HESI Diagnostic Exam- Integration
How should the nurse instruct the parents of a 4-month-old with seborrhea dermatitis (cradle cap) to shampoo the child's hair? A. Avoid scrubbing the scalp until the scales disappear B. Use a soft brush and gently scrub the area C. Avoid washing the child's hair more than once a week D. Use soap and water and avoid shampoos
B. Use a soft brush and gently scrub the area
The mother of a 14-year-old who had below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to provide? A. "It is important to understand your child's needs at this difficult time" B. "I will ask the healthcare provider for a psychiatric consult for your child" C. "A reaction of anger is your child's attempt to cope with this loss" D. "This type of acting out behavior is normal for adolescent"
C. "A reaction of anger is your child's attempt to cope with this loss"
A client who is currently receiving methadone 10 mg q8 hours reports that pain is an 8 on a scale of 1 to 10. Which action should the nurse implement? A. Explore use of non-pharmacological interventions B. Give a PRN dose of an analgesic for breakthrough pain C. Administer the next scheduled dose of methadone early D. Tell client when the next dose of methadone is scheduled
C. Administer the next scheduled dose of methadone early
A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussion fluid intake, the nurse should include which type of fluid limitation? A. Tea and hot chocolate B. Low-sodium soups C. Citrus fruit juices D. Over-all fluid intake
A. Tea and hot chocolate
A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? A. Test her urine for the presence of hematuria. B. Measure her temperature and pulse rate. C. Palpate the right flank for tenderness. D. Evaluate the urine for a strong odor.
A. Test her urine for the presence of hematuria.
A patient had abdominal surgery and has a surgical incision, what should the nurse do next?
*Leave wound uncovered Place a dry sterile dressing over the wound *Place a sterile non-adherent dressing
Meds that can be administered after breakfast
*Levothyroxine for Hypothyroidism *Insulin 70/30 *Sucralfate for peptic ulcer disease *Furosemide for potassium level 4.1
There is a fire inside the building. What should the nurse do?
-Advise the other nurses to evacuate the floor by taking the stairs -Call to confirm there is indeed a fire.
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching? A. Washes the radiation site with antibacterial soap and water B. Dries the area with patting motions after taking a shower C. Applies prescribed lotions to the radiation site D. Wears clothing to cover the radiation site
A. Washes the radiation site with antibacterial soap and water
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription would the nurse teach the client to use for the skin condition? A. Colloidal oatmeal-based lotion B. Topical corticosteroids C. Topical analgesics D. Topical antifungal
B. Topical corticosteroids
A client who recently returned from the Philippines presents to the clinic with high fever, chills, headache, and muscular aches. The healthcare provider suspects severe acute respiratory syndrome (SARS). To prevent transmission of the virus to others, which instruction is most important for the nurse to provide? A. Wear a N95 respirator mask during direct contact with others B. Use meticulous hand washing technique C. Discard all tissues used during coughing in a biohazard bag D. Cover mouth and turn head when coughing
A. Wear a N95 respirator mask during direct contact with others
A patient has developed ABO incompatibility after several blood transfusions
ACUTE HEMOLYTIC REACTION
AV fistula (for dialysis) normal characteristics?
Absent sound Color?
The nurse is counseling a client who is at 6-weeks gestation and is experiencing morning sickness, but does not want to take any drugs for discomfort. Which herbal supplement if likely to help this client with nausea she is experiencing? A. Chamomile B. Ginko C. Ginger D. Peppermint
D. Peppermint
A client with a pulmonary embolism is receiving streptokinase 100,000 International Units (IU)/hour for the next 24 hours. The pharmacy dispensed streptokinsease 1,500,000 in 500 mL of 0.9% normal saline (NS). The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
25
The nurse is documenting a client's fluid intake at lunch, which consisted of four ounces of chicken broth, one cup of water, and one half cup of flavored gelatin. How many mL of intake should be entered in the client's electronic medical record?
