AD1 HESI: Quality of Life, Perioperative, and Palliative Care

Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with a diabetic coma? Sodium bicarbonate, causing alkalosis Ketones as a result of a rapid fat breakdown, causing acidosis Nitrogen from protein catabolism, causing ammonia intoxication Glucose from rapid carbohydrate metabolism, causing drowsiness

Ketones as a result of a rapid fat breakdown, causing acidosis Rationale: Ketones are produced when fat is broken down for energy.

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis report. Which urinary finding indicates the need to notify the primary health care provider? Acidic pH Glucose negative Bacteria negative Presence of large proteins

Presence of large proteins Rationale: The glomeruli are not permeable to large proteins such as albumin or red blood cells, and finding them in the urine is abnormal.

Which parameter monitoring would be the nurse's priority while caring for a client with hypothyroidism? Pulse rate BP Respiratory rate Body temperature

Respiratory Rate Rationale: Hypothyroidism is associated with decreased respiratory rate. Therefore, monitoring the client's RR should be the nurse's top priority.

Which formula is most preferable for an infant that has lactose intolerance? Soy-based formula Whey hydrolysate formula Cow's milk-based formula Amino acid-based formula

Soy-based formula Rationale: Soy-based formula is commercially available formula that has a high amount of protein but does not contain lactose.

The nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation? Inhibin Estrogen Prolactin Progesterone

Prolactin

Which are sources of evidence-informed practice? Select all that apply. Theory Research Time Studies Clinical Expertise Accepted nursing rituals

Theory Research Clinical Expertise Rationale: Evidence-informed nursing care uses information gleaned from theory, research, expert opinion, client history and physical examination, client preferences and values, and the clinical expertise of the nurse.

Ingestion of which chemicals may cause chemical pneumonia? Bleach Lighter fluid Toilet cleaner Mildew remover

Lighter fluid Rationale: Certain hydrocarbons, like lighter fluid, can cause severe pneumonia on ingestion.

Which component of the client's nephron acts as a receptor site for the antidiuretic hormone to regulate water balance? Collecting ducts Bowman capsule Distal convoluted tubule Proximal convoluted tuble

Collecting ducts Rationale: The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone.

Why would the nurse question an adolescent about his or her future education plans? To help identify an adolescent who feels socially isolated To give an adolescent the opportunity to talk about his or her strengths To allow an adolescent to discuss items related to physical development To give an adolescent a chance to talk through significant sources of stress

To give an adolescent a chance to talk through significant sources of stress

Which is the regulator of extracellular osmolarity? Sodium Potassium Chloride Calcium

Sodium Rationale: Sodium is the most abundant extracellular fluid cation and regulates serum osmolarity, as well as nerve impulse transmission and acid-base balance.

Which food selection indicates understanding of sources with high biologic value protein? Apple juice Raw carrots Cottage cheese Whole wheat bread

Cottage cheese Rationale: Cottage cheese contains more protein than the other choices.

When a client who is taking a diuretic has been instructed to eat foods high in potassium, which fruit would the nurse suggest? Apples Grapes Cantaloupe Cranberries

Cantaloupe

Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? Feels that he or she leads a completely worthless life Has multiple fainting episodes due to lack of proper nutrition Shows signs of lack of interest in carrying out social interaction Conveys to the nurse that he or she is estranged from all family members

Has multiple fainting episodes due to lack of proper nutrition Rationale: According to Maslow's hierarchy of needs, the basic lower-level needs of human beings need to be addressed first before moving to the higher levels.

Which behavior of the nurse leader is characterized as 'delegating' according to Hersey's model? Guiding or directing Observing or monitoring Explaining or persuading Encouraging or problem-solving

Observing or monitoring Rationale: Observing or monitoring behavior of the leader is characterized as 'delegating' according to Hersey's model.

A primary health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the medication, the client calls the nurse and complains of feeling tired and looking pale. Which action would the nurse take for this client? Advise the client to get more rest Schedule the client for an appointment Instruct the client to skip one dose daily Tell the client to increase the medication

Schedule the client for an appointment Rationale: The client should be examined by the PCP and blood tests should be prescribed; anemia may result from the bone marrow depressant effect of PTU.

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? Presence of dry skin Loss of body weight Decrease in BP Altered general appearance

Loss of body weight Rationale: Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weights 2.2 lb, 1 kg.

