HESI Basic Care
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1) If the client is allowed to give consent 2) The client cannot make informed decisions about health care. 3) If the client is permitted to give voluntary consent when parents are not available 4) The client probably will be unable to choose between alternatives when asked to consent.
1) If the client is allowed to give consent A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1) Evaluation 2) Assessment 3) Nursing interventions 4) Proposed nursing care
2) Assessment An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1) Multipara in active labor 2) Middle-aged woman with substernal chest pain 3) Older adult male with a partially amputated finger 4) Adolescent boy with an oxygen saturation of 91%
3) Older adult male with a partially amputated finger Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.
A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet? 1) Add extra salt to food 2) Limit intake to 1200 calories 3) Omit protein foods at each meal 4) Restrict the daily intake of fluids to 1 L
Because of diminished mineralocorticoid secretion, clients with Addison disease are prone to develop hyponatremia. Therefore, the addition of salt to the diet is advised. Intake of calories and fluid is determined on an individual basis, not because the client has Addison disease. Protein is not omitted from the diet; ingestion of essential amino acids is necessary for optimum metabolism. Fluids are not restricted for clients with Addison disease.
The nurse is caring for a client who is receiving 24 hour total parental nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notices that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
Infuse 10% dextrose in water at 54 ml/hr. TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed dose will keep the client from experiencing hypoglycemia until the next TPN solution is available.
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1) Encouraging daily physical exercise 2) Performing yearly physical examinations 3) Providing hypertension screening programs 4) Teaching a person with diabetes how to prevent complications
1) Encouraging daily physical exercise Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.
A nurse is working as a triage nurse in the emergency department. Place the following clients in the order in which they should receive care. Infant having a seizure Man with acute pancreatitis Child with a non-life threatening cut that needs stitches Adolescent with a blood glucose level of 190 Woman with acute chest pain
1.Infant having a seizure 2. Woman with acute chest pain 3. Man with acute pancreatitis 4. Child with a non-life threatening cut that needs stitches 5. Adolescent with a blood glucose level of 190 An infant having a seizure should receive care first because the infant is in acute distress. A person having a seizure should never be left alone. The primary responsibilities include maintaining client safety and observing the characteristics of the seizure. A woman having acute chest pain should receive care second because chest pain can indicate a myocardial infarction or other potential fatal cardiac event. Acute pancreatitis is extremely painful and therefore this client should be medicated as soon as possible after clients with life-threatening problems are stabilized. A child with a non-life-threatening cut and needing stitches can wait until the more acute clients are attended to and stabilized. Although a blood glucose level of 190 is elevated it is not life threatening; therefore, meeting the needs of clients with more acute problems first is appropriate.
The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1) Respiratory acidosis 2) Respiratory alkalosis 3) Respiratory compensation 4) Respiratory decompensation
2) Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess carbon dioxide (CO2) retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.
When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning: 1) Reduces general anxiety 2) Is negatively affected by aging 3) Requires continued reinforcement 4) Necessitates readiness of the learner
3) Requires continued reinforcement Neurologic aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1) Droplet precautions 2) Reverse isolation 3) Surgical asepsis 4) Medical asepsis
3) Surgical asepsis Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.
Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of: 1) Raised toilet seat 2) Side rails for the bed 3) Trapeze above the bed 4) Crutches for ambulation
A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL
First convert the 500 mg to its equivalent in grams. Use "Desire over Have" formula of ratio and proportion: Desire 500 mg x g ---------------- = ---- Have 1000 mg 1 g 1000 x = 500 x = 500 ÷ 1000 x = 0.5 g Therefore, 500 mg is equivalent to 0.5 g. Now use "Desire over Have" formula of ratio and proportion to solve the problem. Desire 0.5 g x mL ------------- = ----- Have 1 g 3 mL x = 0.5 x 3 x = 1.5 mL
A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? 1) "Your skin will look like a blistering sunburn." 2) "A localized skin reaction usually occurs." 3) "A daily application of an emollient will prevent a burn." 4) "Your family must have had experience with radiation therapy."
