Exit Hesi Study Material

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next?

"Are you planning to obey the voices?"

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask?

"Have you thought about taking your life?"

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide?

"His smaller size is probably due to the heart disease"

Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

"When I get out of bed quickly, I feel a little dizzy."

the nurse is caring for a client who is admitted to the ED...begins to experience a decreased LOC....vital signs changes indicate the client is manifesting Cushing's triad?

- BP of 180/80, bounding heart rate.....apneic episodes

The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment?

- RN completes the two admission assessments. 1 PN completes the blood glucose measurements, and 1 PN completes the post-operative visit

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? (Select all)

- complaint of increased pain and pressure - change in the quality of the peripheral pulses - loss of sensation to the left lower extremity

An adult woman who was recently diagnosed with type II DM. 5 foot 2 inches....in planning nutrition teaching for this client, what should the nurse recommend? (select all)

- decrease processed carb in diet - eliminate alcohol intake expect for special occasions - increase dietary fiber such as whole grains

A client with a history of schizophrenia is admitted with diabetic ketoacidosis DKA... should the nurse implement during the admission process for this client? (select all)

- obtain psychiatric and medical admission records - interview client about reason for admission to hospital - review the list of home meds and dosages

A male client with COPD smokes 2 packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

-"After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away."

During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse?

-*Cold weather may constrict your blood vessels raising your blood pressure

The nurse is preparing to give fentanyl 0.075 mg IM to a client who is scheduled for a colonoscopy. The medication is labeled 50 mcg/ml. How many ml Should the nurse administer?

-1.5

The healthcare provider prescribes ceftazidime 1 gram every 8 hours. The label on the 1 gram vial reads, "reconstitute with 100ml sterile water." This dilution provides a concentration of how many mg/ml?

-10

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day?

-40

Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses of 500 ml IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many ml/hr?

-5.6

The nurse is caring for a client who reports experiencing pain. The client reads the pain as 2 out of 10 on the numeric 1-10 pain scale. Which prescription should the nurse administer?

-Acetaminophen.

Which client is best to assign to the practical nurse (PN) who's assisting the registered nurse (RN) with the care of a group of clients?

-An adult who is one day postoperative for a laparoscopic cholecystectomy.

Which class of drugs is the only source of a cure for septic shock?

-Anti-infective.

An older adult client us having photocoagulation for macular degeneration. Which intervention should the nurse implement during the post-procedure care in the outpatient surgical unit?

-Apply bilateral eye patches while sleeping.

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this clients plan of care for today?

-Assist client in identifying goals for the day.

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?

-Auscultate bilateral breath sounds.

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first?

-Begin manual ventilation immediately.

Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis?

-Blood and urine cultures.

An older client returns to the clinic and received refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill can be substituted for many of the others. Which instruction should the nurse implement to address the clients concerns?

-Bring all medications, supplements, and herbs currently being taken to the next

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply)

-Brings a heavy can close to body before lifting. -Widens stance while working near the sink.

The mother of a 12 month old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instruction should the nurse provide?

-CPT should be performed more frequently, but at least an hour before meals.

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less than the input flow. Which action should the nurse implement first?

-Change the client's position.

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

-Check for a distended bladder.

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client?

-Chicken broth. -Apple juice.

The nurse includes assessment for fat embolism syndrome (FES) in the femur. Which findings should the nurse include that are often the earliest indications of fat embolism syndrome (FES)?

-Confusion, -restlessness

client complaints of nausea. Which action should the nurse implement first?

-Connect the NGT to low intermittent suction.

The practical nurse (PN) is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the leg straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement?

-Demonstrate to the PN how to position the client more effectively for the procedure.

The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit which initial symptoms?

-Diarrhea, abdominal pain, and weight loss.

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which finding should the nurse include as indicators to begin implementing the detoxification medication protocol?

-Dilated pupils, tachycardia, elevated blood pressure, elation.

The nurse is preparing to administer 1.6 ml of medication intramuscularly to a four-month-old infant. Which action should the nurse include?

-Divide the medication into two injections with volumes under 1 mL.

The husband of an older woman, diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take?

-Explain that memory loss and confusion are common with Vitamin B12 deficiency.

An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factor should the nurse explore further with the client? Select all that apply.

-Family health history. -History of hypertension.

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease client's plan of care? (Select all that apply.)

-Fluid volume excess. -Decreased cardiac output. -Altered peripheral tissue perfusion -Fatigue.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty in concentrating at work. Which coping strategy should the nurse include in the plan of care?