The nurse in the family planning clinic reviews the health history of a sexually active 16 year old girl whose chief concern is a thick, burning vaginal discharge accompanied by low abdominal pain. After her examination, the girl is informed that she may have an STI that requires treatment. The adolescent is concerned that her parents will discover that she is sexually active. She asks the nurse whether her parents will be contacted. How would the nurse respond? You parents will not be contacted because treatment at the clinic is confidential. Your parents need to be informed to sign a consent form for testing and treatment. Your parents will be notified when the insurance company is billed for testing and treatment. Your parents will not be told if you promise to have your sexual contacts tested.

You parents will not be contacted because treatment at the clinic is confidential. Rationale: To prevent disclosure, family planning clinics treat these adolescents as emancipated minors who can sign their own consent forms. Federal law allows family planning clinics to maintain minors' confidentiality, although individual states may have different regulations. There is a concern that teenagers will not seek or continue treatment if they fear disclosure.

The registered nurse is teaching a group of nursing students about leadership principles. Which statement made by a nursing student indicates the need for further teaching? A leader has a formal position. A leader intervenes with courage A leader organizes a group of colleagues A leader is a specific management position after promotion

A leader is a specific management position after promotion Rationale: A leader does not necessarily have a formal position to indicate that they are a leader; rather, leadership refers to performance.

The nurse taught the pregnant client relaxation and distraction techniques to overcome morning sickness. During a follow-up visit, the nurse evaluates the client's response and determines if the condition is resolved. Which model is the nurse using in this situation? Peplau's model Nightingale's model Neuman system model Orem's self-care deficit model

Neuman system model Rationale: The Neuman systems model is based on stress and the client's reaction to the stressor. The role of nursing is to stabilize the client. After applying Neuman systems model, the nurse would assess the stressor and evaluate the client's response.

Which Piaget stage of cognitive development does the child belong, when attempting to find a hidden toy after it has been shown to the child then removed from the line of sight? Sensorimotor Preoperational Formal operations Concrete operations

Sensorimotor Rationale: During the sensorimotor stage, the child learns that objects continue to exist even when they cannot be seen, heard, or touched. This is called object permanence.

Which food would the nurse recommend for a child who is at risk for developing rickets? Yogurt Carrots Fruit juice Dried fruit

Yogurt Rationale: A calcium and vitamin D causes rickets

Which client statement would cause the nurse to stop the health care provider from initiating epidural anesthesia? I'm not exactly sure how an epidural works. I understand that the epidural might or might not take my pain away. I signed the consent form for an epidural at my last clinic appointment. I'm aware that the epidural could cause my contractions to slow down.

I'm not exactly sure how an epidural works. Rationale: A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman received information about analgesia and anesthesia earlier in her pregnancy.

When providing comfort to a client during his or her last hours of life, which would be the nurse's primary concern? Select all that apply. Pain Nausea Elmination Respiratory status Cardiovascular status

Pain Respiratory status Rationale: In the last hours of a client's life, assessments are limited to only those that are needed to determine comfort. Assessment of pain and the respiratory status may be the most important at this time. The nurse can administer pain prescriptions to relieve discomfort and oxygen to help the client breathe easier. Nausea, elimination, and cardiovascular status are not the primary focus in the last hours of life, because the client will appear withdrawn from the physical environment.

Which scenarios would the nursing student consider as examples of feedback component? Select all that apply The nurse notices that the client's pain has decreased after giving a back massage. The caregiver says that the client's body temperature has decreased after administering the prescribed medication. The registered nurse is instructing the nursing assistive personnel to use a shower chair to give a bath to a client with activity intolerance. The nursing supervisor asks the nursing student to keep the side rails of the bed up when caring for an older adult who has a history of falls. The nurse finds that the client has developed breathing issues after the medication is administered through the central venous access device.

The nurse notices that the client's pain has decreased after giving a back massage. The caregiver says that the client's body temperature has decreased after administering the prescribed medication. The nurse finds that the client has developed breathing issues after the medication is administered through the central venous access device. Rationale: The 'feedback' component in the nursing process is the outcome that is reflected by the client's responses to nursing interventions. This component also includes responses from family members and consultation from other health care professionals.

The RN is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? I will avoid the pooling of urine in the tubing. I will avoid prolonged clamping of the tubing. I will avoid draining urine from the tubing before ambulation. I will avoid raising the drainage tube above the level of the bladder.

I will avoid draining urine from the tubing before ambulation.

A 50 year old client is diagnosed with COPD. The clinical data on admission are as follows: a heart rate of 100 bmp, a BP of 138/82, a RR of 32 breaths per min, a tympanic temperature 98.2F (36.8C), and an O2 of 80%. Which vital signs obtained by the nurse indicates a positive outcome? Radial pulse: 70 bpm Temperature: 98.6F (37C) Respiratory Rate: 14 breaths/min BP: 110/70 O2: 92%

Respiratory Rate: 14 breaths/min BP: 110/70 O2: 92% Rationale: The RR ranges in older adults from 12 to 20 breaths/min, and this range may be elevated in clients with COPD. Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high BP. Thus a BP of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95-100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy.

Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine? Dilute urine Hematuria Concentrated urine Myoglobinuria

Dilute urine

Which response will the nurse use to maintain the boundaries of a therapeutic relationship when a client asks, "Can we go out for coffee and a movie after I get discharged?" I'm flattered, but that would be professionally irresponsible and unethical. You feel connected to me now; that will change once you are discharged. The attention I've been giving you isn't social; it's just part of the job. As your nurse, let's talk about how you can form social friendships.

As your nurse, let's talk about how you can form social friendships. Rationale: Clients often become socially interested in the nursing staff. When this occurs, the nurse would remind the client of the nursing role and take the opportunity to discuss the need for friendships and how to achieve them.

Which order of events would the nurse follow when performing a critical analysis using the nursing process as a guide for delegation?

Assessing the situation to determine what is legally appropriate to delegate. Planning an intervention. Determining whether the delegatee is competent to perform the task safely Implementing the paln including an observation of the delagatee Evaluating whether the delegation process was completed safely and effectively

A client who is admitted to the hospital and requires a colon resection states, "I want to be a DNR." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? My doctor will know what to do. My family can make decisions for me. If something happens to me, I do not want CPR. If I have a heart attack, I do not want any medication.

If something happens to me, I do not want CPR. Rationale: The statement, "If something happens to me, I do not want CPR", specifically states that if cardiac or respiratory arrest occurs, the client would rather die peacefully and does not want CPR.

When arterial blood gases done on a client who is being resuscitated after cardiac arrest show a low pH, which factor is the likely cause of the laboratory result? Ketoacidosis Irregular heartbeat Lactic acid production Sodium bicarbonate administration

Lactic acid production Rationale: Cardiac arrest causes decreased tissue perfusion, which results in anaerobic metabolism and lactic acid production.

A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction? Stay at the beside with the family and the deceased. Direct activities related to funeral arrangements. Mobilize the support systems for the family. Present the full reality of the loss to the family.

Stay at the beside with the family and the deceased. Rationale: Staying with the family provides support until coping mechanisms and personal support systems can be mobilzed.

When teaching a client with diabetes about monitoring for episodes of hypoglycemia, which symptom would the nurse include in the teaching plan? Thirst Nausea Anorexia Sweating

Sweating Rationale: When serum glucose decreases, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine; this response causes sweating, tremors, tachycardia, palpitations, nervousness, and hunger.

A newborn with Erb palsy has an asymmetric Moro reflex. Which cause would the nurse suspect? Acquired in utero A tumor arising from muscle tissue An X-linked inheritance pattern An injury to the shoulder during birth

An injury to the shoulder during birth Rationale: Erb palsy results from forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus.

Which long-term effect is associated with untreated congenital hypothyroidism? Myxedema Thyrotoxicosis Spastic paralysis Cognitive impairement

Cognitive impairment Rationale: Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. A decreased level of thyroid hormone affects the fetus before birth during cerebral development, so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months of age will prevent further damage.

A parent whose infant is born with talipes equinovarus (clubfoot) tells the nurse, "I am afraid to have more children because they might have the same problem." Which is the best response by the nurse? Reassuring the parent that this problem is unlikely to occur again Discussing the probability of the defect occurring in future children Exploring the parent's understanding of the probable causes of this disorder Explaining that there is no way of knowing whether the deformity will occur in a future child

Exploring the parent's understanding of the probable causes of this disorder Rationale: Exploring the parent's understanding of the probable causes of this disorder allows the nurse to assess the parent's knowledge and fears. A discussion of the disorder's incidence, geographic variations, and familial tendency can follow.

A family has decided to withhold extraordinary care for a newborn with severe congenital abnormalities. How would the nurse interpret this decision? The newborn has no rights It is the same as euthanasia It is illegal professional practice The newborn is being allowed to die

The newborn is being allowed to die Rationale: The family's decision means that extraordinary care does not have to be employed; the infant's basic needs will be met, and nature will be allowed to take its course; the infant is being allowed to die.

Which response would the nurse give when a husband asks about the results of this wife's psychological assessment tests? Refer the husband to the psychiatrist Describe the results to the husband Suggest that he talk to his wife Explain that test results are confidential

Explain that test results are confidential Rationale: If the wife is mentally competent to make medical decisions, test results would not be disclosed to any relatives without her permission.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgement. Which might the client's body temperature be? 29C 33C 36C 38C

33C Rationale: A body temperature in the range of 36-38C is normal. When skin temperature drops below 35C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia.

