hesi exam 4

Heparin 0.4 units/kg/minute IV is prescribed for a client who weighs 110 pounds. The available solution is labeled heparin sodium 25,000 units in 5% dextrose injection 250 mL. The nurse should program the infusion pump to deliver how many ml/hour?

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A 154-pound client with diabetic ketoacidosis is receiving an IV abnormal saline 100 ml with regular insulin 100 units. The health care provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to infuse how many ml/hour?

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When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays in normal sinus rhythm, but he has no spontaneous respirations, and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Observed for swelling at the fracture site B. Begin chest compressions at 100/minute C. Analyze the cardiac rhythm in another lead D. Obtain a 12-lead electrocardiogram

B. Begin chest compressions at 100/minute The client's lack of spontaneous respirations, absence of a palpable carotid pulse, and a cardiac monitor displaying a normal sinus rhythm suggest cardiac arrest. In such a situation, immediate initiation of cardiopulmonary resuscitation (CPR) with chest compressions is essential to maintain circulation and provide oxygen to vital organs. Chest compressions should be started at a rate of 100-120 compressions per minute. Once CPR is initiated, additional interventions, such as defibrillation or medications, may be needed depending on the client's response and rhythm analysis.

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

C. Ask the client about his expected goals for this hospitalization By discussing the client's expected goals for hospitalization, the nurse can better understand the client's wishes and preferences regarding their care. It allows the nurse to engage in open communication with the client, assess their current needs and priorities, and ensure that their care plan aligns with their goals for palliative care. This conversation can also help determine if the client wishes to continue or cancel further radiation treatments, which should be based on their individual preferences and clinical circumstances.

A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning accident. While providing care to the child, the nurse begins talking with his pre-adolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Tell the older brother that he seems depressed C. Ask the older brother how he felt during the incident D. Commend the older brother for his heroic actions

C. Ask the older brother how he felt during the incident The older brother's feelings and emotions should be acknowledged and explored. He may be experiencing emotional distress or trauma related to the near-drowning incident and his role in the rescue and resuscitation. It's important for the nurse to create a safe and supportive environment for him to express his feelings and concerns.

Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl. The nurse prepares to administer a unit of blood for an emergency transfusion. That client has an AB negative blood type and the blood bank sends a unit of Type A RH negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A. Recheck the clients hemoglobin, blood type, and RH factor B. Administer normal saline until Type AB negative is available C. Obtain additional consent for administration of Type A negative blood D. Transfuse Type A negative blood until Type AB negative is available

D. Transfuse Type A negative blood until Type AB negative is available In an emergency situation with a critically low hemoglobin level, it is important to transfuse compatible blood as soon as possible to address severe anemia and improve oxygen-carrying capacity. In this case, although the client's blood type is AB negative, Type A negative blood can be safely administered until Type AB negative blood becomes available. Type A negative blood is compatible with AB negative recipients for red cell transfusion. The nurse should administer the available blood to address the critical situation, closely monitor the client's vital signs and response, and continue efforts to obtain Type AB negative blood as soon as possible.

Which needles should the nurse administer intravenous fluids via our clients implanted port?

The one with the little lock on the end; choose B, the second needle

Four hours after the nurse administers interferon alpha subcutaneously into a client, the client develops a headache, muscle aches and a fever of 101.8 degrees Fahrenheit. What action should the nurse implement? a. Administer prescribed PRN dose of acetaminophen for these side effects b. Explain that an antihistamine may be needed in response to this allergic reaction c. Document these findings as an idiosyncratic response to this medication d. Observed the site where the medication was injected for signs of local reaction

a. Administer prescribed PRN dose of acetaminophen for these side effects Flu-like symptoms are common side effects of interferon therapy, and acetaminophen can help alleviate these symptoms. It is essential to provide relief to the client to improve their comfort and tolerance of the medication.

The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consultS first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? a. Affirm the nurses plan to review the prescription with the provider b. Advise the nurse to administer the medication as prescribed c. Assume responsibility for discussing the concern with the provider d. Offer to administer the prescription since the nurse has concerns

a. Affirm the nurses plan to review the prescription with the provider The charge nurse should affirm the nurse's plan to review the prescription with the provider. It's important for the nurse to express concerns and seek clarification or additional information from the provider when they believe that a prescription may not be safe or appropriate for a client. Collaborative communication among healthcare team members is essential to ensure safe and effective care.

After reviewing the Braden scale findings of residents in a long term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? a. An older man who sheets are damp each time he is turned b. A woman with osteoporosis who is unable to bear weight c. An older adult who is unstable to communicate elimination needs d. A poorly nourished client who requires liquid supplements

a. An older man who sheets are damp each time he is turned The Braden Scale is a tool used to assess the risk of pressure ulcers in patients. The fact that this resident's sheets are consistently damp indicates that he may be at risk for moisture-related skin issues, which should be a priority for skin care. Skin moisture is one of the factors assessed in the Braden Scale, and in this case, it suggests that this resident may be at risk for skin breakdown due to moisture. The other residents may have their own skin care needs, but based on the information provided, addressing the moisture issue should be a priority.

A male client who arrives at the emergency department after a motor vehicle collision (MVC) tells the nurse "The car started to slide, and I just decided to let it go. Everyone would be better off if I was no longer was around." How should the nurse respond? a. Ask the client if the MVC was a suicide attempt b. Assess the client for other symptoms of depression c. Report to the health care provider that the client may need an antidepressant d. Determine what is going on in the clients life to make him feel depressed

a. Ask the client if the MVC was a suicide attempt Given the client's statement, it's important to directly and sensitively inquire if the MVC was an intentional act to harm himself. This helps to assess the client's risk of suicide and his immediate safety needs. It is crucial to determine if the incident was a suicide attempt in order to provide appropriate care and intervention.

A client with chronic kidney disease is admitted in heart failure and is complaining of shortness of breath and a headache. Assessment findings include blood pressure 180/90 mmHg, heart rate 130 beats/minute, oxygen saturation 89%, and a temperature of 100 degrees Fahrenheit. A temporary dialysis catheter is inserted for immediate hemodialysis and the client is scheduled for replacement of an arterial venous fistula in the left arm. Which action should the nurse implement? a. Avoid using the left arm for IV access b. Initiate oxygen at 110% per face mask c. Give the PRN dose of enalapril d. Administer PRN antipyretic prescription

a. Avoid using the left arm for IV access The client is scheduled for replacement of an arterial venous (AV) fistula in the left arm. It is standard practice to avoid using the arm designated for an AV fistula for IV access, blood draws, or blood pressure measurements to prevent damage to the fistula or veins in that arm.

