissues. Listening to the apical pulse is listening directly to your heart. It's the most efficient way to evaluate heart function. If your pulse is outside of the normal range or you have an irregular heartbeat, your doctor will evaluate you further.

The nurse is performing an initial assessment of an adult client. Which finding indicates that the nurse should evaluate the client for a pulse deficit? a. Point of maximal impulse at anterior axillary line b. Radial pulse of 56 beats/minute c. Dorsalis pedis pulse volume is +1 d. Frequent premature beats auscultated at apical site

b. Platelet count 40,000 x109/pL (40,000 x107L).

The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider prior to the procedure? a. Hemoglobin 12 g/dL (120 g/L). b. Platelet count 40,000 x109/pL (40,000 x107L). c. Hematocrit 38% (0.38). d. White blood cells 9,000/pL (9x109L)

C. Encourage client use of picture charts

The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and becomes frustrated with the nursing staff. Which intervention should the nurse implement? A. Teach the client use of basic sign language B. Speak slowly to the client C. Encourage client use of picture charts D. Ask the client simple questions

d. Rapid weight gain keyword is RAPID

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 health care provider? a. Moon face b. Gastric irritation c. Abdominal striae d. Rapid weight gain

d. When their first blood transfusion was administered The answer to this question is rooted in the fact that prior to 1992, blood transfusions were not screened for hepatitis C. Therefore, if a client had a blood transfusion before 1992, they are at a higher risk of having contracted hepatitis C. This is why the most important information for the nurse to obtain is when the client's first blood transfusion was administered. If it was before 1992, the client is at a higher risk and should be tested for hepatitis C.

When assessing a client for risk factors related to hepatitis C, which information is most important for the nurse to obtain from a client who reports a history of multiple blood transfusions? a. When their most recent blood transfusion was received b. If the individual has received a hepatitis vaccination c. If the individual experienced a blood transfusion reaction d. When their first blood transfusion was administered

d. Global aphasia L-side: Facial weakness Slow, cautious behavior Hemiplegia/hemiparesis R side Dysphagia Aphasia: language impairment/difficulties Apraxia of speech: difficulty engaging muscles in & around mouth to form recognizable speech Cognitive impairments: deficit in memory or problem-solving ability. Impairment in verbal working memory (VBM): difficulty with short-term memory or immediately processing new verbal information Visual loss: one side, particularly in R eye. R-side: Memory loss Facial weakness Poor decision making Quick, overly curious behavior Hemiplegia/hemiparesis L side Prosopagnosia: difficulty recognizing faces Left neglect: unawareness of L side of environment Homonymous Hemianopia: only sees 1/2 of field of vision in each eye simultaneously Anosognosia: R parietal damage may cause neglect or denial of disability Pseudobulbar effect: Sudden, uncontrollable outbursts of laughing or crying.

Which clinical manifestation further supports an assessment of a left-sided brain attack? a. Visual field deficit on the left side b. Spatial-perceptual deficits c. Paresthesia of the left side. d. Global aphasia.

d. Consult with the occupational therapist for a functional assessment

While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to weaknesses. Which action should the nurses take in response to these figures? a. Implement fall precautions to reduce the clients risk of injury. b. Explain that relief of the migraine pain will reduce related symptoms. c. Gather additional assessment data about the pain and weakness. d. Consult with the occupational therapist for a functional assessment

A. Remove all of the morphine patches

*Answer updated* A client with lung cancer who wears 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 first? A. Remove all of the morphine patches B. Administer a narcotic antagonist C. Apply oxygen per face mask D. Measure the client's blood pressure

A. stop the dialysis treatment.

A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment the client's blood pressure drops from 150/90 mmHg to 80/30 mmHg which action should the nurse take first? A. stop the dialysis treatment. B. administer 5% albumin IV. C. Monitor blood pressure q45 minutes. D. lower the head of the chair and elevate feet

a. Administer a topical analgesic

A client with chronic myelogenous leukemia (CML) who has been on long-term corticosteroid therapy develops oral candidiasis. The client tells the nurse that the pain makes it difficult to chew or swallow. Which action should the nurse implement first? a. Administer a topical analgesic b. Obtain a soft diet for the client c. Cleanse the mouth with swabs d. Encourage frequent mouth care

A. Driving a car

A client is recovering from transurethral prostatectomy. Which activity should be limited until afterthe first postoperative visit with his healthcare provider. A. Driving a car B. Walking around the house C. Eating high-fiber foods D. Kegel exercises

mL1000mL/6(hours) =166.6=167mL

A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A. adherence to the regimen is imperative. The 4-month TB treatment regimen consists of high-dose daily rifapentine (RPT) with moxifloxacin (MOX), isoniazid (INH), and pyrazinamide (PZA). The 4-month rifapentine-moxifloxacin regimen has an intensive phase of 2 months, followed by a continuation phase of 2 months and 1 week (total 17 weeks for treatment). The 6- to 9-month RIPE TB treatment regimens consist of Rifampin (RIF), Isoniazid (INH), Pyrazinamide (PZA), and Ethambutol (EMB) RIPE regimens for treating TB disease have an intensive phase of 2 months, followed by a continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment).