Radiodermatitis occurs three to six weeks after the start of treatment. The word "burn" should be avoided because it may increase anxiety. Emollients are contraindicated; they may alter the calculated x-ray route and injure healthy tissue. The response about the client's family does not address the client's concern.
Which combination of foods, in addition to milk, should a nurse encourage a child with glomerulonephritis to include in the diet? 1) Baked potato, ground beef, canned carrots, and banana 2) Rice, corn on the cob, baked chicken breast, and applesauce 3) Canned green beans, baked ham, bread and butter, and chips 4) Hot dog on a bun, French fries, dill pickle slices, and brownie
Rice, corn on the cob, baked chicken breast, and applesauce are all permitted on a low-sodium, low-potassium diet, which people with kidney disease require. Carrots are high in sodium, and a banana is high in potassium; both should be avoided. Canned green beans, baked ham, bread and butter, and chips are high in sodium. A hot dog and bun, French fries, dill pickle slices, and brownies are all high in sodium, potassium, or both and should be avoided.
A nurse in the pediatric clinic plans to administer a booster immunization for polio to a child. Which vaccine should the nurse administer? 1) Hib 2) IPV 3) OPV 4) DTaP
The current polio vaccine is the inactivated polio vaccine (IPV; Salk vaccine) that is injectable. Hib is the Haemophilus influenzae type b vaccine. OPV is the oral polio vaccine (Sabin vaccine); it is no longer administered because it is related to vaccine-associated polio paralysis. However, it is used in the worldwide effort to eliminate the virus in countries where it is endemic. DTaP is the diphtheria, tetanus, and acellular pertussis vaccine.
A laboring client has asked the nurse to help her use a nonpharmacological strategy for pain management. Name the sensory simulation strategy. 1) Gently massage of the abdomen 2) Biofeedback-assisted relaxation techniques 3) Application of a heat pack to the lower back 4) Selecting a focal point and beginning breathing techniques
Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.
The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum? 1) Edema that crosses the suture line 2) Scalp tenderness over the affected area 3) Edema that increases during the first day 4) Scalp over the area becomes ecchymosed
1) Edema that crosses the suture line Edema that crosses the suture line is the sign that differentiates these two conditions; cephalohematoma does not extend beyond the suture line. Pain is not associated with either condition. Edema that increases during the first day of life is unusual; it should shrink. Bruising may occur with either condition.
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1) White blood cell (WBC) count of 15,000 mm3 2) Negative protein in the urine 3) Blood urea nitrogen (BUN) of 20 mg/dL 4) Prothrombin of 12.0 seconds
1) White blood cell (WBC) count of 15,000 mm3 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.
Children's patterns of play change as they grow from infancy through school-age. Rank the order of appearance of each type of play, starting with infant play. 1. Solitary 2. Associative 3. Cooperative 4. Parallel
1. Solitary 2. Parallel 3. Associative 4. Cooperative The infant plays alone, with others initiating the play activity. Toddlers' play activity is described as parallel; they play beside other children but not with them. Preschoolers' play is associative in loose groups, with activities involving interaction among players. The school-age child is capable of cooperative play, which includes organized play such as sports, board games, and card games.
A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1) In the axillae 2) On the hands 3) On the right side 4) On the side that the client prefers
2) On the hands Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side.
During assessment, the nurse asks a patient about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the patient experienced pubertal delay. Which finding in the patient supports the nurse's conclusion? 1) Weight increased by 8-12 kilograms. 2) Menarche occurred 2 years after thelarche. 3) Breast development occurred by 15 years of age. 4) Growth in height stopped 2 years after menarche.
3) Breast development occurred by 15 years of age. When the development of breasts has not occurred by 13 years of age in girls, it is considered pubertal delay. An increase in weight between 7 and 25 kilograms is considered normal during the growth spurt period. The occurrence of menarche within 2 years of onset of breast development or thelarche is a normal finding. Generally in girls, growth in height stops 2 to 2 1/2 years after menarche.