A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first? a. Determine the clients vital signs b. Administer prescribed pain medication c. Apply warm blankets d. Assess the surgical site

a. Determine the clients vital signs Assessing the client's vital signs, including heart rate, blood pressure, respiratory rate, and temperature, is essential to evaluate their hemodynamic stability and overall condition after surgery. This information helps guide further interventions and ensures early detection of any complications.

The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? a. Difficulty breathing b. Increased blood pressure c. Chills and tremors d. Nausea and vomiting

a. Difficulty breathing An air embolism occurs when air bubbles enter the bloodstream and travel to the lungs or other vital organs, leading to symptoms such as difficulty breathing, chest pain, and potentially life-threatening complications. The other options may be associated with various complications of blood transfusions, but difficulty breathing is a classic sign of an air embolism.

The healthcare provider prescribes a placebo instead of pain medication. What intervention should the nurse implement? a. Discuss ethical concerns about placebo use with the health care provider b. Administer the placebo as prescribed when the client complaints of pain c. Tell the charge nurse about the prescribed placebo and refuse to administer it d. Inform the client that the provider prescribed a placebo instead of pain medication

a. Discuss ethical concerns about placebo use with the health care provider Prescribing a placebo instead of actual pain medication raises ethical concerns. The nurse should discuss these concerns with the healthcare provider to ensure that appropriate and ethical pain management options are considered for the client. Administering a placebo without addressing the ethical issues is not a recommended course of action, and it's essential to have an open dialogue with the provider to clarify the intention behind such a prescription.

An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 milliliters of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of bed b. Complete focus assessment c. Offer PRN pain medication d. Send emesis sample to the lab

a. Elevate the head of bed c. Offer PRN pain medication b. Complete focus assessment d. Send emesis sample to the lab

The nurse notes that a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a. Engage the client in non-threatening conversations b. Encourage the client to participate in group activities c. Encourage the clients family to visit more often d. Schedule a daily conference with the social worker

a. Engage the client in non-threatening conversations For a depressed client who has become more withdrawn and noncommunicative, the most important intervention is to engage the client in non-threatening conversations. This approach can help build rapport, provide emotional support, and create a therapeutic environment where the client feels safe expressing their thoughts and feelings. It allows the nurse to assess the client's current emotional state and potentially identify any concerns or issues that may be contributing to the withdrawal and non-communication. Engaging in conversations can be a first step toward addressing the client's depression and promoting their well-being.

An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus is admitted to the telemetry unit for sudden onset of dizziness with palpitations and a burning sensation in her chest. Which intervention should the nurse implement first? a. Evaluate telemetry cardiac rhythm b. Administer an oral antacid c. Assess blood glucose level d. Review clients last meal choices

a. Evaluate telemetry cardiac rhythm The client's history of inferior myocardial infarction, along with the sudden onset of dizziness, palpitations, and a burning sensation in the chest, raises concerns about a cardiac event or arrhythmia. Therefore, the nurse should immediately assess the client's cardiac rhythm using telemetry to determine if any life-threatening arrhythmias or changes in cardiac function are present. This assessment will help guide further interventions and treatment.

A client with chronic kidney disease (CKD) is discharged with a prescription for epoetin alpha subcutaneously. In teaching the client about the medication, the nurse should emphasize the benefit of increasing which food product in the diet? a. Iron rich foods b. High fiber foods c. Citrus fruits and vegetables d. Dairy products

a. Iron rich foods Epoetin alpha is a medication used to treat anemia in CKD by stimulating the production of red blood cells. Iron is essential for the production of hemoglobin, a protein in red blood cells that carries oxygen. In CKD, the kidneys may not produce enough erythropoietin, a hormone that stimulates red blood cell production. Iron-rich foods can help support the production of hemoglobin and red blood cells, which is essential for managing anemia in CKD.

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type one diabetes mellitus, the client tells the nurse in a loud voice to leave the room. What action should the nurse take? a. Leave the clients room and return later in the day b. Explain that insulin is a life saving drug for the client c. Encourage client to implement relaxation techniques d. Refer the client to the social worker for support therapy

a. Leave the clients room and return later in the day This response respects the client's immediate wish for space while acknowledging the importance of the teaching that needs to occur. The client's reaction may be due to a variety of factors such as fear, overwhelm, or denial regarding the new diagnosis. Giving the client some time to process their emotions can be beneficial. The nurse can return later when the client may be more receptive to learning.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate that the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Observe aspiration site b. Monitor skin elasticity c. Measure urinary output d. Assess body temperature

a. Observe aspiration site Following a bone marrow biopsy, it is essential to closely monitor the aspiration site for any signs of bleeding or hematoma formation, especially in a client with thrombocytopenia. Thrombocytopenia means a decreased number of platelets, which are crucial for blood clotting. Monitoring for any signs of bleeding is a priority in clients with low platelet counts. The other assessments (monitoring skin elasticity, measuring urinary output, and assessing body temperature) are important but may not be the primary concern immediately after a bone marrow biopsy, especially in the presence of thrombocytopenia.

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. Plumb line test indicates fetal position curvature c. Babinski tests that reveals fanning out of toes d. Moro test precipitating a startle response

a. Ortolani maneuver causing a click at the hip joint The Ortolani maneuver, which produces a click at the hip joint, is a clinical test used to assess for developmental dysplasia of the hip (DDH) in newborns. A positive Ortolani maneuver suggests hip instability, and it should be reported to the health care provider for further evaluation and assessment of the newborn's hips. Early detection and management of DDH are important to prevent long-term hip problems. The other assessments mentioned are not typically associated with hip joint issues.