43
When preparing a client for a paracentesis, which action is most important to delegate to the unlicensed assistive personnel (UAP) who is assisting the nurse? A. Assist the client to empty bladder B. Measure the client's abdominal girth C. Determine when the client last ate D. Obtain the client's current weight
A. Assist the client to empty bladder
The practical nurse (PN) caring for a client with acute heart failure (HF) and pitting edema tells the charge nurse that a verbal prescription was obtained from the healthcare provider for 1,000 mL of D5 normal saline to be administered over 4 hours. Which action should the charge nurse take? A. Clarify the prescription with the healthcare provider B. Determine if the client has crackles in the lungs C. Ensure that an IV pump is used to administer the infusion D. Assess the PN's ability to carry out the prescription
A. Clarify the prescription with the healthcare provider
An older male client is admitted with hypothermia with a core body temperature of 95° F (35°C) due to the lack of adequate heat in his home. Which findings should the nurse expect to obtain? (Select all that apply) A. Confusion B. Headache C. Hyper-alert state D. Shivering E. Cool skin
A. Confusion B. Headache D. Shivering E. Cool skin
Which of the following four patients is at highest risk for falls?
A patient who had opioid narcotics an hour ago
Which client requires immediate intervention by the nurse? A. A child with acute renal failure and hyperkalemia B. A child with cystic fibrosis who is constipated C. A toddler with chicken pox who is scratching D. An adolescent with a migraine and photophobia
A. A child with acute renal failure and hyperkalemia
A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply) A. Administer oral antispasmodics and narcotic analgesics B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure C. Evaluate the application of the splint to the left leg D. Offer ice chips and oral clear liquids E. Verify pedal pulses using a doppler pulse device
A. Administer oral antispasmodics and narcotic analgesics B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure C. Evaluate the application of the splint to the left leg E. Verify pedal pulses using a doppler pulse device
The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client's plan of care? A. Assess for signs of increased intracranial pressure B. Obtain a prescription for artificial tear drops C. Prepare to administer intravenous levothyroxine D. Review the client's serum electrolyte values
A. Assess for signs of increased intracranial pressure
A client with partial-thickness and full-thickness burns over 50% of the body is admitted to the Emergency Department. The healthcare provider prescribes hydromorphone 4 mg IM every 4 hours for pain. The client is complaining of "9" on the 1 to 10 pain scale. Which intervention should the nurse implement first? A. Contact the healthcare provider and question the prescription B. Assist the client with relaxation techniques and guided imagery C. Rule out any complications prior to administering the medication D. Administer an additional dose of the medication into an unburned area
A. Contact the healthcare provider and question the prescription
During a one-to-one session with the nurse, a female admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, "I don't remember, but my mother ran my father off when I was five." The nurse should recognize that the client may be using which defense mechanism? A. Denial B. Repression C. Regression D. Projection
A. Denial
An adolescent client who has been lacto-ovo-vegetarian for six months tells the nurse about experiencing increasing fatigue. What recommendation should the nurse provide? A. Eliminate carbonated soft drinks from the diet B. Eat spinach three times a week C. Increase intake of fruit to 6 servings per day D. Decrease saturated fat intake
A. Eliminate carbonated soft drinks from the diet
After seven-day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. In providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. What resource should the nurse use first in resolving the situation? A. Healthcare provider B. Medication reference guide C. Hospital pharmacist D. Nursing unit charge nures
A. Healthcare provider
Which action should the nurse take first when a client with systemic sclerosis (Scleroderma) exhibits symptoms of Raynaud's phenomenon? A. Initiate massage and stretching exercises B. Remove any pressure on the involved extremities C. Apply cool compresses to the involved area D. Elevate the involved extremities on pillows
A. Initiate massage and stretching exercises
The nurse orients a client with depression to a new room on the mental health unit. The client states, "It seems strange that I don't have a TV in my room." Which statement is best for the nurse to provide? A. It's important to be out of your room and talking to others. B. You can watch TV as much as you want outside of your room. C. Watching TV is a passive activity and we want you to be active. D. Sometimes clients feel like the TV is sending them messages.