A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis. Which information should the nurse prioritize? A. adherence to the regimen is imperative. B. medication should be taken with food. C. Serum liver panels are collected regularly. D. enhanced protection measures will be needed.

D. pain and burning sensation upon urination, and hematuria. (D) is indicative of a urinary tract issue, which can be a trigger for autonomic dysreflexia in individuals with spinal cord injuries at the level of T6 or above. When a person with a spinal cord injury at or above the T6 level experiences a stimulus such as a distended bladder, it can lead to autonomic dysreflexia, characterized by symptoms such as severe hypertension, headache, diaphoresis, and flushing.

A client who had a C-5 spinal cord injury 2 years ago, is admitted to the emergency department with a diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse suspect this client to exhibit? A. complaints of chest pain and shortness of breath. B. hypotension and venous pooling in the extremities C. Profuse diaphoresis and severe pounding headache. D. pain and burning sensation upon urination and hematuria.

a. Prepare the client to return to the operating room.

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? a. Prepare the client to return to the operating room. b. Auscultate the abdomen for bowel sound activity. c. Obtain a sample of the drainage to send to the lab. d. Bring additional sterile dressing supplies to the room

d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope. b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. c. Verify troponin level assessments are scheduled every 3-6 hours for a series of three. d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.

A. Evaluate the application of the splint to the left leg D. Verify pedal pulses using a doppler pulse device E. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure

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? (Select all that apply.) A. Evaluate the application of the splint to the left leg B. Offer ice chips and oral clear liquids C. Administer oral antispasmodics and narcotic analgesics D. Verify pedal pulses using a doppler pulse device E. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure

B. irregular apical pulse. The nurse should report presence of irregular apical pulse because it is a sign of hypokalemia. In patients with Cushing's syndrome, there is overproduction of cortisol that causes the activation of mineralocorticoid receptors leading to decreased potassium level in blood (increased urinary potassium secretion) which may result in hypokalemia. An irregular heart rhythm (arrhythmias) is a complication that can be life-threatening and is of great concern when potassium levels are very low.

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. purple marks on the skin of the abdomen. B. irregular apical pulse. C. Quarter size blood spot on dressing. D. pitting, ankle edema.

B. Administer 1,000 mL (1 L) normal saline The nurse should prepare to administer 1,000 mL NS because the client is likely experiencing a GI Bleed due to their history of peptic ulcer disease and the symptom of vomiting bright red blood. This can lead to a significant loss of blood volume, which can cause hypovolemic shock if not treated promptly. The client's hemoglobin and hematocrit levels are within normal ranges, but these values can remain normal in the early stages of a bleed because they reflect the concentration of red blood cells in the blood, not the total volume of blood in the body. Administering normal saline is a common initial treatment for hypovolemia because it can quickly increase blood volume and help maintain blood pressure until the source of the bleeding can be identified and treated. This is a critical intervention to prevent further complications such as organ damage from reduced blood flow.

A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of two 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? A. Continue to monitor for blood loss B. Administer 1,000 mL (1 L) normal saline C. Transfuse two units of platelets D. Prepare the client for emergency surgery

A. have the client describe a typical day at work home and social activities. E. have the client demonstrate technique used to monitor blood glucose. (b) this is wrong because even if the client reuses an insulin needle it would not cause an increase in the fasting blood sugar 'mellitus' is a Latin word that means sweet, as the urine of someone with diabetes has a sweet smell. Diabetes Mellitus can be either Type 1 or 2, the word Mellitus just differentiatiates it from Diabetes Insipidus

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 of 325 mg/dL. The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention should the nurse implement? (Select all that apply) A. have the client describe a typical day at work home and social activities. B. determine if the client is using a new insulin needle each administration. C. Evaluate the client's asthma medication that can elevate the blood glucose. D. ask the client if they want a different manufacturer's glucose monitoring device. E. have the client demonstrate technique used to monitor blood glucose.

d. Pain when swallowing

A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? a. Elevated temperature b. Generalized weakness c. Diminished lung sounds d. Pain when swallowing

B. Sodium polystyrene sulfonate 15 g by mouth (this is generic Kayexelate, the antidote to too much K+) Diuretics can also be used to excrete additional potassium. (a and d) Calcium acetate and Sevelamer are used to control high blood levels of phosphorus in people with kidney disease who are on dialysis (medical treatment to clean the blood when the kidneys are not working properly). (c) Epoetin is used to treat severe anemia in patients on kidney dialysis or for those not on dialysis. May also be used to prevent or treat anemia caused by surgery or medicines (eg, zidovudine) used for other conditions, such as HIV or cancer. Epoetin alfa works by signaling the bone marrow to make more red blood cells. This medication is very similar to the natural substance in your body (erythropoietin) that prevents anemia.

A client with acute renal injury (AKI) weighs 50 kg and has a potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first? A. Calcium acetate, one tablet by mouth B. Sodium polystyrene sulfonate 15 g by mouth C. Epoetin alpha, recombinant 2,500 units subcutaneously D. Sevelamer tablet by mouth

A: Monitor urinary stream for decrease in output When the prostate enlarges as a result of BPH, it may compress the urethra and obstruct urine flow. Renal failure occurs when urine cannot be passed out of the body. Urinary incontinence is a symptom of an enlarged prostate.