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1) A physiological response to stress 2) A conscious defense against anxiety 3) An intentional attempt to gain attention 4) An unconscious means of reducing stress
4) An unconscious means of reducing stress When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.
A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach? 1) Z-track 2) Intravenous 3) Subcutaneous 4) Intradermal scratch
4) Intradermal scratch The vaccination is scratched into the skin using a bifurcated needle. An intramuscular injection using the Z-track technique will administer the vaccine too deep. An intravenous injection is unsafe and ineffective. A subcutaneous injection will administer the vaccine too deep.
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1) Promote equalization of osmotic pressures. 2) Prevent hypoxia associated with diaphoresis. 3) Promote integrity of intracerebral neurons. 4) Reduce brain metabolism and limit hypoxia
4) Reduce brain metabolism and limit hypoxia
Which intervention helps prevent hepatic coma in a client with liver dysfunction? 1) Restrict dietary protein. 2) Prepare for emergency surgery. 3) Eliminate carbohydrates from the diet. 4) Give hypertonic small volume enemas.
Because protein breakdown gives off ammonia, which cannot be detoxified by the liver, protein intake should be limited. Surgical intervention will not affect ammonia levels associated with hepatic coma. Carbohydrates are unrelated to protein breakdown and increasing ammonia levels. A hypertonic small volume enema will not affect ammonia associated with hepatic coma; a neomycin enema will limit intestinal bacteria, which break down protein, giving off ammonia.
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. 1) Chronic stress 2) Severe anxiety 3) Generalized pain 4) Excessive caffeine 5) Chronic depression 6) Environmental noise/distractors
Chronic stress Excessive caffeine Environmental noise/distractors Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.
A nurse determines that a postpartum client's fundus is firm and has shifted to the right and two fingerwidths above the umbilicus 2 hours after giving birth. What should the nurse conclude about this finding? 1) Bladder fullness 2) Early involution 3) Retained secundines 4) Concealed hemorrhage
1) Bladder fullness A distended bladder usually displaces the fundus upward and toward the right because of the anatomic proximity of the bladder and uterus. In early involution, the position of the fundus is at the level of the umbilicus or below, in the midline, rather than shifted to the right. If parts of the placenta and/or membranes are retained, the client will be bleeding and the fundus will be boggy. The fundus is firm; therefore bleeding at this time is not a problem.
To decrease abdominal distention following a client's surgery, what actions should the nurse take? Select all that apply. 1) Encourage ambulation 2 ) Give sips of ginger ale. 3) Auscultate bowel sounds. 4) Provide a straw for drinking. 5) Offer an opioid analgesic
1) Encourage ambulation 3) Auscultate bowel sounds. Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1) Tremors 2) Lethargy 3) Palpitations 4) Visual disturbances 5) Decreased pulse rate
1) Tremors 3) Palpitations Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)
2 Methyldopa (Aldomet) Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1) Immediately stop the infusion. 2) Lower the height of the enema bag. 3) Advance the enema tubing 2 to 3 inches. 4) Clamp the tube for 2 minutes, then restart the infusion.
2) Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.
A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1) Limits had to be set to control the child's crying. 2) The child had a right to remain in the room with the other children. 3) The child had to be removed because the other children needed to be considered. 4) Segregation of the child for more than half an hour was too long a period of time.
2) The child had a right to remain in the room with the other children. Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated.
A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by: 1) Providing more oxygen to lung tissue. 2) Adding pressure to lung tissue, which improves gas exchange. 3) Opening collapsed alveoli and keeping them open. 4) Opening collapsed bronchioles, which allows more oxygen to reach lung tissue.
3) Opening collapsed alveoli and keeping them open. The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps to open collapsed alveoli and keep them open. With the primary mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon dioxide and oxygen can take place more efficiently, thus improving oxygenation by providing more oxygen to the lung tissue and improving gas exchange. PEEP may have an indirect effect on opening bronchioles.
