Exit hesi

The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only)

15

Which nurse's behavior is a breach of client A. confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations? A. A daily report sheet with the information of the team's clients is taken home. B. Privileged health information (PH) is mailed through the US postal service C. A client is called by both the first and last name in a public waiting room. D. The ambulance health care provider is given information about the client's history

A daily report sheet with the information of the teams client is taken home

A client is admitted for observation after experiencing a transient ischemic attack(TIA).The nurse and tippy anticipates implementing care for which client problem?

Altered breathing patterns

The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take? A. Ask the client why the bath was refused B. Ask family members to encourage the client to bathe C. Explain the importance of good hygiene to the client D. Reschedule the bath for the following day

Ask the client why the bath was refused

A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake. The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take? A. Defer the thyroid exam and observe the client for signs of myxedema. B. Document that thyroid gland size is normal with no visible goiter. C. Ask the client to swallow while palpating along the sides of the trachea. D. Palpate deeply and firmly over the location of the thyroid gland.

C. Ask the client to swallow while palpating along the sides of the trachea.

A client is admitted with a fever of undermine origin. During rounds to nurse finds the client diaphoretic and linens are damp. What should the nurse do first?

Check the clients vital signs and pain scale

The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend?

Cotton

while changing the dressing of client who is immobile. the PN observes a red and swollen wound with moderate amount of yellow and green drainage and foul odor. before reporting this finding to the HCP the PN should evaluate which client lab value?

Culture for sensitive organism

The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following affecting the right hemisphere. Which action should the PN implement?

Demonstrate to the UAP how to approach the clients left side

In caring for a client following a below the knee amputation (BKA). which task is best for the nurse to delegate to the unlicensed assistive personnel who is assisting with the care of this client?

Empty and measure the drainage in the suction drainage device

The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure?

Encorage the client to reminisce about a favorite past family event

A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choice are cocaine and heroin. What is the greatest health risk for this client

Glaucoma

A clients chief complaint is being able to swallow only small bites of solid foods and liquids for the last three months. The nurse should assess the claim for what additional information?

History of alcohol and tobacco use

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perineal area and anus. Which findings indicates a normal appearance of the anus?

Increased pigmentation and coarse skin

A. Inspect legs for infection of trauma. B. Obtain a blood alcohol level. C. Complete a mental status exam. D. Inquire about dietary salt intake.

Inspect the legs for infection of trauma

In obtaining an orthostatic vital sign measurement, what action should the nurse take first

Instruct the client to lie supine

while changing a client postoperative dressing the PN observes red and swollen wound with a moderate amount of yellow and green drainage and foul odor positive resistances MRSA which is the most important action the PN to take

Limit visitors to immediate family only

A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunsupressant. Which action is most important for the nurse to implement to evaluate for adverse effects from this particular medication? A. Observe the client's skin for bruising B. Auscultate the client bowel sounds C. Monitor the clients intake and output D. Note changes in the clients weight

Note changes in the clients weight

The HCP gives a pregnant prescription

Oatmeal is a good choice for breakfast add lentils and black beans to soup increase leaf veggies

Which nursing activity is within the scope of practice for the practical nurse?

Observe a client rotate the subcutaneous site for an insulin pump

The PN views the midline a epistoinomy of client who reports pain in her stitches. Which action should the PN take first?

Observe suture line for separation and hematoma formation

The nurse assigns an unliscensed assistive personnel (UAP) to feeda client who is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement? A. Inform the UAP that the suction is available at the bedside B. Instruct the UAP to notify the PN if the client begins to choke C. Observe the UAP's ability to implement precautions during feed D. Ask the UAP about previous experience performing this skill

Observe the UAP's ability to implement precautions during feed

The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? A. Raise the bed to ensure the drainage bag remains off the floor B. Attach the drainage bag to the side rail instead frame C. Observe the appearance of the urine in the drainage tubing D. Secure the tubing to the client's gown instead of his abdomen

Observe the appearance of the urine in the drainage tubing

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly woman

Osteoporosis resulting from hormonal changes

A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?

Pain perception in the cerebral cortex is dulled by the units discharge of an electrical stimulus

36 hours after delivery, the nurse determines a clients fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first?

Palpate the bladder for distention

A 75 year old male client with Alzheimer's disease is admitted to an extended care facility. What intervention should the nurse include into the clients nursing care plan?

Plan to have the same nursing staff provide care for the client whenever possible

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse to complete a focused assessment? A. Ask the client how long she has experienced discomfort related to hemorrhoids. B. Place the client in a standing position, leaning over the exam bed for inspection. C. Determine if the client uses any over-the-counter preparation for hemorrhoids. D. Position client in left lateral position to inspect perianal area for fissures or sacs.

Position client in left lateral position to inspect perineal area for fissures or sacs

An elderly postoperative client has the nursing diagnosis, "impaired mobility related to fear of falling."Which desired outcome best direct nursing action for this client?

The client will ambulate with assistance every 4 hours

The nurse is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change? A. Bubble or burp the infant by patting the infant's back B. Encourage the mother to avoid over feeding the infant C. Turn the newborn and bulb suction the mouth and nose D. Wipe away the secretions and finish the diaper change

Turn the newborn and bulb suction the mouth and nose

Which client information is the most important for the PN to consider after providing instruction to that UAP about providing Morning care to the postoperative client

Urinary output 50 mL/h

A Client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse include in the assessment of this client?

What are the voices uttering?