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? A. Monitor urinary stream for decrease in output B. Use incentive spirometer C. Restrict physical activities D. Report when hematuria becomes pink tinged

A. Distended, hard, and rigid abdomen Can be an indication of infection or inflammation of peritoneal cavity, i.e peritonitis. A hard stomach can happen for various reasons, including constipation, gastric cancer, and some chronic digestive conditions, such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).

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 tell the healthcare provider? A. Distended, hard, and rigid abdomen B. Bile-stained emesis C. Clay-colored stool D. Radiating, sharp pain in right shoulder.

b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity e. Institute contact precautions for staff and visitors

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) a. Explain the purpose of a low bacteria diet. b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity d. Use standard precautions and wear a mask e. Institute contact precautions for staff and visitors

a. Hydration of affected dry skin areas

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? a. Hydration of affected dry skin areas b. Reduced pain in eczematous areas. c. Decreased weeping of ulcerations in affected areas. d. Healing with a return to normal skin appearance.

d. Drink at least 8 cups (1920 mL) of water per day.

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Eat high protein foods to achieve ideal body weight. b. Use electric heating pad when pain is at its worse. c. Encourage active range of motion to limit stiffness. d. Drink at least 8 cups (1920 mL) of water per day.

C. Increase the daily intake of oral fluids to liquefy secretions

A client with 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? A. Call the clinic if undesirable side effects of medications occur B. Avoid crowded enclosed areas to reduce pathogen exposure C. Increase the daily intake of oral fluids to liquefy secretions D. Teach anxiety reduction methods for feelings of suffocation

d. Begin straining all urine Hyperparathyroidism leads to an increase in calcium levels in the blood, which can result in kidney stones. Severe flank pain is a common symptom of kidney stones. The intervention "Begin straining all urine" is done to catch any passed kidney stones for analysis. This helps in confirming the diagnosis and planning further treatment. The other options are not directly related to the symptoms or condition of hyperparathyroidism.

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care? a. Implement seizure precautions. b. Initiate cardiac telemetry. c. Administer a PRN dose of a laxative. d. Begin straining all urine

d. Describe the use of an elimination diet to find trigger foods

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? a. Explain that the need to restrict fluids is the primary limitation. b. Advise the client to limit foods that are high in calcium and iron. c. Instruct the client to avoid foods with gluten, such as wheat bread. d. Describe the use of an elimination diet to find trigger foods

d. Blood pressure Pheochromocytoma is a rare tumor of the adrenal gland that can cause severe headaches, sweating, and high blood pressure due to the release of excess hormones like adrenaline and noradrenaline. Therefore, monitoring the blood pressure is crucial in this situation to assess for hypertensive crisis, which is a potential complication of pheochromocytoma.

A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? a. Capillary glucose. b. Oxygen saturation. c. Body temperature. d. Blood pressure

B. Topical corticosteroids

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription would the nurse teach the client to use for the skin condition? A. Colloidal oatmeal-based lotion B. Topical corticosteroids C. Topical analgesics D. Topical antifungal

d. Administer opioids and nonopioid medications simultaneously Pharmacologic guidelines for the treatment of pain at the end of life fall into 3 broad categories of analgesic: opioids, nonopioid analgesics and the adjuvant analgesics which comprise numerous agents in diverse classes. With regard to opioid selection, studies show that pain can be treated adequately even with advanced cancer pain at end of life with only 3% patients experiencing severe pain and 52% experiencing no pain at all if guidelines are followed. Acetaminophen was chosen for a nonopioid analgesic. According to The World Health Organization analgesic ladder for cancer pain suggests that the administration of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) may be additive to that of opioids leading to the possibility of lessening the opioid dosage and reducing the adverse effects.

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? a. Give maximum dosage when score reaches 10 b. Alternate IV and IM analgesic medications. c. Educate client on signs and symptoms of narcotic dependency d. Administer opioids and nonopioid medications simultaneously

b. myalgia in wrists and hands

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication? a. anxiety and sighing b. myalgia in wrists and hands c. hyperactive bowel sounds d. dark yellow urine

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

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? A. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling" B. "I can use a mirror to check the bottoms of my feet for any signs of breakdown." C. "I will use my swimming pool early in the day while the water is still very cool" D. "I will try to keep moving if leg pain occurs to help promote good circulation"

A. Serum sodium of 185 mEq/L (185 mmol/L)

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse? A. Serum sodium of 185 mEq/L (185 mmol/L) B. Dry skin with inelastic turgor. C. Apical rate of 110 beats per minute. D. Polyuria and excessive thirst.

d. Administer IV antibiotics as prescribed Pyelonephritis is an infection of the kidneys and is caused by a bacterial infection of the lower urinary tract, such as a urinary tract infection. The classic signs and symptoms of this condition include flank pain, dysuria, polyuria, urinary urgency, urinary frequency, fever, etc. Patients with mild symptoms are treated with antibiotics for 7 to 14 days in an outpatient setting while patients with severe symptoms require hospitalization and IV antibiotic therapy.