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1) Respiratory rate. 2) Amount of oxygen in the blood. 3) Percentage of hemoglobin-carrying oxygen. 4) Amount of carbon dioxide in the blood.
3) Percentage of hemoglobin-carrying oxygen. The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.
A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem? 1) Two hard-boiled eggs 2) ⅓ cup of red grapes 3) ½ cup of red kidney beans 4) 3 oz of skinless chicken breast
One half cup of red kidney beans contains 2.6 mg of iron. This food contains the greatest amount of iron among the options offered. Two hard-boiled eggs contain 1.2 mg of iron. One third of a cup of red grapes contains 0.1 mg of iron. Three ounces of skinless chicken breast contains 0.9 mg of iron.
The nurse teaches a pregnant client about fetal growth and development. Which statement indicates that the client needs further teaching? 1) "The fetus keeps growing throughout pregnancy." 2) "The fetus may be underweight if it's exposed to smoke." 3) "The fetus gets nutrients from the amniotic fluid." 4) "The fetus gets oxygen from blood in the placenta."
The amniotic fluid provides protection, not nutrition; the fetus depends on the placenta, along with the umbilical blood vessels, for nutrients and oxygen. The statements that the fetus keeps growing throughout pregnancy, that it may be underweight if exposed to smoke, and that it gets oxygen from blood in the placenta all indicate that the client understands the teaching.
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1) Maintain the head of the bed at 35 degrees or less. 2) With the help of another staff member, use a drawsheet when lifting the client in bed. 3) Reposition the client at least every 2 hours and support the client with pillows. 4) At least once every 8 hours, perform passive range-of-motion exercises of all extremities.
2) With the help of another staff member, use a drawsheet when lifting the client in bed. Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows and at least once every 8 hours, and performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force
A nurse is assessing a new client in active labor for fetal position. Where will fetal heart tones best be heard if the fetus' position is LOA?
In the most common position, left occiput anterior (LOA), the fetus's back is on the left side of the mother, in the left occiput anterior position. Position a is correct when the fetus is in the right sacrum anterior position. Position b is correct when the fetus is in the right occiput posterior position. Position c is correct when the fetus is in the left sacrum anterior position.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1) Clean the eyelid and eyelashes. 2) Place the dropper against the eyelid. 3) Apply clean gloves before beginning of procedure. 4) Instill the solution directly onto cornea. 5) Press on the nasolacrimal duct after instilling the solution.
1) Clean the eyelid and eyelashes. 3) Apply clean gloves before beginning of procedure. 5) Press on the nasolacrimal duct after instilling the solution. Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.
A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions? 1) Drink at least 3 L of fluid daily for four weeks 2) Eliminate organ meats from the diet for six weeks 3) Increase the intake of dairy products for five days 4) Restrict movement for three days before resuming usual activities
1) Drink at least 3 L of fluid daily for four weeks Increasing fluid intake aids in the passage of fragments of the calculus that remain after the lithotripsy. Organ meats are high in purine, an amino acid, which is a causative factor in the formation of uric acid crystals; they should be avoided by people with gout. Calcium is the major component of the most common type of calculus; the intake of dairy products, which are high in calcium, should be limited. Early ambulation is encouraged to aid in the passage of fragments of the calculus that remain after a lithotripsy.
During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her that she should restrict her salt intake. What is the nurse's best response? 1) "Your mother is always correct. You should use less salt to prevent swelling during pregnancy." 2) "Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet." 3) "Salt is an essential nutrient that is naturally reduced by the body's estrogen. There's no reason to restrict salt in your diet." 4) "We no longer recommend that salt intake be as restricted as much as in the past, but you still shouldn't add salt to your food."
2) "Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet." Sodium is needed to maintain body water balance; sodium requirements increase slightly during pregnancy to accommodate the increased blood volume. A healthy pregnant woman should not limit her sodium intake. Using less salt could be detrimental to the client's health. Sodium, although essential, is not a nutrient but a mineral. There are no restrictions on salt intake during a healthy pregnancy without compelling indications.