When providing client care, the nurse identifies a problem and develops a related clinical question. Next the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence based. When gathering evidence, which consideration is most important? a. Relevance to the situation b. Related personal values c. Frequency that the problem occurs d. Past experience with similar problems

a. Relevance to the situation When gathering evidence for an evidence-based practice approach, the most important consideration is the relevance of the evidence to the specific clinical situation or problem at hand. Evidence should be directly related to the clinical question or problem, ensuring that it is applicable and valid for the current situation. Personal values, frequency of the problem, and past experiences are important factors to consider but should not take precedence over the relevance of the evidence to the specific clinical scenario.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative. Which nursing care interventions should the nurse include in the client's plan of care? Select all apply. a. Remove urinary catheter as soon as possible and encourage voiding b. Assess pain level and medicate PRN as prescribed c. Maintain sequential compression devices while in bed d. Teach client to use incentives spirometer every two hours while awake e. Administer low molecular weight heparin as prescribed

a. Remove urinary catheter as soon as possible and encourage voiding d. Teach client to use incentives spirometer every two hours while awake a:Prolonged use of a urinary catheter can increase the risk of urinary tract infections (UTIs). Removing it as soon as it is no longer medically necessary and encouraging normal voiding helps to reduce this risk. d: This is important to prevent respiratory complications like pneumonia, which can occur postoperatively, especially in older adults. Using an incentive spirometer helps in keeping the lungs clear and reduces the risk of infection. e: Low molecular weight heparin is used to prevent venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). While not directly an intervention for reducing infection risk, preventing these complications is crucial in overall postoperative care and can indirectly reduce the risk of infection associated with prolonged immobility.

The nurse should withhold which medication if the clients serum potassium level is too high? a. Spironolactone b. Hydrochlorothiazide c. Metolazone d. Furosemide

a. Spironolactone Spironolactone is a potassium-sparing diuretic, which means it helps the body eliminate fluids without causing the loss of potassium. When a client already has elevated potassium levels, administering spironolactone could exacerbate hyperkalemia.

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavior

a. State it is unacceptable to undress during interview Setting clear and firm boundaries in a respectful and non-confrontational manner is crucial. The nurse should calmly but firmly inform the client that undressing during the interview is not acceptable behavior. This approach respects the client's dignity while maintaining a safe and appropriate environment.

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this clients plan of care? a. Teach techniques for scanning the environment b. Practice visual exercises that focus on a still object c. Encourage the use of corrective lenses during the day d. Alternate an eye patch from eye to eye every two hours

a. Teach techniques for scanning the environment When a client with multiple sclerosis experiences scotomas (blind spots) that limit peripheral vision, teaching techniques for scanning the environment is important. Scanning involves systematically looking around the visual field by moving the eyes, head, or both to compensate for blind spots and improve awareness of the surroundings. This technique can help the client navigate their environment more effectively and safely.

A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? Select all that apply. a. Arrange in service training through the education department b. Obtain informed consent from clients who will receive care c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee

a. arrange in service training through the education department d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee a: Education and training are essential for implementing new practices. Arranging in-service training sessions will help in disseminating the new evidence-based practice among the nursing staff and ensure consistent application across the facility. d: The quality improvement department plays a crucial role in evaluating and supporting practice changes in healthcare settings. Inviting them to review the data from the pilot study can provide an objective assessment of the effectiveness and potential impact of the proposed change. e: The nursing committee, often responsible for setting and approving clinical standards, should be involved in the process of adopting new practice guidelines. Presenting the successful outcomes of the pilot study to this committee can facilitate the formal adoption of the new practice across the facility.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include heart rate of 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? a. Bilateral diffuse wheezing b. Temperature of 100.5 c. Yellow expectorated sputum d. Shortness of breath on exertion

a. bilateral diffuse wheezing Bilateral diffuse wheezing indicates significant airway constriction, which can severely compromise respiratory function, particularly in a client with COPD who already has compromised lung function. This symptom can be indicative of an acute exacerbation of COPD or worsening pneumonia, both of which require prompt medical intervention to improve airway patency and oxygenation.

The nurse instructs an unlicensed assistive personnel (UAP) to turn and immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Feed the client a snack c. Assess the breath sounds d. Offer the client oral fluids

a. empty the urinary drainage bag While it may not be necessary to empty the urinary drainage bag every two hours, it is important for the UAP to ensure that the bag is properly positioned each time the client is turned. The bag should be kept below the level of the bladder to prevent backflow of urine and positioned so that it does not pull on the catheter. This helps to prevent infection and discomfort. The UAP should also check that the tubing is not kinked or twisted to ensure proper drainage.

Following breakfast, the nurse is preparing to administer 0900 medications to the clients on the medical floor. Which medication should be held until a later time? a. The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease b. The antifungal nystatin suspension, for a client who has just brushed his teeth c. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour d. The loop diuretic furosemide, for a client with a serum potassium level of 4.2 meq/L

a. the mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease This medication is best administered when the stomach is empty, which would not be the case immediately following breakfast. The nurse should plan to administer this medication either 1 hour before the next meal or 2 hours after the client has finished eating.

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the clients discharge teaching plan? Select all that apply. a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting d. Crossed legs at knee but not at ankle e. Maintain the bed flat while sleeping

a. use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting b: Compression stockings are essential in managing chronic venous insufficiency as they help improve blood flow and reduce swelling in the legs. They should be worn as advised by the healthcare provider. c: Prolonged periods in the same position can exacerbate venous insufficiency by hindering blood flow in the lower extremities. It's important to change positions regularly and take breaks to move around if possible.

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? a. "How do you cope with the voices?" b. "What are the voices saying?" c. "Which medication works best?" d. "When do you hear voices?"

b. "What are the voices saying?" When assessing a client with schizophrenia who reports auditory hallucinations, asking "What are the voices saying?" is the most important question. Understanding the content and nature of the auditory hallucinations can provide valuable information about the client's experiences and may help in formulating an appropriate plan of care and treatment. It can also help determine whether the voices are benign or commanding, which can influence the level of risk and urgency in providing care.

What is the primary goal when planning nursing care for a client with degenerative joint disease? a. Improve stress management skills b. Achieve satisfactory pain control c. Obtain adequate rest and sleep d. Reduce risk for infection

b. Achieve satisfactory pain control Pain control is a central aspect of care for individuals with degenerative joint disease because pain is one of the most common and debilitating symptoms associated with this condition. Effective pain management can improve the client's quality of life, increase mobility, and enhance overall functioning. It is crucial to address pain as a priority when caring for clients with degenerative joint disease to promote their comfort and well-being.

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. Which intervention has the highest priority for this client? a. Administer prescribed PRN sleep medications b. Administer prescribed stool softener c. Encourage use of prescribed analgesic perennial sprays d. Encourage breastfeeding to promote uterine involution

b. Administer prescribed stool softener A fourth-degree midline laceration is a severe perineal laceration that extends through the anal sphincter. Stool softeners are essential to prevent constipation and straining during bowel movements, which can cause pain and potential damage to the repair site. Maintaining bowel regularity and preventing straining is a crucial aspect of postpartum care for clients with this type of laceration.