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Auscultate for the presence of bowel sounds. b. Monitor hemoglobin and hematocrit c. Encourage turning and deep breathing d. Administer IV antibiotics as prescribed

Answer: b. Maintain a patent intravenous site For severe dehydration, start IV fluids immediately. If the patient can drink, give oral rehydration solution (ORS) by mouth while the IV drip is set up. Ringer's lactate IV fluid is preferred. If not available, use normal saline or dextrose solution. The use of IV fluids for dehydration offers many benefits which prevent or treat dehydration and electrolyte imbalances. It helps people regain the water in their bodies and allows the body to function and the treatment may help you feel better

An adult woman with Graves disease is admitted with severe dehydration and malnutrition, who is currently restless and refusing to eat. Which action is most important for the nurse to implement? a. Teach the client relaxation techniques b. Maintain a patent intravenous site c. Keep room temperature cool d. Determine the client food preferences

c. Assist client to an upright position.

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? a. Apply a high-flow venturi mask. b. Encourage client to drink water. c. Assist client to an upright position. d. Administer a prescribed sedative

b. Sensation in feet and legs. c. Skin condition of lower extremities. e. Visual acuity. Sensation in feet and legs: Diabetes can cause nerve damage (diabetic neuropathy), particularly in the feet and legs. Regularly checking for changes in sensation can help detect this complication early. Skin condition of lower extremities: Diabetes can lead to poor circulation and reduced ability to heal, increasing the risk of skin problems, including ulcers, especially on the feet. Visual acuity: Diabetes can affect the blood vessels in the eyes leading to diabetic retinopathy, which can cause vision loss. Regular eye exams can help detect changes in vision early.

An older female client with long-term type 2 diabetes mellitus (DM) is seen for a routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? (Select all that apply) a. Serum creatinine and blood urea nitrogen (BUN). b. Sensation in feet and legs. c. Skin condition of lower extremities. d. Signs of respiratory tract infection e. Visual acuity.

c. Palpate the bladder above the symphysis pubis.

An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary system, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. Review the client's fluid intake prior to bedtime. b. Obtain a finger stick blood glucose level. c. Palpate the bladder above the symphysis pubis. d. Collect a urine specimen for culture analysis

A. Check finger stick glucose B. Assess skin temperature and moisture C. Measure pulse and blood pressure ANSWER: (CAM)

An overweight, young adult who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin

- B: Take prescribed cortisone accurately.

Question 30 of 55 The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan? - A: Avoid extreme environmental temperatures. - B: Take prescribed cortisone accurately. - C: Use a walker when weakness occurs. - D: Increase daily intake of sodium in the diet.

- A: Inspect ankles daily for areas of darkening skin. Regular inspection can help detect any changes or worsening of the condition early. - C: Keep legs elevated when sitting or lying down. Elevation can help reduce swelling and improve blood circulation. - E: Eat a diet that is high in protein and vitamins A and C. A nutritious diet can support wound healing and overall health. The nurse should not include the following instructions: - B: Apply intermittent cold compresses four times daily. There is no evidence from the search results that cold compresses are beneficial for venous leg ulcers. - D: Maintain bed rest as much as possible. On the contrary, physical activity, such as walking, can promote blood circulation and aid in wound healing.

Question 11 of 55 The nurse is providing discharge teaching to an older adult client hospitalized for treatment of venous leg ulcers. Which instruction(s) should the nurse include in the teaching plan? (Select all that apply.) - A Inspect ankles daily for areas of darkening skin. - B Apply intermittent cold compresses four times daily. - C Keep legs elevated when sitting or lying down. - D Maintain bed rest as much as possible. - E Eat a diet that is high in protein and vitamins A and C.

- D Strict intravenous (IV) fluid replacement. The most important intervention for the nurse to include in the client's plan of care, who is suspected of anastomosis leakage post gastric bypass surgery, is D: Strict intravenous (IV) fluid replacement. This is crucial as the client's vital signs indicate possible sepsis due to infection, which can lead to severe dehydration. IV fluid replacement can help maintain the client's blood pressure and prevent further complications. While interventions A, B, and C (Encourage regular turning, Assess wound drainage daily, Monitor skin for breakdown) are generally important in postoperative care, they are not the most critical in this specific situation of suspected anastomotic leakage.

Question 12 of 55 An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 101° F (38.3° C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care? - A Encourage regular turning. - B Assess wound drainage daily. - C Monitor skin for breakdown. - D Strict intravenous (IV) fluid replacement.

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Question 13 of 55 A client receives a prescription for 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number)

- D Move into airborne isolation. Airborne - think MTV: Measles, TB, Varicella

Question 14 of 55 A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? - A Collect specimens for blood cultures. - B Obtain a sputum sample. - C Arrange transport for radiographic imaging. - D Move into airborne isolation.

- C Morphine.

Question 15 of 55 A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? - A Fentanyl. - B Oxycodone. - C Morphine. - D Hydromorphone.

- D Notify the healthcare provider of the client's medication history.

Question 16 of 55 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. Which is the priority nursing action? - A Ensure that the potential for bleeding is explained to the client. - B Observe the heparin injection sites for signs of bruising. - C Have the client sign the surgical and transfusion permits. - D Notify the healthcare provider of the client's medication history.