A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1) It stimulates plasma cells directly. 2) A high titer of antibodies is generated. 3) It provides immediate active immunity. 4) A long-lasting passive immunity is produced.
2) A high titer of antibodies is generated. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.
The way individuals cope with an unexpected hospitalization depends on many factors. However, the one that is most significant is: 1) Cognitive age 2) Basic personality 3) Financial resources 4) General physical health
2) Basic personality Lifelong coping styles are most important in how a person will deal with stress. Age may influence defense mechanisms but lifelong coping styles will most significantly affect a person's behavior. Financial resources are a factor to be considered, but past coping ability is the most significant factor to predict future coping. General physical health is a factor to be considered, but past coping ability is the most significant factor to predict future coping.
A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include? 1) Mammography should be performed annually after age 35 years for women. 2) Fecal occult blood testing should be performed yearly beginning at age 50 years. 3) Breast self-examination should be performed monthly beginning at age 30 years. 4) Digital rectal exams and prostate-specific antigen (PSA) testing should be done yearly after age 40 for men.
2) Fecal occult blood testing should be performed yearly beginning at age 50 years. In addition to this recommendation, the ACS also recommends a colonoscopy every 10 years, flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 years, or computed tomography (CT) colonography (virtual colonoscopy) every 5 years. If any of these tests (other than the colonoscopy) are positive, a colonoscopy should be done. The ACS recommends that women have an annual mammography after age 40 years. Women with a risk greater than 20% (based on family history, genetic tendency, or certain other factors) should have an magnetic resonance imaging (MRI) and mammography yearly at 30 or sooner, based on personal circumstances or preference. A clinical breast exam should be done starting at 20 and through the 30s every 3 years. The ACS recommends that breast self-examinations be performed monthly beginning at age 20 years if a person chooses to do so; it is recommended that women be instructed about the potential benefits and limitations related to breast self-examination. After a discussion with a health care provider, digital rectal examinations and PSA screening should be done annually at age 50 for men who are expected to live at least 10 years longer. African-American men and men with a father or brother with a history of prostate cancer before the age of 65 should begin testing at 45 years of age. Men at even a greater risk (brother or father with a diagnosis of prostate cancer at an early age) should begin testing at age 40. Screening should take place every 3 years with a PSA of less than 2.5 ng/mL, and yearly for a PSA equal to or more than 2.5 ng/mL
In what position should the nurse place a client recovering from general anesthesia? 1) Supine 2) Side-lying 3) High Fowler 4) Trendelenburg
2) Side-lying Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing.
The school nurse presents a program on Reye syndrome to the Parent-Teacher Association. After the program the nurse talks with a group of parents. Which statement by a mother indicates the need for additional education on Reye syndrome? 1) "Aspirin should be avoided in children with viral diseases." 2) "It's OK for me to give my kids Tylenol if they run a fever." 3) "I should watch for my child's skin to turn yellow during the recovery from varicella." 4) "I need to seek medical help right away if my child starts vomiting profusely during the recovery period of a viral illness."
3) "I should watch for my child's skin to turn yellow during the recovery from varicella." Liver involvement is a component of Reye syndrome, but the skin will not turn yellow. Classic early symptoms are vomiting and confusion during the recovery from a viral illness. The mother needs to have the symptoms of Reye syndrome reviewed because her response contains incorrect information. There is an association between aspirin use for viral diseases and the development of Reye syndrome. Acetaminophen (Tylenol) and ibuprofen (Motrin) may be used to treat fevers because there has been no association between these drugs and the development of Reye syndrome. Profuse vomiting is an early sign of Reye syndrome. The child progresses quickly through the five stages of Reye syndrome, and early recognition is important.
A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? 1) Page the on-call health care provider and continue to monitor the blood pressure. 2) Administer ibuprofen and have the client rest quietly for 20 minutes. 3) Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4) Place the client in the supine position, administer oxygen, and notify the health care provider.
