Exit Hesi 4

A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Complete pre-infusion checklist

A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

0.4 Rationale: Convert pounds to kg 42lbs = 19.09 kgNext calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545Then use the desired dose/ dose on hand x volume on hand (9.545/25x1ml =0.3818=0.4 ml)Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml25x = 9.545X= 0.3818 = 0.4)

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9 Rationale: D/H x Q 38/20x1=1.9 mL

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour Rationale:20000/500=40x25=1000

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? A) Altered consciousness within the first 24 hours after injury. B)Cushing reflex and cerebral edema after 24 hours C)Fever, nuchal rigidity and opisthotonos within hours D)Headache and pupillary changes 48 hours after a head injury

A

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? A)Blood pressure 170/98 B)Joint and muscle aches C)Urine output 300 ml/hr D_Dark, rust-colored urine

A

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? A)Serum potassium B)Urine ketones C)Urine albumin D)Serum protein

A

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? A) infectious process B)metastatic process C)autoimmune disorder D)inflammatory disorder

A

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? A) Examine the genitalia as the last part of the total exam. B)Use soothing statements to facilitate cooperation C)Allow the child to keep underpants on to examine genitalia D)Work slowly and methodically so not to stress the child

A

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? A) Cries frequently during the interview B)Stares straight ahead without blinking C)Face does not convey any emotion D)Uses a monotone when speaking

A

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide? A) Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. B)Encourage the client to seek genetic counseling to determine his risk for mental illness. C)Informed the client that his mother schizophrenic has affected his psychological development. D)Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

A

A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

7 Rationale: Convert the client's weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client? A) Blood pressure 149/101 B)Irregular pulse rate of 80 C)Oral temperature is 98.9 F (37.1 C) D)Pain rated 7 on scale 1-10

A

A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? A)Wash hands before cleaning exit site B)Keep the head of the bed flat at night C)Feel for a thrill and a distal pulse nightly D)Do not get up if fluid is left in the abdomen

A

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? A) Overlook the client's behavior. B)Distract client to interfere with the ritual. C)Ask why the client checks the pulse. D)Hold client's hand to stop the behavior.

A

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? A) Auscultate all quadrant of the abdomen. B)Perform a digital rectal exam C)Palpate the liver and spleen D)Obtain a hemoccult of the client's stool

A

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? A)0.9% sodium chloride solution (normal saline) B)0.45% sodium chloride solution (half normal saline) C)10% Dextrose in 0.45% sodium chloride D)5% dextrose in 0.2% sodium chloride

A

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? A) creatinine clearance 25 mL/ minute B)calcium 9 mg/dl C)hemoglobin 12 grams/dl D)partial thromboplastin time (PTT) 30 seconds

A

A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? A)Stroke B)Renal failure C)Left ventricular hypertrophy D)Pulmonary hypertension

A

The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? A) Increase the oxygen flow via nasal cannula if dyspnea is present. B)Place in a Trendelenburg position to increase cerebral blood flow C)Monitor capillary glucose measurements hourly during transfusion. D)Encourage increased intake of oral fluid to improve skin turgor.

A

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? A) Check the TPN solution for cloudiness B)Attach the IV tubing to the central line C)Set the infusion pump at the prescribed rate D)Prime the IV tubing with TPN solution

A

When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next? A) Notify the healthcare provider B)Continue care since this is a normal finding C)Document the finding in the record D)Perform range of motion to the joint

A

Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)? A) Body mass index B)Level of consciousness C)Self-description of pain D)Breath sounds

A

While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? A)Ask the client when a family member last visited her. B)Determine the client's orientation to time and space C)Review the client's record regarding social interactions D)Reassure the client of her family's love for her

A

A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? A) Use a secondary port of the Normal Saline solution to administer the antibiotic. B)Add the antibiotic to the TPN solution, and continue the normal saline solution. C)Stop the TPN infusion for the time needed to administer the prescribed antibiotic. D)Add the antibiotic to the Normal Saline solution and continue both infusions.

A Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? A) Determine the client's responsiveness and respirations B)Bring the crash cart to the room to defibrillate the client. C)Immediately initiate chest compressions. D)Notify the emergency response team

A Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.

An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) A)Move personal items within client's reach B)Lower bed to the lower possible position C)Give directions to call for assistance D)Assist client to the bathroom in 2 hours. E)Encourage the use of the wheelchair F)Raise all bed rails when the client is resting

A B C D Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement? A)Determine current sexual practice B)Prepare a female client for an ultrasound C)Request an sperm sample for ovulation D)Evaluate hormone levels on both client

A Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet? A) Roasted turkey canned vegetables B)Baked potatoes with skin raw carrots C)Pancakes whole-grain cereal's D)Roast pork fresh strawberries

A Rationale: Foods allowed on a low-fiber diet includes roasted or baked turkey and canned vegetables the foods in the other options are not low in fiber

A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? A) Ask the client about his expected goals for the hospitalization B)Explain the palliative care measures can be provided at home C)Notify do radiation department to withhold the treatment for now D)Determine if the client wishes to cancel further radiation treatment

A Rationale: Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client's goals for symptom control while receiving treatment in the hospital. Although home care is available the client may not be legible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and would be appropriate unless the radiation conflicts with the client goals.

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A)Monitor for an elevated temperature B)Measure the abdominal girth daily C)Report the onset of sclera jaundice D)Keep a record of daily urinary output

A Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? a)Intravenous administration of thyroid hormones B(Oral administration of hypnotic agents C)Intravenous bolus of hydrocortisone D)Subcutaneous administration of vitamin k

A Rationale: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A)Initiate intravenous fluid as prescribed B)Notify the HCP of the need to reposition the catheter C)Remove the catheter and apply direct pressure for 5 minute D)Secure the catheter using aseptic technique

A Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? A)A 10-year-old who is receiving chemotherapy and the infusion pump is beeping B)A young adult with Crohn's disease who reports having diarrheal stools C)An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late D)A teenager who reports continued pain 30 minutes after receiving an oral analgesicA

A Rationale: an infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? A)Condition of hair, nails, and skin B)A 24-hour diet history C)History of a recent weight loss D)Status of current petite

A Rationale: the assessment of hair, nails, and skin is most effective of long-term nutritional status, which is important in the healing process.

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? A) The client has asymmetrical chest wall expansion B)The clients complain of pain at the insertion site C)The client chest's x-ray indicates decreased pleural effusion D)The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

A Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? A)headache, photophobia, and nuchal rigidity B)high fever, skin rash, and a productive cough C)nausea, vomiting, and poor skin turgor D)malaise, fever, and stiff, swollen joints

A Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? A) Obtain a prescription for an anticholinergic medication B)Determine how many hours declined slept last night C)Administer the PRN prescription for severe anxiety D)Watch the thyroid cartilage move while the client swallows

A Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented.

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply

A slice of whole grain toast A bowl of cream of wheat

The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply A) Avoid prolonged standing or sitting B)Use recliner for long period of sitting C)continue wearing elastic stocking D)Maintain the bed flat while sleeping E)Cross legs at knee but not at ankle

ABC

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? A)Expiratory stridor and nasal flaring B)Mucous membranes cherry red color C)Carbonaceous particles in sputum D)Pulse oximetry reading of 80 percent

B

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? A)Examine the victim's body surfaces for arterial bleeding B)Stabilize the victim's neck and roll over to evaluate his status C)Return to the car to call emergency response 911 for help D)Open the airway and initiate resuscitative measures

B

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? A) Varicella Virus Vaccine Live B)Hemophilic Influenza Type B (HiB) vaccine C)Pneumococcal vaccine D)Palivizumab vaccine for RSV

B

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? A)Opening the package B)Picking up the second glove C)Picking up the first glove D)Positioning of the table