- C Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. Thrombolytic treatment, also known as fibrinolytic therapy, dissolves dangerous intravascular clots to prevent ischemic damage by improving blood flow.

Question 17 of 55 The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client? - A Maintain elevated positioning of the dependent joints on affected side. - B Verify prescribed laboratory tests include prothrombin time and platelet count. - C Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. - D Administer aspirin to prevent further clot formation and platelet clumping.

- B Lumbar puncture.

Question 18 of 55 The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? - A Magnetic resonance imaging (MRI). - B Lumbar puncture. - C Computerized tomography (CT) scan. - D Skull radiography.

- A Eating patterns of dietary intake.

Question 19 of 55 The nurse is caring for 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? - A Eating patterns of dietary intake. - B Color and consistency of feces. - C Level and amount of physical activity. - D Activity level of bowel sounds.

- A Further decline in level of consciousness.

Question 2 of 55 A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? [Hematocrit (Reference Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)] - A Further decline in level of consciousness. - B Hematocrit of 30% (0.30 volume fraction) - C Cold and dry skin. - D Facial puffiness and periorbital edema

- D Include no more than 1-2 alcoholic beverages in diet per day. The client should understand that common causes of hypoglycemia are excess insulin, deficient intake of food, exercise at peak insulin action, and alcohol intake. Limiting alcohol intake, consuming with meals, or shortly after a meal with sufficient carbohydrates are important strategies in preventing hypoglycemia. This is the most appropriate response because with diabetes, consumption of alcohol must be limited as this can increase blood sugar levels, while if taken on an empty stomach may cause a significant decrease in the sugar causing hypoglycemia. The recommended consumption is 1 drink for women per day, while 2 drinks for men per day. A1c test reflects the blood sugar levels over the past three months and is recommended to be done every 3-6 months. Using salt should be avoided because salty diet increases risk for diabetes.

Question 21 of 55 The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information stated by the client indicates understanding? Reference Range Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L] - A Obtain an A1C blood test every year to monitor glucose control. - B Using salt, herbs, and spices will improve the flavor of foods. - C Apply lotion to entire foot to prevent cracks in the skin. - D Include no more than 1-2 alcoholic beverages in diet per day.

- A Right foot pale with sluggish capillary refill.

Question 22 of 55 After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? - A Right foot pale with sluggish capillary refill. - B Increased temperature to lower extremity. - C Circumferential edema of right foot. - D Complaint of throbbing right leg pain.

- A Teach the client techniques for performing intermittent catheterization.

Question 23 of 55 A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care? - A Teach the client techniques for performing intermittent catheterization. - B Remind the client to practice pelvic floor (Kegel) exercises regularly. - C Provide a bedside commode for immediate use in the client's room. - D Explain the need to limit intake of oral fluids to reduce client discomfort.

- A Continue with the insulin injection.

Question 24 of 55 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? (Please view the video to select the option that applies. - no video see pic) - A Continue with the insulin injection. - B Lie down flat for better skin exposure. - C Select a different injection site. - D Keep the skin flat rather than bunched.

- B Instruct the client after inhaling deeply to quickly and forcefully exhale 2 to 3 times.

Question 25 of 55 The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the client's return demonstration, the client uses pursed lips during exhalation. Which action should the nurse do next? - A Place the client in the semi-Fowler's position and apply oxygen. - B Instruct the client after inhaling deeply to quickly and forcefully exhale 2 to 3 times. - C Advise the client that the procedure is being done correctly. - D Tell the client to take several shallow breaths before the next exhalation.

- C Determine if the client is using an inhaler before exercising.

Question 26 of 55 A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? - A Teach client to use pursed lip breathing when episodes occur. - B Assess client for signs and symptoms of upper airway infection. - C Determine if the client is using an inhaler before exercising. - D Review the client's routine asthma management prescriptions.

- B Assess skin temperature and moisture. - C Measure pulse and blood pressure. - D Check fingerstick glucose level. These actions are important in assessing the client's condition and addressing the symptoms reported. Assessing skin temperature and moisture can provide information about the client's circulation and hydration status. Measuring pulse and blood pressure can help in evaluating the client's cardiovascular status. Checking the fingerstick glucose level is crucial in determining the client's blood sugar level, especially given the recent diagnosis of type 2 diabetes mellitus

Question 27 of 55 An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which action(s) should the nurse implement? (Select all that apply.) - A Administer a PRN dose of regular insulin. - B Assess skin temperature and moisture. - C Measure pulse and blood pressure. - D Check fingerstick glucose level. - E Document anxiety on the surgical checklist.

- A Wearing gloves when handling cold items guards against painful spasms.

Question 28 of 55 A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide? - A Wearing gloves when handling cold items guards against painful spasms. - B Painful areas should be rubbed gently until the pain subsides. - C Enrolling in a pain clinic can provide pain relief alternatives. - D Return appointments will be needed for IV pain medication.

- D: Monitor catheter drainage.

Question 29 of 55 A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). 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? - A: Decrease the flow rate. - B: Irrigate the catheter manually. - C: Discontinue infusing solution. - D: Monitor catheter drainage.