3) Elevate the head of the bed, provide reassurance, and reassess the blood pressure. Blood pressure increases with pain and stress; reevaluation is critical before determining if the health care provider should be notified. Assessment should be completed before notifying the health care provider. Prescribing medications is a dependent function of the nurse, and medication should not be administered until the cause of the headache is determined. Oxygen is not indicated. The head of the bed should be elevated. The health care provider should be notified if a second blood pressure reading remains elevated.
An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? 1) Use the client's first name. 2) Visit with the client frequently. 3) Explain what the client can expect. 4) Listen to what the client has to say.
3) Explain what the client can expect. Explaining procedures and routines should decrease the client's anxiety about the unknown. The nurse should not confuse roles of professional and friend; the client should be called by an appropriate title (Mr., Miss, Ms., Mrs., etc.) unless the client requests otherwise. The nurse should not confuse the role of professional with that of being a friend; "visiting" has a social connotation. Although listening to the client is therapeutic, this does not change the fact that the hospital environment is strange to the client and the client needs information.
A nurse is assigned to care for a newly admitted client. The nurse performs a physical assessment and reviews the admission form and the health care provider's prescriptions. What should the nurse identify as the priorities in this client's plan of care? 1) Intake and output 2) Diet and nutrition 3) Hygiene and comfort 4) Body mechanics and posture
3) Hygiene and comfort Because the client's condition is terminal, the nursing priority should be directed toward providing basic care and comfort. Although intake and output, diet and nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is the priority when caring for a dying client.
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1) Rehabilitation needs are met best by the client's family and community resources. 2) Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3) Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4) Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
3) Immediate or potential rehabilitation needs are exhibited by clients with health problems.
After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client? 1) Dry mouth 2) Skin reactions 3) Mucosal edema 4) Bone marrow suppression
3) Mucosal edema The mucosal lining of the oral cavity, oropharynx, and esophagus is sensitive to the effects of radiation therapy; the inflammatory response causes mucosal edema that may progress to an airway obstruction. A decrease in salivary secretions resulting in dry mouth may interfere with nutritional intake, but it is not life threatening. Erythema of the skin may cause dry or wet desquamation, but it is not life threatening. Radiation to the neck area should not produce as significant bone marrow suppression as radiation to the other sites.
A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? 1) Number of fatalities 2) Cost of nurse overtime 3) Nurse-to-client ratio on units 4) Completion of critical pathways
3) Nurse-to-client ratio on units During a disaster, nursing coverage on all units should remain appropriate for client safety. Disaster nursing is concerned with providing care for clients in imminent danger and requires mobilization of people and resources from other areas. Number of fatalities is not the basis for evaluating the effectiveness of care; during a disaster, many clients may be dead on arrival. Cost is not the concern during a disaster. Completion of critical pathways is not the basis for evaluation of care during a disaster.
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1) Evidence 2) Tort discovery 3) Proximate cause 4) Common cause
3) Proximate cause Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.
What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? 1) 1 to 2 hours 2) 3 to 4 hours 3) 15 to 20 minutes 4) 30 to 40 minutes
Change of position at least every 1 or 2 hours helps prevent the respiratory, urinary, and cutaneous complications of immobility. Too protracted a period of time in one position increases the potential for respiratory, urinary, and neuromuscular impairment; prolonged physical pressure increases the possibility of skin breakdown. Fifteen to 20 minutes and 30 to 40 minutes are unnecessarily short time intervals; too frequent repositioning may interfere with the client's rest.
A health care provider prescribes a low-sodium, high-potassium diet for a client with Cushing syndrome. Which explanation should the nurse provide as to why the client needs to follow this diet? 1) "The use of salt probably contributed to the disease." 2) "Excess weight will be gained if sodium is not limited." 3) "The loss of excess sodium and potassium in the urine requires less renal stimulation." 4) "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium."