A male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink frothy sputum. The nurse sits the client and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. Which action should the nurse take? a. Withhold the morphine until the client's dyspnea resolves b. Administer the dose of morphine sulfate as prescribed c. Consult with the charge nurse regarding the morphine prescription d. Review the need for the prescription with the health care provider

b. Administer the dose of morphine sulfate as prescribed Morphine can help reduce the client's anxiety and decrease the sensation of breathlessness, which can be distressing. Morphine can help reduce the workload on the heart by dilating blood vessels. This can help to alleviate some of the fluid congestion in the lungs. While the client may not be in pain, the calming effect of morphine can be beneficial in this high-stress situation.

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly

b. Affirm that the client should arise slowly from the chair Parkinson's disease is characterized by motor symptoms such as bradykinesia (slowness of movement), rigidity, and tremors. Patients often have difficulty with movements and require more time to perform physical tasks. Rising slowly from a seated position is appropriate for someone with Parkinson's disease as it allows them to adjust and maintain balance, reducing the risk of falls. The nurse should affirm this approach and ensure that the UAP understands the importance of allowing the client to move at their own pace for safety.

Oxygen at 5 L/minute per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? a. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs b. Avoid administration of oxygen at high levels for extended periods c. Oxygen is less toxic when it is humidified with a hydration source d. Increase oxygen rate during sleep to compensate for slower respiratory rate

b. Avoid administration of oxygen at high levels for extended periods When administering oxygen to a child, it's important to avoid using high oxygen levels for extended periods unless absolutely necessary. Oxygen toxicity can occur when high concentrations of oxygen are given over an extended period. Oxygen should be used judiciously and titrated to maintain adequate oxygenation without causing harm. Monitoring oxygen saturation levels and adjusting the oxygen flow rate accordingly is essential to prevent oxygen toxicity.

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? a. Prepare for emergent oral intubation b. Clarify end of life desires c. Offer sips of favorite beverages d. Initiate comfort measures

b. Clarify end of life desires Given the client's diagnosis of end stage metastatic breast cancer and her current condition, it is crucial to understand her wishes for end-of-life care. Clarifying her desires regarding treatment, resuscitation status, and where she wants to receive care (such as at home or in a hospital) is essential for providing respectful, patient-centered care. This could involve discussing advanced directives, palliative care options, and hospice care if not already in place.

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? a. Average client scores improved on specific risk factor knowledge tests b. Clients who develop disease complications promptly received rehabilitation c. Only 30% of clients did not attend self-management education sessions d. More than 50% of at risk clients were diagnosed early in their disease process

b. Clients who develop disease complications promptly received rehabilitation This outcome directly reflects the goals of tertiary prevention, which include preventing further physical deterioration, managing symptoms effectively, and providing rehabilitation when complications arise. Promptly receiving rehabilitation services for complications signifies that the program effectively supports clients in managing the more severe aspects of type 2 diabetes, thereby improving their overall health outcomes.

The mother of a child recently diagnosed with asthma ask the nurse how to help protect her child from having asthma attacks. To avoid triggers for asthma attacks, which instruction should the nurse provide the mother? Select all that apply. a. Decrease the raw sugars in the diet b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair b: This can help minimize exposure to outdoor allergens and pollutants, such as pollen and dust, which can trigger asthma symptoms. c: Sudden changes in temperature can trigger asthma symptoms in some individuals. It's important to try to keep the child's environment as temperature-stable as possible. d: Grass pollen and other particulates released during lawn mowing can be asthma triggers. Staying indoors while grass is being cut can help reduce exposure to these triggers. e: Pet dander, especially from pets with long hair, can be a significant trigger for asthma attacks. It's advisable to avoid or minimize exposure to pets if the child is allergic to them.

A male client who is experiencing musculoskeletal pain is discharged with instructions to take ibuprofen, on non-steroidal anti-inflammatory drug by mouth BID. After receiving discharge teaching, the client states he plans to take the medication twice daily, with breakfast and dinner. How should the nurse respond? a. Review the need to limit intake of leafy, green vegetables such as spinach b. Confirm that the client has an effective plan for when to take the medication c. Explain the need to take the medication before meals to increase absorption d. Remind the client to increase fluid intake while taking the medication

b. Confirm that the client has an effective plan for when to take the medication The client's statement about planning to take ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), twice daily with breakfast and dinner aligns well with the prescribed regimen of BID (twice daily) dosing. Taking NSAIDs with meals can help minimize gastrointestinal side effects such as stomach irritation, which is a common concern with these medications. Therefore, the nurse should confirm that this is an effective and appropriate plan.

A client at 28 weeks' gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? a. Recount the heart rate manually to confirm a monitor malfunction b. Contact the health care provider after initiating oxygen per face mask c. Explain that there is no indication the fetal heart rate is due to trauma d. Evaluate the presence of preterm labor by performing a vaginal examination

b. Contact the health care provider after initiating oxygen per face mask Fetal tachycardia (an abnormally high fetal heart rate) can be an indication of fetal distress or other issues that require medical evaluation. Initiating oxygen via a face mask is a standard initial intervention to ensure that both the mother and fetus receive adequate oxygenation. Following this, it is important to contact the healthcare provider for further assessment and guidance on the next steps in the client's care.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effects is the nurse likely to note as a result of this increase in glaucoma surgeries? a. Decrease morbidity in the elderly population b. Decrease prevalence of glaucoma in the population c. Increase mortality in the elderly population d. Increased incidence of glaucoma in the population

b. Decrease prevalence of glaucoma in the population The increased number of elderly persons electing to undergo surgery for glaucoma is likely to result in a decrease in the prevalence of glaucoma in the population. Glaucoma surgery is performed to lower intraocular pressure and prevent further damage to the optic nerve, which is a common goal in the treatment of glaucoma. By successfully treating glaucoma through surgery, the prevalence of the disease in the population is expected to decrease, as more individuals with glaucoma can have their intraocular pressure controlled and the progression of the disease slowed or halted.

An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she's sick or stressed. How should the nurse respond? a. Describe the use of the vaccination to treat herpes simplex type 2 b. Explain the use of the vaccination to reduce risk for herpes zoster c. Confirm that consent form is signed before administering the vaccination d. Arrange for skin testing to evaluate if the client is a candidate for the vaccine

b. Explain the use of the vaccination to reduce risk for herpes zoster The herpes vaccination mentioned here is likely referring to the herpes zoster vaccine, which is used to reduce the risk of shingles (herpes zoster) in older adults. Herpes simplex type 2 is a different virus that causes genital herpes, and the herpes zoster vaccine is not intended to treat it. Therefore, option (b) is the most appropriate response, as it addresses the client's concern about getting cold sores (caused by herpes simplex virus) and explains the purpose of the herpes zoster vaccine.

