BSN 266 HESI

41. 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 the nearest tenth.)

0.4

22. 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.)

167mL

29. The home health nurse provides teaching about 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. To repeat the video, click the play button again.) a. Continue with the insulin injection. b. Keep the skin flat rather than bunched. c. Lie down flat for better skin exposure. d. Select a different injection site.

A

35. A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for the continuous bladder irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots in the tubing collection bag. Which action should the nurse take? a. Monitoring catheter drainage. Right answer for HESI b. Irrigation the catheter manually. Right answer for EAQ c. Decreasing the flow rate. d. Discounting infusing solution.

A

54. 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.

A Explanation: A carotid bruit, which is an abnormal sound heard over the carotid artery, suggests turbulent blood flow and can indicate atherosclerotic plaque buildup, increasing the client's risk for a stroke. Jugular vein distention, palpable cervical lymph nodes, and nuchal rigidity are not directly linked to an increased risk of stroke.

53. The healthcare provider prescribes diagnostic tests for a client whose chest ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Sputum culture and sensitivity. b. Arterial blood gases (ABG). c. Computerized tomography (CT) of the chest. d. Blood cultures.

A Explanation: A sputum culture and sensitivity test will provide information about the specific microorganism causing the pneumonia and help guide the most appropriate antibiotic treatment. Arterial blood gases, CT of the chest, and blood cultures may provide additional information, but the sputum culture and sensitivity test is the most valuable for determining the most effective treatment for the pneumonia.

30. 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. Determine if the client is using an inhaler before exercising. b. Teach client to use pursed lip breathing when episodes occur. c. Review the client's routine asthma management prescriptions. d. Assess client for signs and symptoms of upper airway infection.

A Explanation: Clients with exercise-induced asthma often benefit from using a short- acting bronchodilator before exercising. The nurse should determine if the client is using an inhaler before exercising to help prevent bronchoconstriction and increased mucous production.

18. 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 nurses to provide this client? a. Maintain prescribed eye drop regimen. b. Eat a diet high in carotene. c. Wear prescription glasses. d. Avoid frequent eye pressure measurement.

A Explanation: Maintaining a prescribed eye drop regimen is crucial for managing glaucoma and preventing further vision loss. While the other suggestions might be helpful for overall eye health, adherence to the prescribed eye drop regimen is the most important action to help prevent the progression of glaucoma.

36. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. Notify the healthcare provider of the client's medication history. b. Observe the heparin injections sites for signs of bruising. c. Have the client sign the surgical and transfusion permits. d. Ensure that the potential for bleeding is explained to the client.

A Explanation: Since the client is on heparin therapy, there is an increased risk of bleeding during surgery. It is crucial for the nurse to notify the healthcare provider of the client's medication history so that appropriate precautions can be taken during surgery.

21. 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. Move into airborne isolation. b. Collect specimens for blood cultures. c. Arrange transport for radiographic imaging. d. Obtain a sputum sample.

A Explanation: The client's symptoms (intermittent fever, night sweats, productive cough with blood) are suggestive of tuberculosis (TB). The nurse should prioritize placing the client in airborne isolation to prevent the potential spread of TB to others while awaiting further assessment and testing.

33. 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. White blood cell (WBC) count. b. Hematocrit. c. Platelet count. d. Blood pH level.

A Explanation: The presence of purulent drainage at the burn wound site may indicate infection. The nurse should review the client's white blood cell (WBC) count, as an elevated WBC count is often associated with infection.

28. Which action should the nurse implement to reduce the risk of vesicant extravasation in NJ the client who is receiving intravenous chemotherapy? a. Monitor the client's intravenous site hourly during the treatment. b. Keep the head of the bed elevated until the treatment is completed. c. Instruct the client to drink plenty of fluids during the treatment. d. Administer an antiemetic before starting the chemotherapy.

A Explanation: To reduce the risk of vesicant extravasation, the nurse should monitor the client's intravenous site hourly during the chemotherapy treatment. This allows for early detection of infiltration or extravasation, which can minimize tissue damage.

23. 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.

A Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry, rough skin in clients with eczema. The expected therapeutic response would be hydration of the affected dry skin areas. While the cream may also help alleviate some symptoms, such as itching or pain, its primary purpose is to moisturize the skin.

32. 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 breathe/minute. blood pressure 168/100 mmHg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? Select at that apply. a. Oxygen saturation. b. Pain scale. c. Lung sounds. d. Urinary output. e. Skin elasticity.