- B Full thickness.

Question 3 of 55 The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document? - A Deep full-thickness. - B Full thickness. - C Deep partial-thickness. - D Superficial partial-thickness.

- D: Stop using the ointment and encourage complete drying of feet and wearing clean socks.

Question 31 of 55 The parent of an adolescent tells the clinic nurse, "My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? - A: Antibiotics take two weeks to become effective against infections such as athlete's foot. - B: Continue using the ointment for a full week, even after the symptoms disappear. - C: Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. - D: Stop using the ointment and encourage complete drying of feet and wearing clean socks.

- D: Lower back pain and hypotension.

Question 32 of 55 A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider? - A: Delayed painful rash with urticaria. - B: Arthritic joint changes and chronic pain. - C: Acute rhinitis and nasal stuffiness. - D: Lower back pain and hypotension.

- A: Medicate for pain and monitor vital signs according to protocol.

Question 33 of 55 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 mm Hg. Which intervention is most important for the nurse to implement? - A: Medicate for pain and monitor vital signs according to protocol. - B: Administer intravenous fluid bolus as prescribed by the healthcare provider. - C: Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. - D: Encourage the client to splint the incision with a pillow to cough and deep breathe.

- D: Maintain prescribed eye drop regimen.

Question 34 of 55 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? - A: Eat a diet high in carotene. - B: Avoid frequent eye pressure measurements. - C: Wear prescription glasses. - D: Maintain prescribed eye drop regimen.

- C: Sputum culture and sensitivity.

Question 35 of 55 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? - A: Blood cultures. - B: Computerized tomography (CT) of the chest. - C: Sputum culture and sensitivity. - D: Arterial blood gases (ABG).

- C: Encourage continued maintenance of the walking routine.

Question 36 of 55 A young adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the park with friends. How should the nurse respond? - A: Suggest a calcium supplement along with continued walking. - B: Advise less weight-bearing to prevent joint destruction. - C: Encourage continued maintenance of the walking routine. - D: Recommend walking indoors for improved stability and safety.

- B: Tenderness upon palpation and generalized erythema.

Question 37 of 55 The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? - A: Brown, rough, greasy, wart-like papules on the face. - B: Tenderness upon palpation and generalized erythema. - C: Thick skin plaques topped by silvery white scales. - D: Requires sunglasses because sunlight hurts eyes.

- A: Eats a vegetarian diet with cheese 2 to 3 times a day.

Question 38 of 55 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? - A: Eats a vegetarian diet with cheese 2 to 3 times a day. - B: Drinks several bottles of carbonated water daily. - C: Jogs more frequently than usual daily routine. - D: Experiences additional stress since adopting a child.

- B: Document the findings.

Question 39 of 55 A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement? - A: Assess the client's temperature. - B: Document the findings. - C: Apply gentle pressure. - D: Elevate the extremity.

- A Urinary output. - B Oxygen saturation. - D Lung sounds. Orthopneic position, sometimes called tripod position, is a sitting position where an individual leans slightly forward with their arms propped up on an overbed table or their knees. Orthopnea is the sensation of breathlessness in the recumbent (lying down) position, relieved by sitting or standing.

Question 4 of 55 An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine the client's response to treatment? (Select all that apply.) - A Urinary output. - B Oxygen saturation. - C Pain scale. - D Lung sounds. - E Skin elasticity.

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Question 40 of 55 A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

0.4

Question 41 of 55: 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? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

- D: Maintain the prescribed fluid restriction.

Question 42 of 55 A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement? - A: Withhold next scheduled dose of treatment. - B: Increase neurologic checks to every 2 hours. - C: Assess for increasing fluid volume overload. - D: Maintain the prescribed fluid restriction.

- B Administer opioid and non-opioid medication simultaneously

Question 43 of 55 A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement? - A Give maximum dosage when score reaches 10. - B Administer opioid and non-opioid medication simultaneously - C Educate client on signs and symptoms of narcotic dependency - D Alternate intravenous (IV) and intramuscular (IM) analgesic medications.

- C White blood cell (WBC) count.

Question 44 of 55 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 client's laboratory values? - A Hematocrit - B Blood pH level. - C White blood cell (WBC) count. - D Platelet count

- C Drink at least 8 cups (1920 mL) of water per day.

Question 45 of 55 A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? - A Eat high protein foods to achieve ideal body weight. - B Use electric heating pad when pain is at its worse. - C Drink at least 8 cups (1920 mL) of water per day. - D Encourage active range of motion to limit stiffness.

- D: Guidelines for oxygen use.

Question 46 of 55 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 intolerance. 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? - A: Strategies for smoking cessation. - B: Approaches to conserve energy. - C: Methods for weight loss. - D: Guidelines for oxygen use.

- B: Maintain the client's NPO status. Maintaining the client's NPO (nothing by mouth) status is important in the initial management of diverticulitis to allow the bowel to rest and to prevent further irritation or inflammation. This approach is commonly used to manage acute diverticulitis and is aimed at reducing the workload on the digestive system, allowing the bowel to heal, and preventing complications.