A. It's important to be out of your room and talking to others.
A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? A. Measure the head circumference while in prone position B. Apply an antibiotic ointment to the exposed area C. Apply a diaper below the myelomeningocele D. Place the infant on the abdomen to protect the sac
A. Measure the head circumference while in prone position
An adult with pneumonia is diaphoretic, tachycardia, and confused. The cardiac monitor indicates sinus tachycardia with frequent premature multifocal ventricular beats. Arterial blood gas (ABG) findings are: pH 7.26, PaCO2 66 mmHgl HCO3 23 mEq/L (22 mmol/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Obtain a 12 lead electrocardiogram (ECG) daily B. Assess for apical-radial pulse deficit with vital signs C. Monitor the respiratory rate and depth continuously D. Maintain a patent IV catheter for antibiotic therapy
A. Obtain a 12 lead electrocardiogram (ECG) daily
A client has been on bed rest following a cerebrovascular accident or stroke that occurred two days ago. On the third day, the plan of care includes getting the client out of bed and into a bedside chair. Prior to assisting the client out of bed for the first time, which action should the nurse take? A. Offer the client to void before getting out of bed B. Assess the client''s brain stem reflexes C. Perform pupillary response assessment D. Assess the client's blood pressure
A. Offer the client to void before getting out of bed
An older client who is agitated, dyspneic, orthopedic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields, An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? (Select all that apply) A. Oxygen saturation B. Lung Sounds C. Urinary output D. Skin elasticity E. Pain Scale
A. Oxygen saturation B. Lung Sounds E. Pain Scale
In assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most for the nurse to obtain? A. Recent recurrence of infections B. Cultural heritage and belief C. Family history of bone disorder D. Occurrence of increased fluid intake
A. Recent recurrence of infections
When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the outlet. What should the nurse do next? A. Release and reinsert the flowmeter in the wall outlet. B. Adjust the position of themes on the client's face C. Adjust the flow rate to the prescribed liters per minute D. Attach the flowmeter to a humidification canister
A. Release and reinsert the flowmeter in the wall outlet.
The nurse is assessing the perianal area of a female client who states she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding should the nurse report to the healthcare provider that is most consistent with the client's complaint? A. Shiny blue skin sacs around anal opening and a linear split B. Flabby skin sac around the anal orifice that is painless C. Anus is moist, hairless, and has pigmented sphincter folds D. Presence of dried brown stool around the perianal area
A. Shiny blue skin sacs around anal opening and a linear split abnormals of perianal area: linear split--fissureflabby skin sac -- hemerrhoidshiny blue skin sac--thrombosed hemorrhoidsmall round opening in anal area--fistulainflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx--pilonidal cystcircular red donut of tissue--rectal prolapse
After 5 months of treatment for Herpes Shingles, a patient continues to experience pain. What intervention should the nurse implement?
Assess for pain Contact HCP to prescribe pain medication Create mental health assessment
The registered nurse (RN) directs the unlicensed assistive personnel (UAP) to administer PO fluids int he ambulatory surgical center. Which adult client should the RN assign to the UAP? A. An obtunded client who requires tactile stimulation to respond. B. A sedated client asking for ice chips when questioned C. An awake client with a gag reflex who is asking for water D. A disoriented client requesting medication upon arrival from PACU
B. A sedated client asking for ice chips when questioned
Following a disaster, which person should the nurse triage with a red tag, indicating that immediate attention is required? A. An older adult with emphysema who has a barrel chest and is coughing. B. A young adult with a history of asthma who is speaking in short sentences. C. A middle-aged man with acute coronary syndrome who has superficial facial lacerations. D. A frail elderly woman with degenerative disk disease who is complaining of back pain.
B. A young adult with a history of asthma who is speaking in short sentences.
The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect to find? (Select all that apply) A. Peristaltic waves observed B. Abdominal distention C. Abdomen soft on palpation D. Dullness on percussion E. High pitched bowel sounds
B. Abdominal distention D. Dullness on percussion E. High pitched bowel sounds
During a high school class on substance abuse, a student tells the group, "If I tried cocaine, I know I could handle it. I know when to stop." What response is best for the nurse to provide? A. Addiction affects all aspects of one's life and one's family. B. An overdose of cocaine can be lethal. C. Mind altering drugs take away one's ability to make good decision D. Denial of an addiction problem is often the first response to the behavior