Which type of brain tumor can originate from cells that form the myelin sheath around nerves? Meningioma Astrocytoma Ependymoma Acoustic neuroma

Acoustic neuroma

Which type of crisis has occurred when a sudden terrorist act causes the deaths of thousands of adults and children and negatively affects their families, friends, communities and the nation?

Adventitious Rationale: An adventitious crisis is a crisis or disaster that is unplanned and accidental; its subcategories include natural disaster, national disasters, and crimes of violence.

The nurse finds that an 80 year old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? Advocating on behalf of the client Discussing the client's problem with another nurse Arranging a permanent accommodation in the hospital Suggesting the family place the client in a long-term health care facility

Advocating on behalf of the client Rationale: The public depends on nurse leaders to move forward the consumer advocacy agenda. As a leader, the nurse would advocate on behalf of the client.

A client is admitted to an intensive care unit with a diagnosis of acute respiratory distress syndrome (ARDS). Which clinical finding would the nurse expect when assessing this client? Hypertension Tenacious sputum Altered mental status Slowed rate of breathing

Altered mental status Rationale: Altered mental status is secondary to cerebral hypoxia, which accompanies ARDS; cognition and LOC are reduced.

Which would the nurse do while communicating with a group of adolescents? Select all that apply Ask adolescents open-ended questions Avoid involving other individuals and resources Avoid discussing sensitive issues such as sex and drugs Be aware of clues about the adolescent's emotional state Avoid looking for the meaning behind an adolescent's words or actions

Ask adolescents open-ended questions Be aware of clues about the adolescent's emotional state

A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving would the nurse conclude the client is experiencing? Bargaining Frustration Depression Rationalization

Bargaining Rationale: Bargaining is one of the stages of grieving stage, in which the client promises some type of desirable behavior to postpone the inevitability of death.

The nurse is caring for an older adult client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment information best reflects the fluid balance of this client? Skin turgor Intake and output results Client's report about fluid intake Blood lab results

Blood lab results Rationale: Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit.

In a child with lead poisoning, where is lead stored while remaining inert? Liver Blood Bones Soft tissues

Bones Rationale: Lead is stored in the bones and teeth, where it remains inert. This makes up the largest portion of the body burden, approximately 75-90%.

Which collecting structure is located at the end of the renal papilla? Calyx Capsule Renal cortex Renal columns

Calyx Rationale: The calyx is a cuplike structure that collects urine and is located at the end of each papilla.

Which health care team member would the registered nurse state is accountable for establishing systems to communicate competency requirements related to delegation? RN Chief nursing officer Licensed practical nurse Unlicensed assistive personnel

Chief nursing officer Rationale: CNOs are accountable for establishing systems to communicate competency related to delegation.

Which delegation right is being used when the nurse is considered whether the right equipment and resources are available to complete a task. Taks Supervision Circumstance Communication

Circumstance Rationale: If the right equipment and resources are available to complete a task, it is considered the right circumstance.

Which theory related to leadership is a nontraditional theory that has emerged from the physical and social sciences? Expectancy theory Complexity theory Motivational theory Management theory

Complexity theory Rationale: Complexity theory is a nontraditional theory emerging from the work of the physical sciences and, more recently, social sciences.

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? Choking Redness Gagging Cyanosis

Cyanosis Rationale: If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis; this is a serious problem that must be corrected immediately.

Which decision-making strategy involves systematic collection and summarization of opinions and judgements on a particular issue from the respondents? Focus group Brainstorming Delphi technique Normal group technique

Delphi technique Rationale: The Delphi technique is a decision-making strategy that involves systematic collection and summarization of opinions and judgements on a particular issue from respondents to achieve consensus among the team members and the leader.

Which action is true as related to the role of the RN in active delegation? Providing direct care to a client Performing the task on behalf of a delegatee Carrying out certain functions as the health care provider Directing an UNP to perform certain tasks

Directing an UNP to perform certain tasks

Which qualities would an effective leader exhibit? Select all that apply Born with the right stuff Elicit a vision from people Bring out the best in people Engender discipline and obedience Inspire people to bring the vision into reality

Elicit a vision from people Bring out the best in people Inspire people to bring the vision into reality Rationale: Leadership is the ability to elicit a vision from people and to inspire and empower those people to do what it takes to bring the vision into reality.