An older client is referred to a rehabilitation facility following a cerebrovascular accident. The client is aphasic with left sided paralysis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? a. Initiate passive range of motion exercises b. Facilitate a consultation for speech therapy c. Use pictures and gestures to communicate d. Arrange for daily home care assistance

b. Facilitate a consultation for speech therapy For an older client who is aphasic and experiencing difficulty swallowing following a cerebrovascular accident (stroke), the most important intervention is to facilitate a consultation for speech therapy. Speech therapy can address communication difficulties and swallowing problems (dysphagia), which are common after a stroke. Speech therapists can work with the client to improve their ability to communicate and assess and treat swallowing issues, reducing the risk of aspiration and related complications. This intervention is critical for the client's recovery and safety.

A client is admitted to the labor and delivery unit in early labor and the nurses assesses the status of her contractions. The frequency of contractions is most accurately valued by counting the minutes and seconds in which manner? a. From the peak of one contraction to the peak of the next contraction b. From the beginning of one contraction to the beginning of the next contraction c. From the beginning of one contraction to the end of that contraction d. From the end of one contraction to the beginning of the next contraction

b. From the beginning of one contraction to the beginning of the next contraction Frequency of contractions refers to the time from the start of one contraction to the start of the next. This measurement includes the length of the contraction itself plus the time between contractions. It provides information about how often contractions are occurring, which is essential for monitoring the progression of labor.

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first? a. Insert a nasogastric tube for feeding b. Initiated a prescribed IV for parenteral fluid c. Give the infant 5% dextrose in water orally d. Feed the infant 3 ounces of isomil

b. Initiated a prescribed IV for parenteral fluid The assessment findings in this infant, including poor skin turgor, significant weight loss, and a palpable mass in the abdomen, suggest dehydration and may indicate a gastrointestinal obstruction. Therefore, the priority intervention is to initiate a prescribed IV for parenteral fluid administration to rehydrate the infant and correct any electrolyte imbalances. Further diagnostic tests and evaluation by a healthcare provider will be needed to determine the cause of the vomiting and the abdominal mass. Nasogastric tube insertion and feeding would be considered after the infant's fluid balance is stabilized. Giving oral fluids may not be sufficient to address the dehydration and underlying issue in this case.

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life threatening and should be reported to the health care provider immediately? a. Difficulty with balance b. Intensifying headache c. Right ear hearing loss d. Facial numbness

b. Intensifying headache An intensifying headache in a client with an acoustic neuroma can be indicative of increased intracranial pressure, which can be life-threatening if not addressed promptly. Acoustic neuromas, though typically benign, can grow and press on adjacent brain structures, leading to increased intracranial pressure. This pressure can cause a severe headache and might lead to serious complications, including brain herniation, if not treated immediately.

A client with cirrhosis of the liver having numerous, liquid, incontinent stools, and continues to be confused. After reviewing the clients laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. IV Human albumin b. Lactulose c. Furosemide d. Loperamide

b. Lactulose Lactulose is a medication specifically used to treat elevated serum ammonia levels in clients with liver disease, particularly cirrhosis. It works by lowering ammonia levels in the blood. Ammonia is a byproduct of protein metabolism that is normally detoxified by the liver. In liver cirrhosis, the liver's ability to detoxify substances like ammonia is compromised, leading to an accumulation in the blood. Elevated ammonia levels can cause hepatic encephalopathy, a decline in brain function, resulting in symptoms such as confusion. Lactulose helps by promoting ammonia excretion through the stool.

The nurse is caring for a group of clients with the help of a practical nurse. Which nursing action should the nurse assign to the PN? Select all that apply. a. Start the second blood transfusion for the client 12 hours following a below knee amputation b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty e. Initiate patient-controlled analgesia pumps for two clients immediately postoperatively

b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty b: This is within the scope of practice for a PN and does not require RN-level intervention. c: Administering insulin according to a sliding scale is within the scope of practice for a PN as long as the PN is trained and competent in administering insulin. d: Taking vital signs for a stable postoperative client is typically within the scope of practice for a PN.

The nurse is caring for a client with a suspected diagnosis of osteomyelitis. Which diagnostic test should the nurse prepare the client to expect the health care provider to prescribe? a. Radiographs b. Radionuclide bone scan c. C reactive protein tests d. Erythrocytes sedimentation rate

b. Radionuclide bone scan A radionuclide bone scan is a diagnostic test commonly used to detect and evaluate bone infections like osteomyelitis. It can help identify areas of increased bone activity, which may be indicative of an infection. This test can provide valuable information to aid in the diagnosis and management of osteomyelitis.

The nurse on a pediatric unit of a healthcare facility observes a colleague leaving and open client electronic health record unattended while taking a lunch break. Which action should the nurse take? a. Close the computer and complete the day's assignments b. Remind the colleague of information security principles c. Comment about the action on a staff discussion board d. Discuss the incident with the facilities risk manager

b. Remind the colleague of information security principles Leaving an open client electronic health record unattended is a breach of patient confidentiality and violates information security principles. It's important to address this issue promptly and professionally. Reminding the colleague about the importance of safeguarding patient information is an appropriate initial step. If there are ongoing concerns about information security practices, it may be necessary to discuss the incident with the facility's risk manager or follow facility-specific protocols for reporting such incidents. Posting about it on a staff discussion board is not the most appropriate way to address this issue.

A male client with hypertension, who is receiving a new antihypertensive prescription at his last visit returns to the clinic 2 weeks later to evaluate his blood pressure. His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad." In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Heart block due to myocardial damage b. Stroke secondary to hemorrhage c. Acute kidney injury due to glomerular damage d. Blindness secondary to cataracts

b. Stroke secondary to hemorrhage Hypertension (high blood pressure) can increase the risk of various cardiovascular and cerebrovascular complications, including stroke. When blood pressure is consistently elevated, it can damage blood vessels throughout the body, including those in the brain. Over time, this can lead to the weakening of blood vessel walls, making them more prone to rupture, which can result in a hemorrhagic stroke.

After spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which is admission assessment findings should the nurse reports of the health care provider? Select all that apply a. Red blood cell count (RBC) b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC) e. Location of the initial IV site

b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC) b: Swollen lymph nodes can indicate that the body is responding to an infection. In the case of an infection in the leg, swollen lymph nodes in the groin area are particularly relevant as they may signify a systemic response to the infection. c: An elevated core body temperature (fever) is a common sign of infection. Reporting the client's temperature will help the healthcare provider assess the severity of the infection and the body's response to it. d: A complete blood count, particularly the white blood cell count, is crucial in the assessment of infection. An elevated WBC count typically indicates an infection or inflammatory process in the body.

A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30-second periods of apnea, the healthcare provider is notified, and STAT arterial blood gases are drawn. What ABG results should the nurse anticipate? a. Compensated respiratory acidosis b. Uncompensated respiratory acidosis c. Uncompensated metabolic acidosis d. Compensated metabolic acidosis

b. Uncompensated respiratory acidosis The client's lethargy, slow respiratory rate, and episodes of apnea indicate respiratory depression, which can lead to an accumulation of carbon dioxide (CO2) in the bloodstream. This results in respiratory acidosis, which is characterized by an increase in the partial pressure of arterial carbon dioxide (PaCO2) and a decrease in pH. Since the client's respiratory rate is slow and there are periods of apnea, there hasn't been enough time for the body to compensate for the acidosis, making it uncompensated respiratory acidosis.

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first? a. Change the surgical dressing to observe the appearance of the incision b. Assess the level of consciousness and vital signs for both clients c. Review the plan of care and the medications that are due for both clients d. Complete a head-to-toe assessment of the client with pneumonia

b. assess the level of consciousness and vital signs for both clients In critical care settings, the priority is always to assess and ensure the stability of the clients. Checking the level of consciousness and vital signs provides immediate information about the clients' hemodynamic status and potential acute needs. This is especially important for a client on mechanical ventilation and another who is postoperative, as both can experience rapid changes in their condition.

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Blood transfusion b. Bone marrow transplantation c. Immunosuppressive therapy d. Chemotherapy

b. bone marrow transplantation This is often considered the treatment of choice, especially for younger patients with a severe form of aplastic anemia and when a suitable donor is available, such as a matched sibling. Bone marrow transplantation can potentially cure the disease by replacing the dysfunctional bone marrow with healthy stem cells, which then generate new blood cells.

A young client involved in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse provide to the practical nurse who is caring for this client? a. Avoid washing the limb when assisting with bathing b. Elevate limb above the heart when lying in bed c. Avoid planter flexion of the affected limb d. Perform range of motion on the affected limb

b. elevate limb above the heart when lying in bed Elevating the injured limb above the heart level helps to reduce swelling and improve venous return. This is particularly important in the case of a muscle laceration, as reducing swelling can alleviate pain and promote healing. Elevation can also help prevent complications such as deep vein thrombosis (DVT) which can occur with reduced mobility.

A seriously ill male client is transferred to the health care facility in a different state. Included in his records are advanced directive and a physician orders for life sustaining treatment. However, the state to which he is transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? a. Request that the new health care provider cosine the POLST document b. Implement the clients wishes as described in his advanced directive c. Ask the clients family to make life sustaining treatment decisions d. Attached an advance directive copy to a medical record prescription page

b. implement the clients wishes as described in his advanced directive The advanced directive is a legal document that outlines a person's preferences for medical treatment in situations where they are unable to make decisions for themselves, such as a coma. Since advanced directives are generally respected across state lines, the healthcare team should honor the wishes expressed in this document.

The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated blood pressure in a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Measure ankle circumference b. Monitor daily sodium intake c. Record usual eating patterns d. Auscultate for irregular heart rate

b. monitor daily sodium intake Chronic kidney disease often impairs the body's ability to regulate electrolytes and fluid balance, and sodium intake plays a crucial role in this. Excessive sodium can exacerbate hypertension (high blood pressure) and can contribute to fluid retention, worsening both blood pressure control and the electrolyte imbalance. Careful monitoring and management of sodium intake are essential in managing these complications in clients with chronic kidney disease.

For the second time in four months, and overweight client is seen in the clinic because of vulvovaginitis resulting from a candida infection. Which intervention should the nurse implement first? a. Determine the client's typical menstrual cycle b. Obtain the client's blood glucose level c. Ask the client about recent sexual activity d. Review the client results for a complete blood count

b. obtain the client's blood glucose level Recurrent vulvovaginal candidiasis (yeast infections) can be a sign of uncontrolled diabetes, as elevated glucose levels can promote the growth of Candida. Overweight individuals are at a higher risk for type 2 diabetes. Therefore, checking the blood glucose level is a critical first step in identifying a possible underlying cause of the recurrent infections.

The parents bring their one-year-old child with a ventricular septal defect to the clinic for a well child visit. Which assessment finding should the nurse report to the health care provider immediately? a. Respirations of 26 breaths/minute at rest b. Expected weight and growth care for an infant c. 2+ pitting edema in the extremities d. Heart rate of 105 beats/minute

c. 2+ pitting edema in the extremities Pitting edema in a one-year-old child with a ventricular septal defect can indicate worsening heart failure or fluid overload. This is a significant concern, and the nurse should report it to the healthcare provider immediately for further evaluation and management. Pitting edema suggests that there is excessive fluid accumulation in the tissues, which may be related to the cardiac defect. The healthcare provider will need to assess the child's cardiac status and adjust the treatment plan accordingly.

When should intimate partner violence screening occur? a. Once the clinician confirms a history of abuse b. Only when a client presents with an unexplained injury c. As a routine part of each healthcare encounter d. As soon as the clinician suspects a problem

c. As a routine part of each healthcare encounter Intimate partner violence screening should occur as a routine part of each healthcare encounter, regardless of whether there is a confirmed history of abuse, the presence of unexplained injuries, or when abuse is suspected. Screening during every healthcare encounter helps identify potential cases of intimate partner violence early, ensuring that individuals affected by such violence receive appropriate support and interventions. This approach is consistent with guidelines and recommendations to address and prevent intimate partner violence in healthcare settings.

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? Select all that apply. a. Chicken bouillon soup and toast b. Fresh vegetables with mayonnaise dip c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples e. Soda crackers and peanut butter

c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples c: Fresh turkey, especially if it's lean and not processed, is a good source of protein and is generally low in saturated fat. Berries are high in antioxidants and fiber, making them an excellent choice for a heart-healthy diet. d: Almonds are a good source of healthy fats, fiber, and protein, and they are beneficial for heart health when eaten in moderation. Apples are high in fiber and various health-promoting compounds. Choosing unsalted almonds helps to keep sodium intake low.