B. An overdose of cocaine can be lethal.
A client reports epigastric pain after receiving an oral dose of ketolorac. Which action should the nurse implement? A. Offer the client a PRN dose of ibuprofen B. Ask if the client is taking home remedies C. Administer subsequent doses with meals D. Continue to monitor the client for GI distress
B. Ask if the client is taking home remedies
A client reports epigastric pain an hour after receiving an oral dose of ketolorac. Which action should the nurse implement? A. Offer the client a PRN dose of ibuprofen B. Ask if the client is taking home remedies C. Administer subsequent doses with meals D. Continue to monitor the client for GI distress
B. Ask if the client is taking home remedies
Two days after an abscess of the chin was drained, the client returns to the clinic with fever, chills, and a maculopapular rash with pruritus. The client has taken an oral antibiotic and cleaned wound today with providone-iodine solution. Which intervention should the nurse implement first? A. Review recent mediation history and allergies B. Assess airway latency and oxygen saturation C. Obtain samples for complete blood count and cultures. D. Determine if the client has a history of diabetes
B. Assess airway latency and oxygen saturation
A client receives a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which information should the nurse include in the discharge teaching? A. Monitor blood pressure regularly B. Assess heart rate before each dose C. Report a decrease in sexual interest D. Avoid consumption of aged cheeses
B. Assess heart rate before each dose D. Avoid consumption of aged cheeses Can't choose
A nurse arrives at the scene of a motor vehicle collision, and finds that the male driver is sitting in the car screaming about severe knee pain. He is alert and oriented, but his knee is crushed into the dashboard. A bystander reports that a 911 call has been made and help is on the way. What intervention should the nurse implement? A. Place a rolled pillow behind the driver's neck to stabilize the spinal cord. B. Carefully assist the driver out of the car to assess and treat the injury. C. Tell the driver to try to see if he can move his toes on the affected leg. D. Instruct the driver to stay in the car and try not to move unnecessarily.
B. Carefully assist the driver out of the car to assess and treat the injury.
A female client reports feeling hopeless and is unable to stop crying. She explains that she is worried about losing her job. Since the client's husband recently lost his job, she feels her employment is essential to the family's survival. To evaluate the effectiveness of cognitive-behavioral techniques which client outcome should the nurse include in the plan of care? A. Describes how the family can resolve problems B. Changes thought patterns related to problem solving C. Relates insight into problematic relationships D. Demonstrates a healthy relationship with husband
B. Changes thought patterns related to problem solving (Not sure)
The parents of a 4 week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain? A. Level of infant's distress after vomiting B. Degree of forcefulness of vomiting episodes C. Odor and texture associated with emesis D. Position of the infant when vomiting occurs
B. Degree of forcefulness of vomiting episodes
An overweight, young adult who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply) A. Assess skin temperature and moisture B. Document anxiety on the surgical checklist C. Check finger stick glucose level D. Measure pulse and blood pressure E. Administer a PRN dose of regular insulin
B. Document anxiety on the surgical checklist C. Check finger stick glucose level D. Measure pulse and blood pressure E. Administer a PRN dose of regular insulin
A client taking atorvastatin develops an increased serum creatine phosphokinase (CK) level. The nurse should assess the client for the onset of which problem? A. Excessive bruising B. Muscle tenderness C. Peripheral edema D. Nausea and vomiting
B. Muscle tenderness (Could indicate a type of myopathy know as rhabdomyolysis: destruction of striated muscle cells)
An older client who is admitted with a cerebrovascular accident is placed on a ventilator. The client's family member arrives with a durable power of attorney, and a living will that indicates the client wants no extraordinary life saving measures. Which action should the nurse take? A. Review the medical record B. Notify the healthcare provider C. Discontinue the ventilator D. Refer to the risk manager
B. Notify the healthcare provider
The nurse is assessing a client who is admitted with diaphoresis and intermittent sharp abdominal pain radiating into the back and groin. While examining the abdomen, the nurse finds an abdominal mass. Which action should the nurse implement immediately? A. Assess the distal pulses B. Notify the healthcare provider C. Auscultate for bowel sounds D. Place the client in a prone position
B. Notify the healthcare provider