Question 47 of 55 An older client is admitted with an acute onset of diverticulitis and intravenous antibiotic therapy is initiated. Which intervention should the nurse implement next? - A: Teach the client to increase dietary fiber. - B: Maintain the client's NPO status. - C: Elevate the head of the bed. - D: Initiate bowel prep protocol for surgery.

- B: Move the client to a private room, keep the door closed, and initiate droplet precautions. This action is crucial to prevent the potential spread of COVID-19, especially considering the client's symptoms and the known exposure to someone recovering from the virus. Isolating the client in a private room and initiating droplet precautions aligns with the infection control measures recommended for suspected or confirmed cases of COVID-19 to minimize the risk of transmission to others.

Question 48 of 55 A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from the coronavirus (COVID-19). After obtaining a nasal swab to test the client for COVID-19, which action is most important for the nurse to take? - A: Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. - B: Move the client to a private room, keep the door closed, and initiate droplet precautions. - C: Explain to the client to inform others that they may have been potentially exposed in the last 14 days. - D: Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results.

- B: Prepare ice packs for placement in the client's axillary area. This action is important as it can help to reduce the client's body temperature, especially in the context of succinylcholine-induced hyperthermia and muscle rigidity. Ice packs can be used to assist in cooling the client and managing the symptoms associated with succinylcholine administration. Succinylcholine (SUK seh nil KOH leen) is a skeletal muscle relaxant. It is used to relax muscles during surgery or while on a breathing machine.

Question 49 of 55 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? - A: Call the PACU nurse to prepare for prolonged ventilatory support. - B: Prepare ice packs for placement in the client's axillary area. - C: Hold a prescription for dantrolene until fever is reduced. - D: Determine if prescribed antibiotics were administered preoperatively.

- B Crohn's disease with colectomy. Question # 5 Rationale - B Crohn's disease with colectomy. The nurse should recognize that clients with extensive intra-abdominal surgical history are not candidates for peritoneal dialysis, as these clients may have decreased peritoneal membrane surface areas and scar tissue formation, which would make it insufficient for adequate dialysis exchange.

Question 5 of 55 A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? - A Nephrotic syndrome history. - B Crohn's disease with colectomy. - C Type 2 diabetes mellitus. - D Latent hepatitis C.

- C: Monitor the client's intravenous site hourly during the treatment. Monitoring the client's intravenous site hourly during the treatment is an important measure to reduce the risk of vesicant extravasation. This allows for early detection of any signs of extravasation, such as swelling, pain, or redness at the site, which can prompt timely intervention to minimize the potential damage caused by extravasation of vesicant chemotherapy agents

Question 50 of 55 Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? - A: Instruct the client to drink plenty of fluids during the treatment. - B: Keep the head of the bed elevated until the treatment is completed. - C: Monitor the client's intravenous site hourly during the treatment. - D: Administer an antiemetic before starting the chemotherapy.

- B: Administer a topical analgesic. Administering a topical analgesic would help alleviate the burning and soreness in the mouth, providing the client with relief from discomfort. This aligns with the priority of addressing the client's immediate symptoms and promoting comfort. After addressing the pain, other interventions such as mouth cleansing and encouraging frequent mouth care can be implemented as part of the overall management of oral thrush

Question 51 of 55 The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the mouth. Which intervention should the nurse implement first? - A: Obtain a soft diet for the client. - B: Administer a topical analgesic. - C: Cleanse the mouth with swabs. - D: Encourage frequent mouth care.

- A: Sensory loss at T-8. Sensory loss at T-8 can indicate a significant neurological complication that requires immediate attention. This finding may suggest the potential for spinal cord compromise, which could lead to respiratory compromise and the need for urgent intervention, including potential intubation to ensure adequate ventilation and oxygenation. Therefore, immediate action is necessary to address this critical assessment finding and prevent further deterioration in the client's condition

Question 52 of 55 While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? - A: Sensory loss at T-8. - B: Profuse diaphoresis. - C: Lower leg weakness. - D: Leg pain worsening at night.

- C: Monitor urinary stream for decreased output. Instructing the client to monitor the urinary stream for decreased output is important as it can indicate potential complications related to right hydronephrosis and renal calculi. This instruction allows for the early detection of any abnormal signs in the urinary stream, which is crucial for monitoring the client's condition and ensuring timely intervention if necessary.

Question 53 of 55 A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions? - A: Use incentive spirometer. - B: Report when hematuria becomes pink-tinged. - C: Monitor urinary stream for decreased output. - D: Restrict physical activities.

- D: Oatmeal, raisins, and fruit with skin. Good sources of fiber and antioxidant vitamins C and D, beta-carotene, and selenium, such as fruit, vegetables, and whole grains, can help decrease the risk for colon cancer. Oatmeal, raisins, and fruit with skin have been shown to help reduce the risk for colon cancer while also providing fiber, roughage, and vitamins to the consumer.

Question 54 of 55 Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? - A: Chicken, rice, and wheat products. - B: Lean beef, salads, and baked potatoes. - C: Potatoes, low-fat breads, and applesauce. - D: Oatmeal, raisins, and fruit with skin.

- A: Drink 3 liters of water each day. It's super important post TURP to increase fluids to prevent clotting in the catheter. There is no need to clamp the catheter during showering. Usually, we only clamp it to gather a sample or sometimes right before it is removed.