B

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating A)A paced rhythm with 100% capture after pacemaker replacement B)Normal sinus rhythm and complaining of chest pain C)Atrial fibrillation with congestive heart failure and complaining of fatigue D)Sinus tachycardia 3 days after a myocardial infarction

B

The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber? A)Lower the IV bag to a flat surface B)Compress the drip chamber C)Open the roller clamp D)Squeeze the bag of IV solution

B

Which intervention should the nurse include in the plan of care for a client with leukocytosis? A) Avoid intramuscular injections B)Monitor temperature regularly C)Assess skin for petechiae or bruising D)Implement protective isolation measures

B

A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? A) Does she knows the person who raped her? B)Has she taken a bath since the raped occurred? C)Is the place where she lived a safe place? D)Did she report the rape to the police Department?

B RATIONALE: The priority action is collected the forensic evidence, so asking if the has taken a bath since the rape occurred is the most important information to obtain. Other options are used by law enforcement to determine the perpetrator and are not vital in providing client care at this time.

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? A) White blood count of 19,000 mm3 B)Oral temperature of 100.6 F C)Fundus deviated to the right side D)Breasts are firm when palpated

B Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A) Pain scale rating at 9 on a 0-10 scale B)Last menstrual period was 7 weeks ago C)Reports white curdy vaginal discharge D)History of irritable bowel syndrome IBS

B Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options are not the most important concerns.

In assessing a pressure ulcer on a client's hip, which action should the nurse include? A)Determine the degree of elasticity surrounding the lesion B)Photograph the lesion with a ruler placed next to the lesion C)Stage the depth of the ulcer using the Braden numeric scale D)Use a gloved finger to palpate for tunneling around the lesion

B Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? A) Understand pain management scale B)Maintain effective breathing patterns C)Absence of ventilator associated pneumonia D)No injuries refer to soft restrains occur

B Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C)

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care? A) Encourage Progressive active range of motion B)Teach need for dietary and supplementary vitamin D3 C)Explain the need for skin exposure to sunlight without sunscreen D)Instruct the client to use of muscle strengthening exercises

B Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normal-appearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.

The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? A)Body mass index of (BMI) of 31 B)20 pack-year history of cigarette smoking C)Birth control pill usage until age 45 D)Diabetes mellitus in family history

B Rationale: Cigarette smoking (2 packs/day x 310 years = 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens, and are also protective against development of osteoporosis. D is not related to the development of osteoporosis.

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement? A) Tell the client to drive over the bridge until fear is manageable B)Teach client to listen to music or audio books while driving C)Encourage client to have spouse drive in stressful places. D)Recommend that the client avoid driving over the bridge.

B Rationale: Desensitization is component in the treatment plan for clients with panic attacks which is best approached with anxiety-reducing strategies, such as listening to audio book (B) during situation that precipitate symptoms (A) is a flooding technique that requires professional guidance.

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? A) High salt can damage the lining of the blood vessels B)Too much salt can cause the kidneys to retain fluid C)Excessive salt can cause blood vessels to constrict D)Salt can cause information inside the blood vessels

B Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? A)Rebound abdominal tenderness B)nausea and projectile vomit C)rib pain with deep inspiration D)diminished bilateral breath sounds

B Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A) A listing of African-American women so live in the community B)Participation of community leaders in planning the program C)Morbidity data for breast cancer in women of all races D)Technical assistance to produce a video on breast self-examination.

B Rationale: When developing a culturally-competent health promotion project, the participation of stakeholders and community leaders is most important. A and B might be useful background information, but t=first the program should be developed. D may be useful fulfilling the plan developed by the health care team and the community leaders if funding for this assistance is included in the budget.

A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? A) Implements decisions about future hospices services within the next 3 months. B)Marinating pain level below 4 when implementing outpatient pain clinic strategies. C)Request home health care if independence become compromised for 5 days. D)Arranges for short term counseling stressors impact work schedule for 2 weeks.

B Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also the client has a terminal disease and is being discharge home, hospice and health care are not indicating at this time. Short term counseling is not an option.

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? A) Urinary incontinence B)Left forearm hematoma C)Disorientation to surroundings D)Dislodge intravenous site

B Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent concern.

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications? A) Nitroglycerin (nitro-dur), an antianginal, to be given transdermally B)Methylprednisolone (solu-medrol), a corticosteroid, to be given IV C)Furosemide (lasix), a loop diuretic, to be given intravenously D)Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous E)Clopidogrel (Plavix), an antiplatelet agent, given orally

BDE Clopidogrel (Plavix), an antiplatelet agent, given orally.Methylprednisolone (solu-medrol), a corticosteroid, to be given IV.Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous.

During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply) A)Situation B) Background C) Assessment D) Recommendation

Background. Assessment. Recommendation. Rationale: BCD are correct. The current situation is reported regarding the client's nausea and pain (A). Based on SBAR communication, critical information about the client's clinical history (B), and assessment (C) such as pain scale or vital signs related to client's response to medication, are not included, nor are any recommendations for further follow-up (D). (E) Is not a component of SBAR communication

A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? A) Encourage the family to plan daily activities to keep the client busy B)Have friends and family visit the client at a welcome home party C)Discuss the importance of continuing the usual at-home activities D)Instruct family to monitor the client's choice of television programs

C

A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication? A) Administer the entire pre-filled syringe deep in the dorsogluteal site. B)Use a separate syringe to remove 15mg from the pre-filled syringe and give in the back of the arm. C)Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site. D)Call the healthcare provider to request a prescription change to match the dispensed 30mg dose.

C

A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? A) Review record of recent analgesia B)Provide frequent pulmonary toilet C)Prepare the client for intubation D)Obtain STAT arterial blood gases

C

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? A) Encourage the nurse to purchase reading glasses in the hospital gift shop B)Request another nurse to assist the staff nurse with her documentation C)Ask the nurse to return home and get her prescription eyeglasses for work. D)Tell the staff nurse to take a day off and change her weekly work schedule

C

The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents? A) A set order in fetal development is expected B)Growth normally occurs within one organ at a time C)Development progress from head to rump D)Organ formation is directed by brain development

C

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? A) Fruity breath odor B)Polyphagia C)Diaphoresis D)Polydipsia

C

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? A)Include the family in client's care B)Request the chaplain's presence C)Ask the family to identify a specific spokesperson D)Page the healthcare provider to speak with family.

C

While caring for a client's postoperative dressing, 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) Serum albumin B)Creatinine level C)Culture for sensitive organisms. D)Serum blood glucose (BG) level

C RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client's laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.

The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? A) Hold the client at arm's length while transferring to better distribute the body weight. B)Apply the gait belt around the client's waits once standing position has been assumed. C)Place a client's locked wheelchair on the client's strong side next to the bed. D)Pull the client into position by reaching from the opposite side of the bed

C RATIONALE: Placing the wheelchair on the client's strong side offers the greatest stability for the transfer. Holding the client arm's length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client, but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position.

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? A) Check the client's temperature, blood sugar, and urine output. B)Transport the client for laboratory client for laboratory test and electrocardiogram (EKG) C)Delegate care of the crying client to an unlicensed assistant D)Send the client to the shelter's nutrient center to obtain water and food.

C Rationale: According to the simple triage and Rapid Treatment (START) protocol of triage, the nurse should determine which client fit the objective of providing the greatest good for the greatest number of people who are most likely to survive. Delegating the care of the crying person to an unlicensed assistant allow the nurse to care for the injured who require intervention based on their ability to breath, maintain circulation and follow simple commands. A and B are not indicated at this time. Although food and water may be indicative, the woman's distress should not be dismissed by sending her to the shelter alone.

A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? A) Identifies his ethnocentric values and behaviors B)States an understanding of the medical treatment C)Participated actively in all treatments regimens D)Expresses a desire for cultural assimilation

C Rationale: C indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural clash between the two forms of treatment. The client has already identify he's cultural values (A). (B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural values with the prescribed medical treatment (D).