ACD Explanation: To determine the client's response to furosemide, the nurse should assess oxygen saturation (to evaluate improvements in gas exchange), lung sounds (to identify any reduction in wheezes and crackles), and urinary output (to monitor diuresis, as furosemide is a diuretic).

50. 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).

B

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

48. A client who has a history of hypothyroidism was initially with lethargy and confusion. Which additional finishing warrants finding warrants the most immediate action by the nurse? a. Facial puffiness and periorbital edema. b. Further decline in level consciousness. c. Hematocrit of 30% (0.30). d. Cold and dry skin.

B Explanation: A further decline in the level of consciousness in a client with hypothyroidism may indicate a worsening condition or the development of a myxedema coma, which is a life-threatening emergency. The nurse should prioritize addressing this finding. Other symptoms such as facial puffiness, low hematocrit, and cold and dry skin are also important to consider, but the decline in the level of consciousness is the most urgent.

10. 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. Jogs more frequently than usual daily routine. b. Eats a vegetarian diet with cheese 2 to 3 times a day. c. Experiences additional stress since adopting a child. d. Drinks several bottles of carbonated water daily.

B Explanation: Diets high in animal protein, such as cheese, can increase the risk of kidney stones. While the other options do not pose a direct risk for renal calculi, a diet high in animal protein can contribute to the formation of stones.

44. 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. Assesses the client's radical pulses and capillary refill time. b. Discuss approaches to chronic pain control with the client. c. Notify the healthcare provider of the finding immediately. d. Review the client's dietary intake of high-protein foods.

B Explanation: Heberden's nodes are bony enlargements that can occur in degenerative joint disease and can be painful for the client. The nurse should discuss approaches to chronic pain control with the client to help manage this symptom. Assessing radial pulses, notifying the healthcare provider immediately, and reviewing dietary intake are not the most appropriate actions in this situation.

43. 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.

B Explanation: In a client with ALS, a weakened cough effort may indicate a decline in respiratory function, which can lead to respiratory complications or failure. Immediate intervention is necessary to address respiratory issues and prevent further complications. Other symptoms, such as inappropriate laughter, asymmetrical weakness, and increasing anxiety, are common in ALS but are less urgent in this context.

46. The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough and shortness of breath. Which action is most important for the nurse to take? a. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. b. Move the client to a private room, keep the door closed, and initiate droplet precautions. c. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results. d. Assist the client to recall everyone possibly exposed since onset symptoms.

B Explanation: In order to minimize the risk of transmission of COVID-19 to other patients and staff, it is important to isolate the client in a private room with the door closed and initiate droplet precautions. While counseling family members, assisting the client to recall exposed individuals, and preparing for potential antiviral treatment may be necessary, the priority is to prevent the spread of the virus within the healthcare setting.

5. A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics 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. Uremic irritation of mucous membranes and skin surfaces. b. Hypovolemia and electrocardiographic (ECG) changes. c. Side effects of total parental nutrition (TPN) and Intralipids. d. Elevated creatinine and blood urea nitrogen (BUN).

B Explanation: During the diuretic phase of AKI, the client may experience increased urine output, which can lead to hypovolemia and electrolyte imbalances. Monitoring for hypovolemia and ECG changes can help detect any complications or worsening of the client's condition.

15. 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. Hypoalbuminemia that results in a decreased colloidal onoctic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation.

B Explanation: In cirrhosis, the liver's ability to produce albumin is compromised, leading to hypoalbuminemia. This causes a decrease in colloidal oncotic pressure, allowing fluid to leak into the interstitial spaces and leading to edema and ascites.

24. 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. Activity level of bowel sounds. b. Eating patterns of dietary intake. c. Level and amount of physical activity d. Color and consistency of feces.

B Explanation: In clients with chronic pancreatitis, the nurse should assess eating patterns of dietary intake to help manage persistent abdominal pain. The pain is often related to the type and amount of food consumed, and adjusting the diet can help alleviate discomfort. Clients are usually advised to eat smaller, more frequent meals, and avoid high-fat foods.

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

B Explanation: Overexposure to PUVA treatment can cause skin irritation, tenderness, and erythema. If the client exhibits these symptoms, the nurse should notify the healthcare provider for possible treatment modifications.

34. 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. Platelet count. c. White blood cell count. d. Hemoglobin levels.

B Explanation: Petechiae and ecchymosis are often associated with low platelet counts, which can lead to impaired clotting and increased bleeding risk. The nurse should review the client's platelet count to assess for thrombocytopenia, which may be the cause of the observed skin findings.