A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client discharge teaching? a. Use of topical applications to manage pruritis b. Strategies to promote independent self-care c. Instructions regarding a restricted protein diet d. Need for maintaining good oral hygiene

c. Instructions regarding a restricted protein diet Dietary management is a crucial aspect of caring for clients with chronic renal insufficiency. A restricted protein diet helps reduce the burden on the kidneys, as breaking down protein produces waste products that the kidneys need to filter. By consuming less protein, the workload on the kidneys is reduced, which can help slow the progression of kidney disease and manage symptoms.

While changing the clients postoperative dressing, the nurse observes are red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the health care provider, the nurse should evaluate which of the client's laboratory values? a. C reactive protein level b. Serum albumin c. Neutrophil count d. Creatinine level

c. Neutrophil count Neutrophils are white blood cells that play a significant role in the body's defense against bacterial infections. An elevated neutrophil count (neutrophilia) may indicate an active infection. Evaluating the neutrophil count can help provide information about the severity of the infection and guide the appropriate treatment.

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Obtain the infants vital signs b. Observe the instant latching on to the breast c. Place the ID bands on the infant and mother d. Administer vitamin K injection

c. Place the ID bands on the infant and mother Placing identification bands on both the infant and the mother is an essential safety measure to ensure proper identification and matching of mother and baby. This helps prevent any mix-ups or confusion in the postpartum period. The infant's vital signs (option a) are typically assessed after birth, but the priority is to ensure proper identification first. Observing the infant latching on to the breast (option b) and administering a vitamin K injection (option d) can occur after proper identification is established.

The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asked the nurse for information about the scheduled procedure. What action should the nurse implement? a. Reassure the client that whatever the outcome, he will be able to cope with the results b. Encourage the client to take deep breaths in to avoid thinking negative thoughts c. Repeat the client teaching and leave written instructions for the client d. Remind the client of the instructions that were provided an hour ago

c. Repeat the client teaching and leave written instructions for the client It's important to provide clear and accurate information to the client about the scheduled procedure. Since the client asked for information again, it's best to repeat the teaching and provide written instructions to ensure the client has the necessary information to prepare for the procedure. This helps promote the client's understanding and cooperation.

The nurse is managing for clients in the intensive care unit who were mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? a. High pressure alarm sounds when the client is coughing b. Diminished breath sounds in the right posterior base c. Restrained and restless with a low volume alarm sounding d. An audible voice when client is trying to communicate

c. Restrained and restless with a low volume alarm sounding This situation suggests that the client may be experiencing breathing difficulties or issues with the ventilator circuit, such as a disconnection or leak. The combination of restlessness, being restrained, and a low volume alarm indicates a potentially urgent situation that could compromise the client's ventilation and oxygenation.

What is the priority nursing problem for a client with hypoparathyroidism? a. Anxiety b. Imbalanced nutrition c. Risk for injury d. Deficient knowledge

c. Risk for injury The priority nursing problem for a client with hypoparathyroidism is the risk for injury. Hypoparathyroidism is characterized by low levels of parathyroid hormone (PTH), which can lead to decreased calcium levels in the blood (hypocalcemia). Hypocalcemia can cause muscle cramps, tetany, and seizures, which pose a significant risk for injury to the client. Therefore, the immediate concern is to monitor and manage the client's calcium levels to prevent these complications and ensure their safety.

A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a. Serum ph of 7.45 b. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c. Serum potassium of 3.0 mg/dl d. Gastric output of 100 ml in the last 8 hours

c. Serum potassium of 3.0 mg/dl A serum potassium level of 3.0 mg/dl is below the normal range (normal range is typically 3.5-5.0 mEq/L), and it indicates hypokalemia. Hypokalemia can lead to various cardiac and neuromuscular abnormalities, which can be especially concerning in a pediatric patient. It's crucial to report this finding to the healthcare provider for further evaluation and intervention.

A middle-aged man in the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide? a. Keep the infected area covered until the infection is resolved b. Use a fine-tooth comb to remove any knits observed on the scalp c. Take your medication with a glass of water two hours after meals d. Wash your bed linens and hot water after starting the medication

c. Take your medication with a glass of water two hours after meals Tetracycline is a type of antibiotic, and its absorption can be affected by the presence of food or dairy products. To ensure optimal absorption, tetracycline should be taken on an empty stomach, typically about 1-2 hours before or 2-3 hours after meals. Therefore, the instruction to take the medication with a glass of water two hours after meals is accurate. The other options do not pertain to the administration of tetracycline.

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach

c. Use cold and allergy medications only as directed by a health care provider When teaching a client taking cyclobenzaprine for low back pain, it's important to emphasize the potential for drug interactions. Cyclobenzaprine can interact with certain cold and allergy medications, so the client should be advised to use such medications only as directed by their healthcare provider.

The nurse learns in report that a client was unstable during the previous shift. The nurse should plan to carefully monitor which parameter? a. Circadian rhythms b. Basal metabolic rate c. Vital signs d. Stress levels

c. Vital signs When a client is reported as unstable, it is essential to carefully monitor their vital signs. Vital signs include parameters such as blood pressure, heart rate, respiratory rate, and temperature. Monitoring these parameters helps assess the client's overall physiological status and can provide early indications of any worsening condition or instability. This allows for timely intervention and appropriate nursing care.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider? a. Nausea and headache b. Yellow tinged sputum c. Watery diarrhea d. Increased fatigue

c. Watery diarrhea Linezolid is an antibiotic that belongs to the class of drugs known as oxazolidinones. One of the potential adverse effects of linezolid is the development of diarrhea, which can range from mild to severe. Severe diarrhea or diarrhea with additional symptoms like abdominal pain or fever could be indicative of a condition called Clostridium difficile-associated diarrhea (CDAD) or pseudomembranous colitis, which is a serious infection of the colon. Therefore, watery diarrhea in a client receiving linezolid should be reported to the healthcare provider promptly for further evaluation and possible treatment adjustments.

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? a. Remind the UAP to wash hands frequently while in the room b. Help the UAP reposition the gown sleeve over the glove edges c. Confirm that the gown is tied securely at the neck and waist d. Assist the UAP with application of a face mask or face shield

c. confirm that the gown is tied securely at the neck and waist

An adult male is brought into the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Nausea with projectile vomiting b. Rebound abdominal tenderness c. Diminished bilateral breath sounds d. Rib pain with deep inspiration

c. diminished bilateral breath sounds Diminished bilateral breath sounds in a trauma patient can be indicative of a serious respiratory issue, such as a pneumothorax or hemothorax, especially following a high-impact event like a motorcycle accident. This condition can quickly become life-threatening and requires immediate attention to ensure adequate oxygenation and ventilation.