Which statement regarding calcitonin is correct? It is secreted by follicular cells. It's actions are opposite to that of parathyroid hormone. It decreases phosphorus levels by increasing bone resorption. It works along with thyroid hormone to maintain normal calcium levels in blood.

Its actions are opposite to that of parathyroid hormone. Rationale: Calcitonin reduces serum calcium levels, whereas parathyroid hormone increases calcium levels. Calcitonin is secreted by parafollicular cells of the thyroid gland. Calcitonin decreases calcium and phosphorus levels by decreasing bone resorption. It works along with parathyroid hormone to maintain calcium levels in blood.

Which type of relationship between the nurse and delegator and delegatee causes the nurse delegator to use the leadership behavior of 'telling'? Limited Established New or developing Developing or ongoing

Limited Rationale: When the delegator and delegatee are unlikely to work together again, the relationship is limited and the delegator uses the leadership behavior of "telling".

A pathology report states a client's urinary calculus is composed of uric acid. Which food item would the nurse instruct the client to avoid? Milk Liver Cheese Vegetables

Liver Rationale: A low-purine diet controls the development of uric acid stones. Clients with uric acid stones should avoid foods high in purine, such as organ meats and extracts.

Which foods identified by the mother of a child with celiac disease indicate that she understands which foods to avoid feeding the child? Bacon and eggs Macaroni and cheese Tuna salad and rice cakes Chicken leg and corn on the cob

Macaroni and cheese Rationale: Children with celiac disease cannot digest the gliadin component of gluten. Foods containing grains such as wheat, rye, oats, and barley should be avoided; macaroni is contraindicated because it is a wheat product.

Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak? Medical Reserve Corps (MRC) National Disaster Medical Systems (NDMS) Disaster Medical Assistance Team (DMAT) Federal Emergency Management Agency (FEMA)

Medical Reserve Corps (MRC)

Which medication would the nurse identify as being used both for cervical ripening during labor and as a stomach protectant? Raloxifene Clomiphene Misoprostol Dinoprostone

Misoprostol

Which actions can the mentor take to develop effective leadership qualities in the aspiring leader? Select all that apply Avoiding criticism Modeling behavior Noting the mistakes Giving timely feedback Providing appropriate advice

Modeling behavior Giving timely feedback Providing appropriate advice Rationale: The mentor would model professional and desired behavior and give timely feedback and appropriate advice to make the aspiring leader an effective leader.

Which purpose does a community health center serve in preventive and primary care services? Outpatient clinics that provide primary care to specific population Aim to increase worker productivity, decrease absenteeism, and reduce the use of costly health principles Emphasize program management, interdisciplinary collaboration, and community health principles Include a complete program designed for health promotion and accident or illness prevention in the workplace.

Outpatient clinics that provide primary care to specific population Rationale: Community health centers are outpatient clinics that provide primary care to a specific population, such as clients with young children or clients with diabetes.

A nursing student is listing the steps that need to be followed for applying developmental theory when caring for chronically ill older adults with depression. Which step listed by the nursing student needs correction? Understand adult development and its implications for practice. Be aware of signs of depression such as general fatigue or insomnia. Recognize the need to identify depression so that heart failure can be prevented. Understand the older adult concept of depression and views on treatment for mental illness.

Recognize the need to identify depression so that heart failure can be prevented.

In a health care organization, which role would a resource person assigned by the nurse manager have? Delegates tasks Supervises actions Serves as a mentor Reassigns duties to workers

Serves as a mentor Rationale: The nurse manager assigns a resource person in a health care organization to serve as a mentor for the agency nurse to prevent potential problems that could arise if the staff member does not know the institutional routine.

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus would the nurse assess the client? Select all that apply Sharp chest pain Acute onset of dyspnea Pain in the residual limb Absence of popliteal pulse Blanching of the affected extremity

Sharp chest pain Acute onset of dyspnea Rationale: Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized sharp chest pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea.

The nurse is caring for a client 2 days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? Sooty Frothy Yellow Tenacious

Sooty Rationale: The mucous membranes of the respiratory tract may be charred after inhalation burns; this is evidenced by the production of sooty sputum.

A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? Tremors Anasarca Bradypnea Tachycardia

Tachycardia Rationale: The heart rate increases in an attempt to compensate for the lack of oxygen to body cells.

Which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? Oxygen therapy Cardiac monitoring Nutrition supplements Venous thromboembolism prevention

Venous thromboembolism prevention Rationale: after hip surgery, development of VTE commonly occurs. Nursing must implement preventive intervention; this is a component of core measures.