To control asthma, a client in a residential treatment facility uses a fluticasone propionate and salmetrol discus inhalation system, which provides inhaled powdered form of these combined medications. Which instruction should the nurse provide to this client's caregivers? A. Clients using the discus may experience decreased blood pressure B. Offer the discus to the client for use during an acute asthma attack C. When using the discus, have the client breathe out rapidly into the mouthpiece D. Explain that the client should not use the discus more than twice daily
B. Offer the discus to the client for use during an acute asthma attack
A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she starts taking a calcium supplement to reduce her menstrual cramps, but quit taking the calcium because it caused constipation. The client wants to know what can she do to relieve her menstrual cramps. Which action should the nurse implement first to address the client's concern? A. Ask her how much calcium she had been taking daily B. Question the client about her use of birth control pills C. Encourage client to increase her dietary intake of fiber D. Determine if she takes any over-the-counter analgesics
B. Question the client about her use of birth control pills
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take? A. Document the absence of the radial pulse B. Record a palpable systolic pressure of 90 C. Inflate blood pressure cuff to 120 mm Hg D. Release the manometer valve immediately
B. Record a palpable systolic pressure of 90
A newborn with a respiratory rate of 40 breaths/minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should the nurse take? A. Assess bowel sounds B. Rub the infant's back C. Continue to monitor D. Assist with intubation
B. Rub the infant's back
A 6-year-old male with a body mass index (BMI) in the 95th percentile for gender and age arrives at the clinic after a referral from the school nurse. His laboratory findings include hemoglobin A1c of 5.5% (0.06), blood pressure (BP) in the 50th percentile for age, height int he 75th percentile, and an LDL cholesterol of 90 mg/dL (2.33 mmol/L). Which lifestyle modification should the nurse discuss with the parents? A. Recommend increasing daily fruits and vegetables and daily exercise B. See a healthcare provider to further assess for diabetes and hypertension C. Return in one month for another evaluation of serum lipids and blood pressure D. Instruct the parents to weight the child weekly and measure his BP daily
B. See a healthcare provider to further assess for diabetes and hypertension
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide? A. Describe genetic testing protocols B. Sign up for group therapy sessions C. Start a prenatal care plan as soon as possible D. Discontinue the methadone right away
B. Sign up for group therapy sessions (Methadone is recommended as part of a multi-treatment approach to heroin addiction; peer support groups and individual counseling should be offered)
A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Recently became a vegetarian and eats a lot of high fiber foods B. Snacks on foods with very high salt content on a daily basis C. Consumes 10 or more drinks of alcohol every weekend D. Exercises vigorously every evening right before going to bed
B. Snacks on foods with very high salt content on a daily basis
Which client should the charge nurse assign to the care of a practical nurse (PN)? A. An adolescent with a chest tube that drained 500 mL in the past 8 hours. B. An adult who is receiving chemotherapy via an implanted venous access device. C. An older client who is receiving multiple antihypertensive medications. D. An adult type 1 diabetes mellitus who is receiving a titrated insulin infusion.
C. An older client who is receiving multiple antihypertensive medications.
The nurse on the day shift receives report about a client with depression who was in bed most of the weekend. The nurse walks into the client's room in the morning and finds the client in bed. What intervention is best for the nurse to implement? A. Monitor the client's appetite and pattern of sleep B. Explain that staff will check on the client every 30 minutes C. Assist the client to get out of bed and involved in an activity D. Assess the client's feelings about hospital stay
C. Assist the client to get out of bed and involved in an activity
A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal. What food choice should the nurse encourage the client to omit? A. Ketchup B. Ice cream C. Bread D. Beef broth
C. Bread
A mother is concerned that her 3-year-old son wants to play with female doll figures. The child is not interested in building blocks, trucks, or other typical "boy" toys. How should the nurse respond to the mother's concern? A. Experimenting with different toys is an acceptable behavior B. Replacing female doll figures with male doll figures reinforces masculinity C. Exploring different roles in imaginary play is typical at this age D. Letting male toddlers play with female-typed toys can have negative effects
C. Exploring different roles in imaginary play is typical at this age
The nurse is evaluating a young child with atopic dermatitis. Which question should the nurse ask the parent while obtaining the child's history? A. What time of day does the rash appear on the body? B. Can any particular ___ be associated with onset of the rash? C. Has the child displayed any symptoms of asthma or hay fever? D. Does the child have any nausea or vomiting?