37. 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 its 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. Approaches to conserve energy. b. Guidelines for oxygen use. c. Methods for weight loss. d. Strategies for smoking cessation.

B Explanation: The client is being discharged with oxygen therapy, so it is most important for the nurse to emphasize guidelines for oxygen use, including safety measures, proper administration, and monitoring. While other topics like energy conservation, weight loss, and smoking cessation are important, the priority in this situation is to ensure that the client knows how to use the prescribed oxygen therapy safely and effectively.

38. The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headache or trauma. Which intervention should the nurse should perform in the immediate management of the client? a. Place an indwelling urinary catheter and measure strict output. b. Notify the stroke team to assist with acute assessment and management. c. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. d. Begin continuous observation for transient episodes of neurologic dysfunction.

B Explanation: The client's sudden onset of a severe headache, facial numbness, uneven smile, and weaker hand grasp on one side may indicate a stroke. The nurse should notify the stroke team immediately to begin the acute assessment and management of the client's condition.

45. A client with draining skin lesions of the lover 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.

BCE Explanation: Monitoring the client's white blood cell count can help assess the severity of the infection and response to treatment. Sending wound drainage for culture and sensitivity will help identify the causative organism and guide appropriate antibiotic therapy. Instituting contact precautions for staff and visitors will prevent the potential spread of MRSA. A low bacteria diet is not necessary in this situation, and using standard precautions with a mask is insufficient for preventing the spread of MRSA

27. 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 tight flow venturi mask. b. Encourage client to drink water. c. Assist client to an upright position. d. Administer a prescribed sedative.

C

26. After falling down the basement steps, a client is brought to the emergency room. X-ray confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

C Explanation: A pale right foot with sluggish capillary refill following the application of a leg cast may indicate compromised blood flow to the extremity, which requires immediate intervention by the nurse. The other findings are expected after a fracture and cast application, but do not warrant immediate intervention.

12. The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the 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.

C Explanation: Carcinogens are substances that can cause changes in a cell's DNA, leading to the development of cancer. Understanding that carcinogens are potential sources of cancer indicates accurate knowledge of this concept.

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

C Explanation: Clients with diabetes mellitus and peripheral neuropathy are at risk for foot complications. It is important for the client to perform regular foot exams, and enlisting the help of family members can ensure that any issues are identified promptly. The other options are not recommended, as they may increase the risk of injury or infection.

14. 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. Latent hepatitis C. c. Crohn's disease with colectomy. d. Type 2 diabetes mellitus.

C Explanation: Crohn's disease with a history of colectomy is a contraindication for peritoneal dialysis due to the increased risk of peritonitis and complications related to abdominal surgery. The other conditions listed do not directly contraindicate peritoneal dialysis.

16. 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.

C Explanation: Ensuring that oral suction is available is essential for an unconscious client who has seizures. Suctioning can help to maintain a patent airway and prevent aspiration of secretions during and after a seizure.

40. Four days following and 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 Explanation: If pedal pulses are not palpable, the nurse should use a vascular Doppler to assess the pulses more accurately. This can provide information on the adequacy of blood flow to the extremities and help identify any potential complications related to the abdominal aortic aneurysm repair.

11. 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 fingerstick blood glucose level. c. Palpate the bladder above the symphysis pubis. d. Collect a urine specimen for culture analysis.

C Explanation: The client's symptoms suggest possible urinary retention, which is common in older males with benign prostatic hyperplasia (BPH). Palpating the bladder above the symphysis pubis can help the nurse assess for bladder distention and provide information to guide further evaluation and management.

7. 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 mmHg. Which intervention is most important for the nurse to include in the client's plan of care? a. Encourage regular turning. b. Monitor skin for breakdown. c. Strict IV fluid replacement. d. Assess wound drainage daily.

C Explanation: The client's vital signs indicate possible sepsis or systemic infection. Strict IV fluid replacement is important to maintain adequate circulation, support blood pressure, and treat potential sepsis. The other interventions are also essential but not as critical as fluid replacement in this situation.

42. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. b. Medicate for pain and monitor vital signs according to protocol. c. Administer intravenous fluid bolus as prescribed by the healthcare provider. d. Encourage the client to splint the incision with a pillow to cough and deep breathe.

C Explanation: The client's vital signs indicate tachycardia and tachypnea, which may be signs of hypovolemia or inadequate perfusion. Administering a prescribed intravenous fluid bolus can help address this issue and stabilize the client's vital signs. While other interventions may be necessary, addressing the potential hypovolemia is the most important initial step.