4) "Excessive aldosterone and cortisone cause retention of sodium and loss of potassium." Clients with Cushing syndrome must limit their intake of salt and increase their intake of potassium. The kidneys are retaining sodium and excreting potassium. An excessive secretion of adrenocortical hormones in Cushing syndrome, not increased or high sodium intake, is the problem. Although sodium retention causes fluid retention and weight gain, the need for increased potassium also must be considered. Because of steroid therapy, excess sodium may be retained, although potassium may be excreted.
A 24-year-old client complains to the nurse in the women's health clinic that her breasts become tender before her menstrual period. What should the nurse recommend that the client do 1 week before an expected menses? 1) Take salt tablets daily. 2) Increase protein intake. 3) Eliminate daily exercise. 4) Decrease caffeine intake.
4) Decrease caffeine intake. The client is exhibiting one symptom of premenstrual syndrome (PMS); eliminating food and beverages containing caffeine can limit breast swelling. Salt intake should be reduced premenstrually to limit the development of edema. Increased protein intake is unnecessary if the client is eating a nutritious diet. Exercise should be increased before the menstrual period to help ease the symptoms of PMS.
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1) Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3) Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4) Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought.
4) Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.
A nurse is caring for a client who is receiving serum albumin. What indicates that the albumin is effective? 1) Improved clotting of blood 2) Formation of red blood cells 3) Activation of white blood cells 4) Maintenance of oncotic pressure
4) Maintenance of oncotic pressure Serum albumin, a protein, establishes the plasma colloid osmotic (oncotic) pressure because of its high molecular weight and size. Blood clotting involves blood protein fractions other than albumin; for example, prothrombin and fibrinogen are within the alpha- and beta-globulin fractions. Red blood cell formation (erythropoiesis) occurs in red marrow and can be related to albumin only indirectly; albumin is the blood transport protein for thyroxine, which stimulates metabolism in all cells, including those in red bone marrow. Albumin does not activate white blood cells (WBCs); WBCs are activated by antigens and substances released from damaged or diseased cells.
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: 1) Urge incontinence 2) Stress incontinence 3) Reflex incontinence 4) Overflow incontinence
4) Overflow incontinence Overflow incontinence describes what is happening with this client; overflow incontinence occurs with retention of urine with overflow of urine. Urge incontinence describes a strong need to void that leads to involuntary urination. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Reflex incontinence is an involuntary loss of urine at fairly predictable intervals when certain urinary bladder intervals are reached.
A client is admitted to the birthing unit in active labor. What should the nurse expect after amniotomy is performed? 1) Diminished bloody show 2) Increased and more variable fetal heart rate 3) Less discomfort with contractions 4) Progressive dilation and effacement
4) Progressive dilation and effacement Artificial rupture of the membranes (amniotomy) allows more effective exertion of pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Amniotomy does not directly affect the fetal heart rate. Discomfort may become greater because contractions usually increase in intensity and frequency after amniotomy.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for 15 seconds, large amounts of thick yellow secretions return. What action should the nurse perform next? 1) Encourage the client to cough to loosen the secretions 2) Advise the client to increase intake of oral fluids 3) Rotate the suction catheter to obtain any remaining secretions 4) Re-oxygenate the client before attempting to suction again
4) Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than 10-15 seconds since the patient's oxygenation is compromised during this time. 1, 2, and 3 may be performed after the patient is re-oxygenated and additional suctioning is performed.
A client in labor states that she feels an urge to push. After a vaginal examination, the nurse determines that the cervix is 10 cm dilated. Which breathing pattern does the nurse encourage the client to use? 1) Expulsion breathing 2) Rhythmic chest breathing 3) Continuous blowing-breathing 4) Accelerated-decelerated breathing
Expulsion breathing (pushing) should not be encouraged until the cervix is fully dilated; doing it too early may cause cervical trauma and fatigue. A breathing pattern consisting of continuous blowing can assist in overcoming the urge to push when a client is in transition. Rhythmic chest breathing is used in the early active phase of labor for relief of discomfort; it is not used to overcome the desire to push. Accelerated-decelerated breathing is not effective in overcoming the urge to push.