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? A)Decreased white blood cell count B)Pruritus and muscle aches C)Elevated liver function tests D)Vomiting and diarrhea

C Rationale: Elevated liver function enzymes are a serious side effect of antivirals and should be reported. A decrease white blood count is a consistent finding with shingle B and (C and D) are side effects that affect that are of less priority than A.

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? A) Low-grade fever, headache, and malaise for the past 72 hours B)Unable to bear weight on the left foot, with the swelling and bruising C)Chest discomfort one hour after consuming a large, spicy meal D)One-inch bleeding laceration on the chain of the crying five-year-old

C Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A)Evaluate the client's ability to use an incentive spirometer B)Monitor the amount of drainage from the client's incision C)Observe both lower extremities for redness and swelling D)Palpate all peripheral pulse points for volume and strength

C Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis.

When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? A) Wash hands frequently B)Avoid drinking lake water C)Wear long sleeves and pants D)Do not share personal products

C Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? A)Review the heart rhythm on cardiac monitors B)Check urinary catheter for obstruction C)Auscultated bilateral breath sounds D)Give PRN dose of lorazepam (Ativan)

C Rationale: Restlessness often results from decreased oxygenation so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Contact the regional organ procurement agency

A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A) Check the visual difficulties B)Note most recent hemoglobin level C)Assessed for he and Hand joint pain D)Observe rhythm on telemetry monitor

D Rationale: If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels.

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? A)Early treatment is very effective B)I will clean my hot tub better C)These warts are caused by a fungus D)I need to have regular pap smears

D

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? A)Tell the UAP to offer more choices during the personal care to prevent anxiety B)Meet with the UAP later to role model more assertive communication techniques C)Assume care of the client to ensure that effective communication is maintained. D)Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

D Affirm that the UAP is using and effective strategy to reduce the client's anxiety.Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase... an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide? A) Vanilla-flavored yogurt B)Low fat chocolate milk. C)Calcium fortified juice D)Cinnamon applesauce

D RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snack should be avoided by a client who is taking ciprofloxacin.

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? A) Lip smacking and frequent eye blinking B)Shuffling gait and stooped posture C)Rocks back and forth in the chair D)Muscle spasms of the back and neck

D Rationale: An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by antipsychotic medication medications used to manage schizophrenia (D) has the highest priority to insure client safety is (A)

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and thready. What action should the nurse take? A) Document that an accurate oxygen saturation reading cannot be obtained B)Elevate to client's hands for five minutes prior to obtaining a reading from the finger C)Increase the oxygen based on the clients breathing patterns and lung sounds D)Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

D Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? A)Transfer a client to another unit B)Monitor the central telemetry C)Perform the admission D)Assist cardiac nurses with their assignments

D Rationale: When receiving staff from another specialty unit, the charge nurse should allow the nurse to assist where possible (D) without taking a client assignment so that the nurse is not asked to perform unfamiliar skills (A, B, C) are likely to involve skills the nurse is not accustomed to performing.

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Encourage use of analgesics before position change

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?

Hypocapnea reduces ICP

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Observe the amount of urine in the client's urinary drainage bag

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

Observe the wound for dehiscence

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

Obtain a prescription for DNR

A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important?

Obtain a prescription to increase the IV rate

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Place a washcloth in the sink while cleaning the dentures

A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

Risk for self-directed violence related to impulsive actions

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

The body cells develop resistance to the action of insulin.

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

The child should avoid eating homemade cookies and cupcakes during parties

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

The family reports a great reduction in client's maniac behavior

The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug? A) It blocks the effects of histamine, causing decreased secretion of acid B)Ranitidine will neutralize gastric acid and decrease gastric pH C)This drug provides a protective coating over the gastric mucosa D)It effectively blocks 97% of the gastric acid secreted in the stomach

a

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

image