The nurse assesses a client with dry and brittle hair, flaky skin, and a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? A food allergy Noncompliance with medications Side effects from medications A nutritional deficiency

A nutritional deficiency

While taking the blood pressure of a client with hypertension, the nurse hears the first Korotkoff sound at 128 mm Hg, then no sound is heard until the manometer is at 110 mm Hg, and then Korotkoff sounds are heard until sounds disappear completely at 72 mm Hg. Which abnormal finding will the nurse document? Auscultatory gap Pulsus paradoxus Widened pulse pressure Isolated systolic hypertension

Auscultatory gap Rationale: Auscultatory gap occurs when there is absence of Korotkoff sounds between the first and second sounds and can be as large as 40 mm Hg.

In which order would the nursing student arrange the scenarios from the highest to the lowest level of needs based on Maslow's hierarchy? My father threatens to commit me to an asylum if I dare disobey him I have been feeling depressed ever since my sibling stopped speaking to me. I do not have any skills that will help me be an achiever in life. I want to maintain good health because I intend to be the best soccer player on my team.

I want to maintain good health because I intend to be the best soccer player on my team. I do not have any skills that will help me be an achiever in life. I have been feeling depressed ever since my sibling stopped speaking to me. My father threatens to commit me to an asylum if I dare disobey him Rationale: According to Maslow's hierarchy of needs, self-actualization is the highest level of need for an individual. If the client intends to reach his or her full potential as a human being, this statement indicates the need to achieve self-actualization.

A client sustains a back injury after falling 20 ft. In which position would the nurse place the client? Lateral position with a pillow between the knees Any position that reduces pain and is comfortable Supine position while not allowing the spine to flex Sitting position with a pillow placed in the small of the back

Supine position while not allowing the spine to flex Rationale: When caring for a client with a suspected back injury, the client should be positioned to keep the vertebral column in alignment to prevent further spinal cord damage by vertebral movements.

Which assignment in an emergency department is a high priority for the nurse providing care for clients during a mass casualty? Resolving stock availability problems Taking inventory and restocking supplies Debriefing to promote effective coping strategies Outlining emergency expectations and arrangements

Taking inventory and restocking supplies

A client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force? Maintain the head of the bed at 30 degrees or less. Use draw sheets to pull up, transfer, and position the client. Reposition the client every 2 hours, propping with pillows. Perform passive ROM exercise every 8 hours.

Use draw sheets to pull up, transfer, and position the client. Rationale: Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a draw sheet or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing tearing of the skin. Using a draw sheet can reduce and minimize friction and shearing force.

Which statement is true regarding varicoceles? Varicoceles are commonly seen in prepubertal children. Varicoceles result in a partial or complete venous occulsion. Varicoceles result in a red, warm, and edematous scrotum. Varicoceles cause an elongation of the veins of the spermatic cord.

Varicoceles cause an elongation of the veins of the spermatic cord. Rationale: Varicocele is characterized by a dilation and elongation of the veins of the spermatic cord that is presently superior to a testicle. This condition is rarely seen in prepubertal children.

A victim of a car crash tells the nurse, "I don't believe in God anymore now that I'm paralyzed." The nurse asks the client to discuss how the condition has affected his or her ability to express what is important to them. Which aspect of spiritual assessment would this question address? Faith Vocation Connectedness Life and self-responsibility

Vocation Rationale: In discussing how the client's condition has affected his or her ability to express what is important to him or her, the nurse is addressing the vocation aspect of the client's spirituality.

Which examples mentioned by the nurse belong to the third level of needs according to Maslow's hierarchy? Select all that apply A client is depressed because his or her spouse has passed away. A client is constipated due to excess loss of fluids from the body. A client wants to reconnect with old friends after being diagnosed with cancer. A client has to live in a rat-infested apartment due to lack of financial resources. A client never goes to family gatherings because he or she is not accepted by family members.

A client is depressed because his or her spouse has passed away. A client wants to reconnect with old friends after being diagnosed with cancer. A client never goes to family gatherings because he or she is not accepted by family members. Rationale: According to Maslow's hierarchy of needs, the third level of needs is love and belonging. This includes friendship, social relationships, sexual love, and so on.

Several clients report unrelieved pain, and the charge nurse observes that their assigned nurse appears uncoordinated and drowsy and has slurred speech. Which action would the charge nurse take? Ask the nurse manager to be present before confronting the staff nurse. Tell the nurse that everyone now knows who has been stealing the morphine. Ask other staff whether they have noticed anything unusual lately. Secretly observe the nurse while she is preparing and administering morphine.

Ask the nurse manager to be present before confronting the staff nurse. Rationale: Arranging for the nurse manager to be present before confronting the staff nurse is important because this is a serious allegation, and confrontation should occur in the presence of a person in a supervisory position.