C. Has the child displayed any symptoms of asthma or hay fever?
The nurse is evaluating a young child with atopic dermatitis. Which question should the nurse ask the parent while obtaining the child's history? A. What time of day does the rash appear on the body? B. Can any particular be associated with onset of the rash? C. Has the child displayed any symptoms of asthma or hay fever? D. Does the child have any nausea or vomiting?
C. Has the child displayed any symptoms of asthma or hay fever?
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? A. Describe the use of an elimination diet to find trigger foods B. Explain that the need to restrict fluids is the primary limitation C. Instruct the client to avoid foods with gluten, such as wheat bread D. Advise the client to limit foods that are high in calcium and iron
C. Instruct the client to avoid foods with gluten, such as wheat bread
Which medication should the nurse anticipate administering to a client in the emergency department who is experiencing a hypertensive crisis? A. Mannitol B. Dopamine hydrochloride C. Labetalol hydrochloride D. Nitropress
C. Labetalol hydrochloride
A 30-year-old male client tells the nurse that about half of this diet comes from eating meat and eggs. What instruction should the nurse provide? A. Maintain protein intake but substitute fish and nuts for meat and eggs B. Increase protein intake with the additional intake of dairy products C. Maintain protein intake and increase intake of fruits and vegetables D. Decrease protein intake and eat more whole grains and vegetables
C. Maintain protein intake and increase intake of fruits and vegetables
When assessing a client who is returned to the unit following a left nephrectomy, then ruse notes a small amount of bloody drainage at the drain site. Which intervention is most important for the nurse to include in this client's plan of care? A. Provide sips of water and ice chips B. Turn, cough, deep breath C. Monitor urinary output hourly D. Document temperature every four hours
C. Monitor urinary output hourly
A toddler is hospitalized with Kawasaki's disease. Pharmacological management includes aspirin therapy. Which is the primary benefit of the aspirin? A. Minimize vascular inflammation B. Control high fever C. Reduce joint swelling D. Manage irritability
C. Reduce joint swelling
A client receives a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which information should the nurse include in the discharge teaching? A. Monitor blood pressure regularly B. Assess heart rate before each dose C. Report a decrease in sexual interest D. Avoid consumption of aged cheeses
C. Report a decrease in sexual interest
A client with end-stage metastatic cancer has a living will stating no extraordinary measures are to be taken as death approaches, and the healthcare provider writes a "Do Not Resuscitate" (DNR) prescription. When the client begins to take gasping breaths, the nurse determines the client's oximetry meter reading is 85%. What action should the nurse implement? A. Determine if client wishes have changed B. Manually ventilate using a bag-valve-mask apparatus C. Report client's status to the healthcare provider D. Administer oxygen via nasal cannula
C. Report client's status to the healthcare provider
Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with lens implant? A. Turn, cough, and deep breathe every 2 hours B. Observe pupil response of the right eye C. Sleep flat in a supine position D. Administer a stoll softener
C. Sleep flat in a supine position
A client has a viral hepatitis A and hepatic encephalopathy. An unlicensed assistive personnel (UAP) is assigned to help the client with a bath. Which information should the nurse reinforce with the UAP? A. Don a mask when handling bedpan B. Maintain strict reverse isolation C. Wear gloves while giving the bath D. Restrict the client's family visitation
C. Wear gloves while giving the bath
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A. Use a walker when weakness occurs B. Avoid extreme environmental temperatures C. Increase daily intake of sodium in diet D. Take prescribed cortisone accurately
D. Take prescribed cortisone accurately
An elderly patient is worried about incontinence. When the patient walked to the bathroom, the nurse notes that the patient is short of breath. What interventions should the nurse implement?