-Focus on small achievable tasks, not taxing problems.

When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (Select all that apply.)

-Fruits without sauce -Fresh or frozen vegetables without sauce.

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

-Gently pat the skin dry after rinsing with water.

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)

-Headache and tremors -Irregular heart rate -Pallor and diaphoresis

In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, hematocrit of 28%, heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow up?

-Hematocrit of 28% (0.28 volume fraction).

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

-Hemoglobin.

A client in menopause reports being lactose intolerant. She exercises three times a week, drinks wine one to three times a month, and drinks a cup of coffee daily. Which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis?

-Increase calcium intake.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

-Ineffective coping related to denial,

A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement?

-Insert an indwelling urinary catheter.

A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client?

-Is it possible that you will be in direct contact with the children at the school

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

-Monitor abdominal girth. -Report serum albumin and globulin levels. -Note signs of swelling and edema.

A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include?

-Monitor cardiac rhythm via telemetry. -Report changes in pre-existing murmurs. -Schedule rest periods between activities. -Maintain record of fluid intake and output.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior?

-Note date and time of the behavior. 1 -Discuss the issue privately with the UAP. 2 -Plan for scheduled break times. 3 -Evaluate the UAP for signs of improvement. 4

A client with cellulitis of the right great toe has been taking an antibiotic for 7 days. Which assessment

-Observe for signs of inflammation on and surrounding the toe.

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)

-Obtain blood glucose level. -Verify the insulin prescription. -Draw insulin into insulin syringe. -Cleanse the selected site.

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids." What nursing intervention is most useful in assisting the resident to meet this goal?

-Offer a glass of fluid every hour while awake.

Which assessment finding is most important when planning to provide a complete bed bath to a bed fast client?

-Orthopnea

Which clients' vital signs indicating increased intracranial pressure (ICP) should the nurse report to the health care provider?

-P 55, BP 160/70 mmHg: P 50, BP 194/70 mimHg; irregular respirations.

A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The client's arterial blood gases (ABGs) indicate respiratory acidosis. An increase in which laboratory test results supports this finding?

-Pac02.

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

-Persistent coughing while drinking.

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are: temperature 99.6 degrees F, Heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement?

-Place the client in a forward-leaning position.

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply)

-Plain, air-popped popcorn. -Natural whole almonds.

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value?

-Potassium.

A client with end-stage renal disease (ESRD) is refusing all treatment and requests that no life-saving me action should the nurse take?

-Provide the healthcare provider with a copy of the client's bill of rights.

A low-risk primigravida at 28-weeks gestation arrives for her regular antenatal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

-Pulse increase of 10 beats/minute.

Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complaints of a headache. Which intervention should the nurse implement first?

-Relieve any kinks or obstruction in the client's Foley tubing.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:

-Remove sequential compression devices.

A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over the chest and back. Which intervention should the nurse implement?

-Replace the transfusion with normal saline.

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).

-Report mental status change to the healthcare provider -Assess the client's breath sounds and oxygen saturation -Review the client's most recent serum electrolyte values

A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone?

-Respiratory rate of 12 breaths/minute.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food select

-Roasted turkey, canned vegetables.

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?

-Send a stool sample to the lab for a guaiac test.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the HCP?

-Serum lithium level of 1.6 mEq/L or mmol/L (SI).

A client with diabetes insipidus (DI) has an average urinary output of 500 mL of dilute urine every hour for the last four hours. Which laboratory test is most important for the nurse to monitor?

-Serum sodium.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

-Supervise a newly hired graduate nurse during an admission assessment.

A client who is pregnant seems confused and presents with the onset of headache, polyurea, fatigue, and blurry vision. Which action should the nurse implement?

-Take serial blood pressure readings.

A school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow up. The teacher should be instructed to report which situations to the school nurse? Select all that apply.

-Thirst and frequent requests for bathroom breaks. -Shaking that changes the child's handwriting legibility. -Sunburn with blisters on the face, arms, and hands.

A mother brings her four-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter supposed to fix her child hernia. Which explanation should the nurse provide?

-This hernia is a normal variation that resolves without treatment.

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

-Tracheal deviation toward the left lung.

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

-You seem quite frightened right now."

Which conditions are most likely to respond to treatment with antihistamines? SATA.

-allergic rhinitis -contact dermatitis

A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits?

-if dose is vomited within 1 hour of administration, repeat that oral dose.

the nurse us preparing a dose of 60 mcg of teriparatide. the medication is labeled 750 mcg/2.4 mL. how many ml should the nurse administer?