The nurse provides education to a client about colostomy care. To be effective when providing the teaching, the nurse would start with which step? Wait until a family member is present Assess barriers to learning colostomy care Provide simple written instructions concerning the care Wait until the client has accepted the change in body image

Assess barriers to learning colostomy care Rationale: Before a teaching plan can be developed, the factors that interfere with learning must be identified.

The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be most likely associated with the client's colitis? Food allergy Infectious agent Dietary components Genetic predisposition

Genetic predisposition Rationale: Studies indicate that inflammatory bowel diseases, which include ulcerative colitis and Crohn diseases, are familial, which suggests that they are hereditary.

An increase in which blood component is responsible for the acidosis related to untreated diabetes mellitus? Ketones Glucose Lactic acid Glutamic acid

Ketones Rationale: The ketones produced excessively in diabetes are a byproduct of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis.

Which result would the nurse expect to see on the ECG tracing monitor when a client has diabetic ketoacidosis and a potassium level of 5.4 mEq/L? Abnormal P waves and depressed T waves Peaked T waves and widened QRS complexes Abnormal Q waves and prolonged ST segments Peaked P waves and an increased number of T waves

Peaked T waves and widened QRS complexes Rationale: Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results.

The nurse receives an order to prepare the solution for administering a cleansing enema to a 3 year old child. Which is the volume of solution the nurse would prepare? 150-250 mL 250-350 mL 300-500 mL 500-750 mL

250-350 mL Rationale: The nurse would prepare 250-350 mL of warmed solution for administering a cleansing enema in a toddler.

Before treatment requiring informed consent can be performed, which information must the health care team give to the client? Select all that apply. Cost of the treatment Alternative treatment options Risks and benefits of the treatment Risks involved in refusing the treatment Nature of the problem requiring the treatment

Alternative treatment options Risks and benefits of the treatment Risks involved in refusing the treatment Nature of the problem requiring the treatment Rationale: For consent to be legal, it must be informed. The information provided to the client includes the nature of the problem, the nature and purpose of the treatment, risk and benefits of the treatment, alternative treatment options, the probability that the proposed treatment will be successful and the risks involved in not consenting to the treatment.

Which is the role of the nurse executive as a leader? Orientation Empowerment Employee selection Financial accountability

Empowerment Rationale: The role of the nurse executive as the leader is to empower followers or to share the authority with the followers by asking them to actively participate in the given task.

A client with advanced bone caner is experiencing cachexia. The nurse reviews the nutritional components of palliative care with the client's family members. The nurse recognizes that the teaching is designed to achieve which outcome? Enhance the quality of the client's life Reduce the likelihood of a respiratory infection Prevent malabsorption syndrome Cure the cachexia that results from bone cancer and chemotherapy

Enhance the quality of the client's life Rationale: Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. Palliative care focuses on reducing symptoms and increasing quality; it does not focus on finding a cure.

Which scenarios would the nursing student consider as content components? Select all that apply The nurse assessing a client's medical records before surgery finds that the client is allergic to latex. The nurse-in-charge asks the nurse to check the IV tubing for air bubbles to prevent air emboli. The nurse checks the client's medical records for any blood transfusion reactions before administering a blood transfusion. The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy. The nurse knows that clients with airborne diseases would be placed in an airborne infection isolation room to prevent the spread of pathogens.

The nurse-in-charge asks the nurse to check the IV tubing for air bubbles to prevent air emboli. The nurse understands that many clients buy prescribed medications from multiple medical stores; this is known as polypharmacy. The nurse knows that clients with airborne diseases would be placed in an airborne infection isolation room to prevent the spread of pathogens. Rationale: The component involves information about the nursing interventions for clients with specific health care problems.

A client is admitted to the hospital with Laennec cirrhosis and chronic pancreatitis. Bile salts are prescribed, and the client asks why they are needed. How would the nurse respond? They stimulate prothrombin production They aid in the absorption of fat-soluble vitamins They promote bilirubin secretion in urine They help the common bile duct contract stronger

They aid in the absorption of fat-soluble vitamins Rationale: Bile salts are used to aid in digestion of fats and absorption of the fat-soluble vitamins A, D, E, and K.

Which blood gas result would the nurse expect an adolescent with diabetic ketoacidosis to exhibit? pH 7.30, CO2 40 mmHg, HCO3 -20 mEq/L pH 7.35, CO2 47 mmHg, HCO3 -24 mEq/L pH 7.46, CO2 30 mmHg, HCO3 -24 mEq/L pH 7.50, CO2 50 mmHg, HCO3 -22 mEq/L

pH 7.30, CO2 40 mmHg, HCO3 -20 mEq/L Rationale: A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic, and the HCO3- will be low.