Give patient a bedside commode Check the patient's medication chart
When entering the room of a sedated postoperative client, which assessment requires the most immediate intervention by the nurse? A. The urinary catheter drainage bag is almost completely full of amber urine B. Low intermittent suction prescribed for the nasogastric tube is turned off C. A Hemovac drain is partially full of serous drainage and is not compressed D. Oxygen is being administered via nasal cannula at 4 L/min without humidification
D. Oxygen is being administered via nasal cannula at 4 L/min without humidification
Signs and symptoms of patient receiving too much Prednisone for adrenocortical insufficiency (Addison's Disease)
Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia (excess amount of glucose) Prednisone: Adverse Reactions/Side effects: Depression, euphoria, hypertension, anorexia, nausea, vomiting, acne, adrenal suppression, thrombembolis, moon fast, violent Prednisone: Nursing Assessment: Assess involved symptoms, assess for signs of adrenal insufficiency, i & o ratios, daily weights, hypotension, nausea, lethargy, confusion
Which statement by a client with systemic lupus erythematous (SLE) indicates the best understanding of proper skin care? A. "Tanning booths are okay to use but I need to stay out of direct sunlight" B. "I should apply drying agents on my draining lesions every day" C. "I need to make sure no one else comes in contact with my skin rash" D. "If I'm out int he sun, I need to use a very strong sun block"
D. "If I'm out int he sun, I need to use a very strong sun block"
The nurse notes that a client's plan of care includes the problem, "Deficient Knowledge (Dietary changes)." In developing a teaching plan, what information is most important for the nurse to obtain? A. Etiology of the problem B. Availability of the dietician for consultation C. Family members involved in the client's care D. Age of the client
D. Age of the client
An elderly client with Alzheimer's disease is being discharged with several prescriptions and the nurse plants to teach the daughter, who is the primary caregiver, about drug administration. What is the best method to use in evaluating the daughter's understanding? A. Observe the daughter administering the medication before leaving the hospital B. Evaluate the questions asked by the daughter after providing them with written instructions C. Administer a written test on medication administration after watching the nurse administer the drugs. D. Ask the daughter to repeat the dosages and methods for administration to assess her understanding
D. Ask the daughter to repeat the dosages and methods for administration to assess her understanding
The clinic medical receptionist is responsible for taking client calls relaying messages to the office nurse. Which client call should the nurse return first? A. Anginal pain relieved after taking 3 SL tablets of nitroglycerin B. Spinal osteomyelitis feeling nauseated for past 6 hours C. Hepatits A with complaint of arms and legs itching D. Casted right leg has a funny feeling tingling sensation
D. Casted right leg has a funny feeling tingling sensation (Numbness, tingling, sensation of the limb "falling asleep," coldness of the casted/splinted extremity and discoloration of the fingers or toes are due to the cast/splint being too tight)
The nurse is teaching a client about coronary artery disease (CAD) preventative health. Which behavior stated by the client indicates a need for additional information and teaching? A. Increased fiber, complex carbohydrates, and vegetables in the diet B. Performs 30 minutes of physical activity 5 days per week C. Avoids foods that are high in saturated fats D. Decreased the number of cigarettes smoked per day
D. Decreased the number of cigarettes smoked per day (This is the only one that made sense. You would need to cease smoking completely- not reduce)
The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority? A. Polycythemia B. Hyperbilirubinemia C. Hypoglycemia D. Hyperthermia
D. Hyperthermia
The nurse is providing wound care to a client with a stage 3 pressure ulcer that has large amount of eschar. The wound care prescription states, "Clean the wound and then apply collagenase." Collagenase is a deriding agent. The prescription does not specify a cleansing method. Which technique should the nurse use to cleanse the pressure ulcer? A. Lightly coat the wound with providone-iodine solution B. Remove the eschar with a wet-to-dry dressing C. Flush the wound with sterile hydrogen peroxide D. Irrigate the wound with sterile normal saline
D. Irrigate the wound with sterile normal saline
The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L SI) and glucose level of 180 mg/dL (10.0 mmol/L SI). Which evaluation is most important for the nurse to include in this client's plan of care? A. Monitor and document strict intake and output B. Evaluate glucose levels before and after meals C. Assess the serum potassium level q4 hours D. Obtain a 12-lead electrocardiogram daily