4While 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

C Explanation: The nurse should gather additional assessment data about the pain and weakness to better understand the client's condition and to determine if there is an underlying issue or if the symptoms are related to the migraine headaches.

20. Which information should the nurse include on 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. Sleep without pillows at night to maintain neck alignment. c. Minimize symptoms by wearing loose, comfortable clothing. d. Avoid participation in any aerobic exercise programs.

C Explanation: Wearing loose, comfortable clothing can help minimize GERD symptoms by reducing pressure on the abdomen and lower esophageal sphincter. Other lifestyle changes, such as smaller, more frequent meals, elevating the head of the bed, and avoiding foods that trigger symptoms, are also important for managing GERD.

51. 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 south, Which intervention should the nurse implement first. a. Cleanse the mouth with swabs. b. Encourage frequent mouth care. c. Obtain a soft diet for the client. d. Administer a topical analgesic.

D

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.

D

52. 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 dehiscences and eviscerates. The nurse moistens an available sterile dressing and places 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 fo the drainage to send to the lab. d. Bring additional sterile dressing supplies to the room.

D Explanation: After placing a moistened sterile dressing over the eviscerated wound, the nurse should bring additional sterile dressing supplies to the room to be prepared for further wound care. Preparing the client to return to the operating room, auscultating the abdomen for bowel sound activity, and obtaining a sample of the drainage are important, but the priority is to stabilize the wound and prevent infection.

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. Encourage active range of motion to limit stiffness. d. Drink at least 8 cups (1920 mL) of water per day.

D Explanation: Drinking at least 8 cups (1920 mL) of water per day can help dilute the urine and reduce the risk of crystal formation, which contributes to gout attacks. Eating high-protein foods may actually exacerbate gout, as purine-rich foods can increase uric acid levels. Using an electric heating pad is not recommended due to the risk of burns. Encouraging active range of motion may be helpful but is not as crucial as maintaining proper hydration.

47. A client with multiple sclerosis has urinary retention related to sensorimotor details. Which action should the nurse include in the client's plan of care? a. Remind the client to practice pelvic floor (Kegel) exercises regularly. b. Provide a bedside commode for immediate use in the client's discomfort. c. Explain the need to limit intake of oral fluids to reduce client discomfort. d. Teach the client techniques for performing intermittent catheterization.

D Explanation: In a client with multiple sclerosis who is experiencing urinary retention, teaching the client techniques for performing intermittent catheterization can help manage their bladder issues. Pelvic floor exercises may not be as effective for sensorimotor deficits, and limiting fluid intake is not recommended for clients with urinary retention. Providing a bedside commode may be helpful for convenience but does not address the root issue of urinary retention.

13. 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.

D Explanation: Clients with pheochromocytoma can experience paroxysmal episodes of hypertension due to the release of catecholamines from the tumor. The onset of a severe headache and diaphoresis in a client with pheochromocytoma may indicate a hypertensive crisis, so the nurse should obtain the client's blood pressure next.

8. A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? a. Painful areas should be rubbed gently until the pain subsides. b. Return appointments will be needed for IV pain medications. c. Enrolling in a pain clinic can provide relief alternatives. d. Wearing gloves when handling cold items guards against painful spasms.

D Explanation: For clients with Raynaud's disease, cold temperatures can trigger painful episodes. Instructing the client to wear gloves when handling cold items can help protect against these episodes and manage pain.

17. A client presents to the emergency department reporting chest pain that is radiation to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? a. Fentanyl. b. Hydromorphone. c. Oxycodone. d. Morphine.

D Explanation: Morphine is commonly used to treat chest pain associated with myocardial infarction (heart attack) as it provides pain relief, reduces anxiety, and has a vasodilatory effect that can improve blood flow to the heart. The other medications listed are not typically the first choice for managing chest pain related to a heart attack.

25. A client with hyperparathyroidism reports a sudden monster 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 Explanation: Sudden onset of severe flank pain in a client with hyperparathyroidism may indicate the presence of kidney stones. The nurse should include straining all urine in the client's plan of care to collect any passed stones for analysis and to monitor the progress of stone passage.

31. 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.

D Explanation: The client's symptoms of urinary frequency, burning, and right lower back pain may indicate a urinary tract infection (UTI) with possible involvement of the kidneys. The nurse should first measure the client's temperature and pulse rate to assess for signs of systemic infection

9. 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 Explanation: Individuals with Crohn's disease often have specific trigger foods that exacerbate their symptoms. The nurse should describe the use of an elimination diet to help the client identify and avoid these trigger foods to better manage their condition.