When caring for a client with symptomatic bradycardia caused by heart block, the nurse will anticipate the need to teach the client about which treatment option? Overdrive pacing Demand pacemakers Cardiac resynchronization therapy Implantable cardioverter-defibrillators

Demand pacemakers Rationale: Treatment for symptomatic bradycardia typically includes placement of a temporary or permanent demand pacemaker to prevent heart rate from dropping below a reset rate.

Which scenario would contribute to health disparities? An English-speaking critical care nurse assesses a Hispanic client in a coma An English-speaking nurse plans the nursing procedures for a black Latino client. An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing. An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.

An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English. Rationale: As per the US Department of Health and Human Services Office of Minority Health, health care organizations should offer and provide language assistance services, including an interpreter, to each client with limited English proficiency at all points of contact during all hours of operation and service.

A client with emphysema reports increased shortness of breath and becoming increasingly anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse recognizes that this prescription is appropriate for which reason? The client does not need any more than 1 L/min High concentrations of oxygen cause alveoli to rupture High concentrations of oxygen eliminate the respiratory drive The oxygen at 1 L/min should be enough to diminish the anxiety

High concentrations of oxygen eliminate the respiratory drive Rationale: Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. Too much oxygen will knock out the stimulus to breathe.

Which situations qualify under the fourth level of Maslow's hierarchy of needs? Select all that apply A client laments that he or she is the ugliest person in the whole world. A client informs the nurse that he or she has been living alone for the past decade. A client tells the nurse that he or she feels out of breath, even when walking slowly. A client tells the nurse that he or she is the only member in the family who does not work. A client feels that he or she has not been living up to his or her partner's expectations.

A client laments that he or she is the ugliest person in the whole world. A client tells the nurse that he or she is the only member in the family who does not work. A client feels that he or she has not been living up to his or her partner's expectations. Rationale: According to Maslow's hierarchy of needs, the fourth level needs constitute the esteem and self-esteem needs. This includes self-confidence, usefulness, achievement, and self-worth.

Which situations come under the second level of Maslow's hierarchy of needs? Select all that apply A client tells the nurse that he or she has no friends. A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she does not like interacting with people. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals.

A client tells the nurse that he or she is taunted by his or her boss every day. A client tells the nurse that his or her spouse belongs to a criminal gang. A client tells the nurse that he or she lives beside a factory that manufactures harmful chemicals. Rationale: According to Maslow's hierarchy of needs, the second level of needs involves safety and security needs. This includes both physical and psychological security and safety of the person.

During a health history, an older client reports having fallen three times in the past 6 months. Which would the nurse ask to obtain other risk factors? The level of education attained The use of supplemental oxygen A subscription to call alert systems Asking the client to walk across the room

Asking the client to walk across the room Rationale: When a client reports more than two falls in 12 months, the nurse would obtain further information to determine risk factors. Asking the client to walk across the room can determine any abnormalities in the gait or loss of balance.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had tetanus immunization. The adolescent responds that all the immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which describes the nurse's responsibility in this situation? The nurse's judgment was adequate, and the client was treated accordingly. The possibility of tetanus was not foreseen because the client was immunized. Nurses would routinely administer immunization against tetanus after such an injury. Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.

Assessment by the nurse was incomplete and, as a result, the treatment was insufficient. Rationale: The nurse's data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse's assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a 'tetanus-prone' wound, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.

Which malnourished condition may predispose a client to secondary immunodeficiency? Cachexia Cirrhosis Diabetes mellitus Hodgkin lymphoma

Cachexia Rationale: Cachexia is a nutrition disorder that may occur because of wasting of muscle mass and weight, resulting in a secondary immunodeficiency disorder.

A client in need of a lung transplant tells the nurse, "I will not take the organ of any person belonging to a different religion." The nurse initiates the process for resolving the ethical dilemma by collaborating with other health care team members. Which would team do after agreeing to a statement of the problem? Interview the family members of the client. Initiate negotiations for the appropriate course of action. Assess whether the client is satisfied with the course of action taken. Determine all the possible courses of action based on available information.

Determine all the possible courses of action based on available information. Rationale: When resolving an ethical dilemma, the health care team should determine all possible courses of action after agreeing to a statement of the problem. At this stage, the members of the team weigh all options to address the situation.

Which preventive and primary care service provided by a community health center is most expensive? Running errands Health education Disease management Routine physical examinations

Disease management