Question 55 of 55 Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? - A: Drink 3 liters of water each day. - B: Clamp the catheter when taking a shower. - C: Avoid driving a car for 2 weeks. - D: Eliminate all spicy foods from your diet.

- D Hypoalbuminemia that results in a decreased colloidal oncotic pressure. The three main things that the liver produces are albumin, bile (digestive enzymes), and prothrombin (clotting factors). Albumin plays many important roles including maintenance of appropriate osmotic pressure, binding and transport of various substances like hormones, drugs etc. in blood, and neutralisation of free radicals. It prevents fluid from leaking out of blood vessels into your tissues. Albumin is also responsible for transporting vitamins, enzymes and hormones throughout your body. Albumin makes up 50% of the proteins found in your plasma.

Question 6 of 55 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? - A Decreased portacaval pressure with greater collateral circulation. - B Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. - C Decreased renin-angiotensin response related to an increase in renal blood flow. - D Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

- B Discuss approaches to chronic pain control with the client.

Question 7 of 55 While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? - A Review the client's dietary intake of high-protein foods. - B Discuss approaches to chronic pain control with the client. - C Notify the healthcare provider of the finding immediately. - D Assess the client's radial pulses and capillary refill time.

- B Minimize symptoms by wearing loose, comfortable clothing.

Question 8 of 55 Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? - A Adjust food intake to three full meals per day and no snacks. - B Minimize symptoms by wearing loose, comfortable clothing. - C Avoid participation in any aerobic exercise programs. - D Sleep without pillows at night to maintain neck alignment.

B. a change has recently occurred in his handwriting.

The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son, who is human immunodeficiency virus (HIV) positive. Which symptoms confirm their suspicions? A. he has begun to sleep 18 out of 24 hours. B. a change has recently occurred in his handwriting. C. He refuses to see any of his friends or to return their phone calls. D. he exhibits angry outbursts, when the subject of dying is approached.

D. Obtain a prescription for artificial teardrops.

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 these findings, what action should the nurse include in this client's Plan of care? A. assess for signs of increased intracranial pressure. B. prepare to administer intravenous levothyroxine. C. Review the client's serum electrolyte values D. Obtain a prescription for artificial teardrops.

c. Substances that change a cell so that it becomes cancerous are potential sources of cancer

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of carcinogens, which statement indicates an accurate understanding? a. Environmental factors such as sunlight and chemicals can cause cancer to spread. b. Carcinogens are substances that contain cancerous cells. c. Substances that change a cell so that it becomes cancerous are potential sources of cancer d. Carcinogens are in the environment and cannot be avoided.

A. pneumatic compression devices. E. calf pump exercises. F. prescribed anticoagulant therapy.

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? (Select all that apply.) A. pneumatic compression devices. B. incentive spirometry C. Assisted ambulation. D. patient controlled analgesia. E. calf pump exercises. F. prescribed anticoagulant therapy.

C. Protect the skin of the radiation portal site from sunlight exposure

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide? A. Remove the ink marks of the portal after each radiation treatment B. Apply moisture lotions daily to the radiation portal site C. Protect the skin of the radiation portal site from sunlight exposure D. Avoid washing the skin inside the radiation portal site

c. The client's daily blood pressure will be less than 140/80 mmhg this month The question asks for an outcome. An outcome should be like SMART goal

The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred vision. Which outcome should the nurse include in the plan of care for this client? a. The client will take up to 4 nitroglycerine tablets sublingually for chest pain b. The nurse will encourage the client to walk thirty minutes every day c. The client's daily blood pressure will be less than 140/80 mmhg this month d. The client's blood pressure readings will be less than 160/90 mmhg

d. Rhythm of apical pulse

The nurse is reviewing the echocardiogram results for a client with left sided heart failure which reveals ineffective ventricular contractions. The client is tachycardic and reports feeling anxious and weak. Which assessment is most important for the nurse to perform? a. Degree of skin elasticity b. Volume of pedal pulses c. Length of capillary refill d. Rhythm of apical pulse

Answer: d. Breathe deeply, followed by coughing up the sputum Take a very deep breath and hold the air for 5 seconds then slowly breathe out. Take another deep breath and cough hard until some sputum comes up into your mouth. Spit the sputum into the plastic cup. Sputum specimens should be collected in the early morning if possible. Collect 3 sputum specimens on 3 consecutive days unless otherwise instructed and specimens should be kept in the refrigerator until they are submitted to the laboratory.

The nurse is teaching a client how to collect a sputum specimen. Which step should the nurse instruct the client to follow when collecting sputum? a. Avoid mouth care prior to collecting the sputum b. Obtain the specimen before bedtime c. Restrict fluids before expectorating the sputum specimen d. Breathe deeply, followed by coughing up the sputum

D. Increase the flow of the bladder irrigation

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? A. Administer a PRN dose of an antispasmodic agent B. Measure the client's intake and output C. Provide additional oral fluid intake D. Increase the flow of the bladder irrigation

a. Carotid bruit.

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? a. Carotid bruit. b. Jugular vein distention. c. Palpable cervical lymph node. d. Nuchal rigidity