D. Obtain a 12-lead electrocardiogram daily (I would say D, hyperkalemia can cause chest pain/ palpitations due to increased levels of potassium; normal 3.5-5.5)
A gravida 2 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide? A. Rho (D) immune globulin injections must be administered within 24 hours after delivery B. It is likely that the husband is Rh-negative, and if so Rho (D) immune globulin injection is not needed C. Rho (D) immune globulin is not indicated since both previous babies were Rh-negative D. The newborn's blood type should be tested to determine the need for Rho (D) immune globulin injection
D. The newborn's blood type should be tested to determine the need for Rho (D) immune globulin injection
A home-bond client with severe, end-stage chronic obstructive pulmonary disease (COPD) is being visited by the home health. nurse. Which instruction should the nurse include in the client's teaching plan? A. Use the beta-agonist inhalers q2h, around the clock B. Use pursed-lip breathing techniques continually, around the clock C. Cluster activities together, first thing in the morning D. Use oxygen continuously, at the lowest dose possible
D. Use oxygen continuously, at the lowest dose possible
Hyperglycemic Hyperosmolar State (HHS)
HHS presentation: blood glucose over 600 serum osmolarity increased present with altered LOC, confusion & possible having seizures Profound dehydration, fluid loss of about 8 liters HHS generally occurs in: elderly type 2 diabetics, can be pretentiated by other processes, infection causes of HHS: environment, infection or emotional stresser which decreases amount of insulin HHS causes the breakdown of glycogen to glucose which causes hyperglycemia and osmotic diuresis treating HHS: establish & maintain open patent airwaycorrect hypovolemic shockmaintain fluid volume by vigorous infusion of IVFadminister potassium with hypokalemiagive insulintreat underlying cause
A school nurse is called to the wood shop class for a student who has a deep laceration to right forearm and is bleeding profusely. What should the nurse do while the paramedics arrive?
Have the patient lay down and elevate feet Clean the wound, apply a dressing and elevate arm
A patient with paranoia is standing in the corner of the room and is not communicating, what intervention should the nurse implement?
Instruct the patient on the nurse's role Show the patient the room
A patient has a herniated intervertebral lumbar disc and is experiencing right leg pain. How should the patient get up from the bed?
Lie on side to get out of bed/ Turn to the side and use hands to prop themselves up from the bed
A woman gave birth to an 8 lb. newborn a few Horus ago, while in the bathroom , the nurse notes the patient has blood running down her legs. What should the nurse do?
Palpate the fundus
An elderly patient in a nursing home develops hypothermia, what findings will the nurse include? SATA
Patient is confused Patient is cold and shivering
A client with opioid dependence arrives to the emergency department and is unresponsive with bradypnea and pinpoint pupils. What is the nurse's first intervention?
Possibilities: Establish an airway Assess neurological status
Which person should be triaged with a red tag indication as an immediate action?
Review Triage Colors
Head Lice= Pediculosis Capitis
S/S of active Lice Infestation: 1. Pruritus 2. Tickling feeling 3. Irritability & difficulty sleeping 4. Sores on head caused by scratching
Most immediate intervention for patient with diabetes insipidus
Serum sodium is the priority laboratory value to evaluate in patients diagnosed with DI. The inability of the kidneys to respond to ADH leads to increased sodium levels. Hypernatremia: high sodium (thirst, weakness, nausea, loss of appetite)
The patient complains of shortness of breath and chest pain. What diagnostic result should the nurse check for?
Troponin (Marker of heart injury/ damage)
A patient with viral hepatitis and hepatic encephalopathy: What instructions should the nurse give the UAP?
Wear gloves when bathing the patient Wear a mask
The charge nurse working on a rehabilitation unit is making client assignments for 2 registered nurses (RN) that have been in the department over 3 years, and one new RN graduate who completed orientation this week. Which client should the charge nurse assign to the new RN graduate? The client A. with a T-12 spinal cord injury who is being transferred from the neurological unit B. with a head injury who is being discharged home with multiple referrals c. whose family is meeting with the rehabilitation team to discuss a treatment plan d. with a total knee replacement who has 3 hours of prescribed physical therapy
c. whose family is meeting with the rehabilitation team to discuss a treatment plan
Ferrous sulfate elixir
do not dilute liquid
cholelithiasis
gallstones