0.2

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.

0.33

A school aged child who weighs 42 pounds receives a post-tonsillectomy prescription..... IM to prevent post-op nausea. the med is available in 25 mg/ml.....should the nurse administer?

0.4ml

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order priority, with the highest priority first, and least priority last or at the bottom.)

1. Stop the infusion 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate an adverse event report.

An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

1000, 1600, 2200, 0400.

following a house fire, an adult male is admitted to the ED with partial and full thickness burns... burned on the dorsal surfaces of both arms and hands and his anterior legs. using the rule of nines to assess the....surface area should the nurse document

27%

a client is receiving a nitro infucion at 20 mcg/min. the pharmacy.....nitro 75 mg in 250 ml of D5W. the nurse should program the infusion pump to how many ml/hour?

4

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?

A bucket of water was spilled in the hallway.

The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching?

A diet of healthy fruits, such as bananas and kiwis, are best for the child.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply).

A full pitcher of water is on the bedside table The client is lying in a supine position in bed

The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin?

Absence of seizure activity for the duration of treatment.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first?

Activate the lockdown procedure.

an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the - 10 cm H20 mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

Add sterile water to the suction control chamber.

A client is admitted with a severe asthma attack. For the last 3 hours the client has experienced increasing shor mmol/). Which intervention should the nurse implement?

Administer PRN dose of albuterol.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

Administer a nebulizer Treatment

An older woman with a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily an value or 5.0. Upon admission, which prescription should the nurse expect to implement?

Administer vitamin K injection.

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action?

Advise the UP to stop providing care so the nurse can assess the client's condition

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

An 18-year-old client with antisocial behavior who is being yelled at by other clients

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)

An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Anxiety

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement?

Apply an ice pack to the perinium for the first 24 hours.

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first?

Assess the delivery mechanism of the oxygen tank, tubing, and cannula

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first

Assess the surroundings for noise and distractions.

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement?

Assist him in identifying popular fast foods that are within his meal plan for diabetes.

A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the should the charge nurse take?

Assist the nurse in changing the intravenous tubbing attached to the blood.

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, sooner" Which intervention is best for the nurse to implement?

Assure the parents that a terminal diagnosis was inevitable.

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client?

Avoid urinary catheterization.

The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available?

Bacterial meningitis

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first?

Begin supplemental oxygen.

The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (Select all that apply.)

Blurred vision Headache. Swollen hands.

Which information is more important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

Body mass index

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Body mass index BMI of 17.

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course.

A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses should the nurse implement?

Check neurovascular status of the distal digits.

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective?

Clients who incurred disease complications promptly received rehabilitation.

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

Cloudy opacity of the crystalline lens.

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take?

Communicate the colleague's actions to the unit charge nurse.

An adult client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Compulsion

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important?

Confirm that the client has been NPO since midnight.

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?

Confusion and tremors

A client is admitted with the diagnosis of Wernicke's Syndrome. What assessment finding should the nurse use in planning the clients care?

Confusion.

After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next?

Continue with the blood pressure assessment.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Current diagnosis of hepatitis B.

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

Defibrillate with one shock.

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?

Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

Determine the client's level of mobility and need for assistance.

A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure.

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide

Dialysis would need to be resumed if chronic rejection becomes a reality

The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which interventions should the nurse implement before the client leaves the medical unit?

Document that the client has remained NPO.

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms?

Does the calf pain occur when walking short distances?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Ear pain and fever.

Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Eat small meal throughout the day to avoid a full stomach.

A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?

Encourage popsicles and fluids of choice

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care?

Ensure adequate IV and oral fluid intake.

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement?

Ensure that the client is assigned to a room close to the nurses' station.

A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm

Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

Eosinophils

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?

Evaluate closet proximal pulse

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

Evaluate swallow

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Evaluate the newly hired UAP's level of competency by observing him deliver care.

The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Examine the genitalia as the last part of the total exam.

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure?

Experience facial swelling after eating crab.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Explain that counseling will be provided to give her information about her cancer risk

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

Explain that the client will start to lose consciousness and his body system will slow

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. Which response should the nurse provide?

Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother

Explore the client's decision to refuse treatment and offer support

A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Frequency that the child uses a rescue inhaler during the week.

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger?

Full bladder

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?

Give a dose of regular insulin per sliding scale

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?

Have the client vocalize the instructions provided.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?

Hydrocortisone

The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed?

Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmg.

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication?

Hypertension.

A female client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurses on duty now." Which response is best for the nurse to provide to this clients dichotomous tendency?