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1) Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2) After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3) Clean the insertion site daily using a solution of one part vinegar to two parts water. 4) Replace the drainage bag with a new bag once a week.
4) Replace the drainage bag with a new bag once a week. Once a day, the client should wash the first inches of the catheter starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution. It is recommended to change the bag at least once a week.
An 8-year-old child who is cognitively impaired and blind does not speak or respond to the nurse. What should the nurse do when entering the child's room? 1) Blink the room's lights before starting care. 2) Start care and explain actions as care is given. 3) Nonverbally acknowledge the child before starting to give care. 4) Say the child's name and touch the child's arm before starting care.
4) Say the child's name and touch the child's arm before starting care. Letting the child know that the nurse is in the room is vital; vocal and tactile contact will accomplish this. The child is blind and cannot see blinking lights. The nurse should let the child know that someone is present before beginning care. Nonverbal acknowledgment is difficult because the child is blind.
On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged? 1) There is an overabundance of milk. 2) Breastfeeding is probably ineffective. 3) The breasts have been inadequately supported. 4) The lymphatic system in the breasts is congested.
4) The lymphatic system in the breasts is congested. An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breastfeeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequately support of the breasts does not cause engorgement, but support may relieve some of the discomfort.
When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1) Sodium 2) Potassium 3) Calcium 4) Calcitonin
A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water to move out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity, as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.
A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client? 1) "Eye surgery may improve your vision." 2) "Activities should be spaced throughout the day." 3) "Opioids may be necessary for the pains in your legs." 4) "Leg restraints will decrease the chance of physical injury."
ALS is a disease of the motor neurons characterized by muscle wasting and weakness. Conserving the energy and spacing activities throughout the day are useful strategies. The senses, such as vision, are not affected with ALS. Opioids generally are not a part of the treatment for ALS because they can contribute to inhibition of the client's respirations. The use of leg restraints is not a part of treatment for ALS; however, leg braces or a walker may maximize independence by promoting ambulation.
The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply. A) "Your child should be able to show the grasp reflex." B) "Your child should be able to coo, babble, and chuckle." C) "Your child should be able to pull at blankets or clothes." D) "Your child should be able to put feet into the mouth when supine." E) "Your child's head can come up to a 45- to 90-degree angle from the table."
B) "Your child should be able to coo, babble, and chuckle." C) "Your child should be able to pull at blankets or clothes." E) "Your child's head can come up to a 45- to 90-degree angle from the table." Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.
A common method for assessing the size of a burn wound is to use the Rule of Nines. Based on this method, estimate the extent of burns if the front chest, front abdomen, both sides of both upper extremities, and entire head were affected. Using the Rule of Nines, the estimate is: __% (Record your answer as a whole number)
The chest is 9%, the front abdomen is 9%, each upper extremity is 9%, and the entire head and neck are 9%. Chest 9 + front abdomen 9 + extremities 18 + head 9 = 9+9+18+9=45
While caring for a client during labor, the nurse remembers that the second stage of labor: 1) Ends at the time of birth 2) Ends as the placenta is expelled 3) Begins with the transition phase of labor 4) Begins with the onset of strong contractions
The second stage of labor starts with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
Physical assessment of a client in active labor reveals that the cervix is dilated 3 to 4 cm and 50% effaced, the fetus is in the right sacrum anterior (RSA) position, and contractions are 5 minutes apart. Where should the nurse place the stethoscope to best locate the fetal heart tones?
When the fetus's back is on the right side of the mother and the fetal sacrum is in the lower portion of the fundus, the fetus is in the right sacrum anterior (RSA) position and the fetal heart can be heard in the right upper quadrant. Location B is appropriate when the fetus is in the left sacrum anterior (LSA) position. Location C is appropriate when the fetus is in the right occipital anterior (ROA) position. Location D is appropriate when the fetus is in the left occipital anterior (LOA) position.