I am happy that you are getting better and will be able to go home.

After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone?

If sequential doses are missed, notify the healthcare provider.

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmH. In addition to reporting the finding to the surgeon. Which action should the nurse implement first?

Increase the infusion rate of Lactated Ringer's solution.

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

Inform the client that gradual tapering must be used to discontinue the medication.

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?

Initiate intravenous fluids as prescribed.

A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the best initial nursing action?

Initiate seizure precautions.

A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

Initiate seizure precautions.

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?

Initiate the dosage lockout mechanism on the PCA pump

An older client arrives to the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute, respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which intervention is most important for the nurse to implement?

Keep head of bed raised 45 degrees.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Keep the nails trimmed short.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

Leave the room and close the door quietly

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

Limit oral water intake.

A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client's plan of care?

Maintain the client on NPO status.

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

Measure the client's body weight each morning.

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia.

A client with metabolic syndrome plans to begin an exercise program. What instruction is most important for the nurse to provide this client?

Monitor blood pressure and heart rate as exercise activity is increased.

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care?

Monitor for secondary infections.

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolved immediately.

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

Neurologically stable without indications of an increased IC

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take?

Notify the healthcare provider of the client's wishes.

After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?

Notify the healthcare provider of the client's lack of understanding.

A client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

Observe for bleeding side effects related to heparin therapy.

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Observe for unilateral swelling

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Obtain a capillary glucose level

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Place the implant in a lead container using long-handled forceps

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Place the side rails in an up position

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?

Play a board game with the client and begin taking about stressor

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take?

Postpone the feeding until the infant's vital signs and stable

The nurse is providing teaching to a client who has been recently diagnosed with gestational diabetes mellitus. Which complication poses the greatest risk to the fetus if euglycemia is not maintained?

Preterm birth.

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child anxiety, what action is best for the nurse to implement?

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting?

Provide information on ways to increase activity for the family.

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?

Recent compliance with prescribed medications.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?

Redress the abdominal incision.

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first?

Reduce environmental stimuli.

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Report any painful urination, blood in urine, or fever.

The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take?

Request a consultation to confirm dysphagia.

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

Request a consultation with the hospital social worker.

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?

Request thick nectar liquids for the client.

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

Review the client's current list of medications.

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Risk for infection.

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse?

Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)

which laboratory results should the nurse closely monitor in a client who has end stage renal disease?

Serum potassium, calcium, phosphorous.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?

Sitting upright.

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement?

Stand on the client's right side as he walks.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Supervised a newly hired graduate nurse during an admission assessment

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider?

The client denies being thirsty.

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

The client's skin on the lower legs will be intact at the next clinical visit.

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?

The xenograft is taken from nonhuman sources.

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement

Use a water soluble lubricant on affected oral and nasal mucosa

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women

the nurse is working on an infectious disease unit. which client should be assigned to a room with negative airflow.. and requiring staff to observe airborne, as well as standard precautions?

a client with a positive Mantoux and sputum cultures results positive for AFB

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply:

a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate.

the nurse is assessing a client's breath sounds. which medication from the clients.....most positive effect on this respiratory finding? sound = wheezing

albuterol

the nurse is preparing a hepatitis teaching program. which individual has the greatest......prophylactic hepatitis B immunizations?

an office worker who requires hemodialysis for chronic kidney disease

a male client suffering from depression has been taking an antidepressant medication.... nurse that he is smiling more and feeling better. which response is best?

antidepressants usually begin to improve your mood after 2-3 days

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

anxiety

The nurse assumes care of a post-op adult client with type II DM and learns that the client has a current blood glucose level of 750 mg/dL. Upon assessing the client, what is the priority?

assess for signs of fluid volume deficit

a male client who fell off a roof has right and left femur fractures and crushing injuries to both ankles. he is supine with....awaiting surgery within the next 4 hours. when asked to evaluate his pain on a scale of 1- 10, he screams that it is 20.... his vital signs are HR 130bpm, RR 32bpm, BP 180/90. What should the nurse implement?

assess the extremities for signs of compartment syndrome every 2 hours

a client with leukemia who is receiving a myleosuppressive chemo has a platelet count of 25,000. what should the nurse include in this client's plan of care?

assess urine and stool for occult blood

the nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. which findings...

diminished breath sounds over the trocar insertion site

the parents of a 6 year old child recently diagnosed with Duchenne muscular dystropy.....child wants to continue attending swimming classes. how should the nurse respond?

encourage the parents to allow the child to continue with supervision

the nurse observes a PN pouring warm water over.... frequent urinary incontinence while the client is positioned on a bedpan...

evaluate the effectiveness of this measure to stimulation

a 41 week gestation primigravida woman is admitted to labor and delivery..... should the nurse report to the HCP before initiating the....

fetal heart tones located in upper right quadrant

The PN reports that a client who has a fingerstick glucose....and diaphoretic. what action should the charge nurse take?

give the client a glass of orange juice

which woman should the nurse consider at the highest risk for cervical cancer?

history of unprotected sex with multiple partners

the nurse is caring for a client admitted for evaluation of a descending aortic....documenting, the nurse hears the client screaming. the client tells the nurse that something inside is ripping and tearing. the client also reports dizziness...cause?

impending rupture of the aneurysm

a client is receiving IV heparin and oral warfarin after a PE... client's aPTT value is two times the normal... PT level is the same as the control and the INR.... prescription should the nurse implement?

increase the warfarin dose

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?

initiate IV fluids as prescribed

the nurse is assisting the HCP with a wound debridement.....confused. the client is draped and a sterile field is created. which nursing action should implement for client safety?

instruct the client to keep hands under the sterile field

which intervention is most important for the nurse to include in the plan of care for a mechanically ventilated and is receiving continuous enteral feedings?

maintain the head of the bed elevated at 45 degrees

the nurse notices that a male client is particularly delusional one afternoon.... appears to be losing control of himself. which intervention is best for the nurse to implement?

move the client to a quiet place on the unit

while changing a client's post-op dressing, the nurse observes purulent drainage at the site. before reporting.....which of the clients lab values?

neutrophil count

the nurse prepares an IV solution and tubing for a client with a saline lock, as seen in the video.... the option that applies.

open the roller clamp on the tubing

A female child is brought to the ED after awakening with....arrival to the hospital, her respirations are labored, and she is drooling. what should the nurse implement?

prepare for emergency tracheotomy

the nurse is providing care for a child who is brough to the ED....to the leg from a barbed wire fence. the child has not received any tetanus.....early signs of muscular rigidity with spasms and jaw clenching or trismus. what is the nurse's highest priority for this child?

prepare for intubation with mechanical ventilation

The nurse should be most concerned about risk for injury/falls after administering what med

promethazine

to prevent med errors by an older client who is sometimes confused, which intervention by the home health nurse should be implemented?

provide education both verbally and in written format

the laboratory findings for a client with chronic kidney disease include elevated.... and serum creatinine levels. the client reports feeling fatigued and is unable to conce.... assessments. based on these findings, which action should the nurse implement?

provide high protein snack

after removing a clients dressing that is saturated with sanguineous drainage, where should the nurse put the dressing?

red biohazard bag

the nurse observes a UAP applying an alcohol-based hand rub while leaving a client's room, what action should the nurse take?

remind the UAP to continue rubbing the hands together until they are dry

A client with atrial Fibrillation receives a new prescription for dabigatran etexilate... for the nurse to emphasize when teaching the client about this med?

report unusual bruising or bleeding

while changing a client's post-op dressing, the nurse observes......amount of yellow and green drainage and a foul odor. given there is....... MRSA, which is the most important action?

request a wound culture and sensitivity

a multiparous client who delivered her infant 3 hours ago asks the nurse....because it helped reduce perineal pain after her last delivery. what action should the nurse take?

review the use of sitz bath equipment with the client

The nurse is assigned to care for a client diagnosed with psoriasis....client's psychosocial need for acceptance?

shaking the client's hand during an introduction

an older client is admitted with fluid volume deficit and dehydration. which assessment finding is the best indicator of hydration?

skin tenting occurs when the client's forearm is pinched

which snack selection indicates to the nurse that a school age boy with... dietary restrictions?

sugar cookies

an older male was recently admitted to the rehab unit with unilateral neglect syndrome as the result of... include in the plan of care?

teach the client to turn his head from side to side for visual scanning

a male client on the psychiatric unit is making sexual advances towards a female nurse. which action should the nurse take?

tell the client in a matter-of-fact manner to stop the sexual advances

the nurse is teaching a client newly diagnosed with lupus....accurate for the nurse to provide?

the disease is characterized by alternating periods of flare-ups and....

the nurse is caring for 4 clients. Client A who has emphysema and whose O2 sat is 94%; Client B with....newly diagnosed with a potassium level of 3.8 and Client D scheduled for an appendectomy who......what intervention should the nurse implement?

verify that client B has two units of packed cells available