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? Select all that apply. a. Flat affect b. Frequent drooling c. Frequent syncope d. Blurred vision e. Occasional nocturia

c. frequent syncope d. blurred vision Syncope (fainting) can be related to orthostatic hypotension, a condition often seen in Parkinson's disease where blood pressure drops significantly upon standing or changing positions. This information is crucial for the nurse as it indicates the need to take blood pressure readings in different positions (sitting, standing, and lying down) to assess for orthostatic changes.

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? a. Maintain head of bed at 45 degrees b. Infuse 0.9% sodium chloride 500 ml bolus c. Insert nasogastric tube to intermittent suction d. Document strict and intake and output

c. insert nasogastric tube to intermittent suction Intractable vomiting associated with a bowel obstruction can lead to significant complications, including dehydration, electrolyte imbalances, and aspiration. An immediate priority is to relieve the pressure and distention caused by the obstruction. Inserting a nasogastric (NG) tube and setting it to intermittent suction can help decompress the stomach, remove gastric contents, and reduce vomiting, thereby decreasing the risk of aspiration and providing symptomatic relief.

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome. Which information is most important to provide parents of newborns and infants? a. Do not pop bottles for an infant during naps and bedtime b. Remove pillows and soft toys from the crib at bedtime c. Position the intent in a supine position while sleeping d. Keep a bulb syringe accessible for use for an infant

c. position the infant in a supine position while sleeping Placing infants on their backs to sleep is one of the most effective ways to reduce the risk of SIDS. The "Back to Sleep" campaign, which emphasizes the importance of placing infants in a supine position for sleep, has been instrumental in reducing the incidence of SIDS.

Prior to surgery, written consent must be obtained. Which is the nurses legal responsibility with regard to obtaining written consent? a. Ask the client or a family member to sign the surgical consent form b. Explain the surgical procedure to the client and ask the client to sign a consent form c. Validate the clients understanding of the surgical procedure to be conducted d. Determine that the surgical consent form has been signed and is included in the clients record

c. validate the clients understanding of the surgical procedure to be conducted It is essential for the nurse to ensure that the client has a clear understanding of the surgical procedure, including the risks, benefits, and alternatives. This is part of the informed consent process. While the surgeon or healthcare provider performing the procedure is responsible for explaining the details of the surgery, the nurse plays a critical role in confirming that the client comprehends this information and is making an informed decision.

A 300 ml unit of packed red blood cells is prescribed for a client with heart failure who has 3+ pitting adima, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood? a. 50 ml/hour b. 150 ml/hour c. 300 ml/hour d. 75 ml/hour

d. 75 ml/hour

A female client is scheduled for an intravenous pyelography today. The nurse instructs the client that the X-ray visualizes the kidneys, uterus, and bladder. Which information is most important for the nurse together before the client goes for the X-ray? a. Determine the last time the client had a bowel movement b. Inquire if she is taking her regularly scheduled medications c. Find out if the client can lie prone for the X-ray d. Ask if the client has an allergy to shellfish

d. Ask if the client has an allergy to shellfish Before undergoing an intravenous pyelography (IVP), it is crucial to assess the client for any allergies, particularly iodine or shellfish allergies. IVP involves the use of a contrast dye containing iodine, and individuals with iodine or shellfish allergies may be at risk of an allergic reaction to the contrast dye used in the procedure. It is essential to identify and document any allergies to ensure the client's safety during the test.

An adult client is admitted to the psychiatric unit with a diagnosis of major depression. After two weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving personal belongings away to visitors, and is in a better mood. Which intervention is best for the nurse to implement? a. Tell the client to keep one's belongings because they will be needed at discharge b. Support the client by validating the progress that has been made c. Reassure the client that the antidepressant drugs are apparently effective d. Ask the client if there are any recent thoughts of harming self

d. Ask the client if there are any recent thoughts of harming self These changes in behavior can be indicative of a potential manic episode or mixed state in a client with bipolar disorder. The nurse should assess for any signs of self-harm or suicidal ideation to ensure the client's safety. This assessment is crucial to determine the appropriate intervention, which may include adjusting medication or increasing monitoring and support.

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give to this nurse? a. Transfer a client to another unit b. Perform the admission of a new client c. Monitor the central telemetry d. Assist cardiac nurses with their assignments

d. Assist cardiac nurses with their assignments Since the nurse from labor and delivery may not have the same level of expertise in cardiac care as the nurses in the cardiac care unit, the best assignment would be to assist the cardiac nurses with their assignments. This allows the nurse to contribute to the unit's workload while working under the supervision of experienced cardiac nurses. It ensures patient safety and utilizes the nurse's skills effectively in a different area of care.

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. What teaching should the nurse provide? a. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals b. Multivitamins are contraindicated during treatment with weight control medications such as Orlistat c. Following a well-balanced diet is a much healthier approach to a good nutrition than depending on a multivitamin d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness

d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness Orlistat can interfere with the absorption of fat-soluble vitamins (A, D, E, and K) and some other nutrients. Taking the multivitamin and orlistat at least two hours apart can help minimize this interference and ensure proper absorption of essential vitamins and minerals.

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are being taken so often. Which response by the nurse is most accurate? a. Hypertension leading to sudden shock can develop at any time b. Blood pressure fluctuations means that the condition has become chronic c. Sodium intake with meals and snacks affects the blood pressure d. Elevated blood pressure must be anticipated and identified quickly

d. Elevated blood pressure must be anticipated and identified quickly In acute glomerulonephritis, monitoring blood pressure is crucial because hypertension (elevated blood pressure) is a common complication of this condition. Hypertension can worsen kidney damage and potentially lead to further complications. Therefore, frequent blood pressure readings are essential to identify any elevation promptly and take appropriate actions to manage it.

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? a. Importance of recording daily weights b. Adherence to a high fiber low fat diet c. Need to check temperature daily d. Events requiring steroid dosage adjustments

d. Events requiring steroid dosage adjustments For a client with Addison's disease, it's crucial to provide instructions on events or situations that may require adjustments to their steroid dosage. Addison's disease is characterized by insufficient adrenal hormone production, particularly cortisol. During times of stress, illness, or trauma, the body may require higher doses of steroids to cope with the increased physiological demands. Therefore, the client should be educated about when to adjust their steroid dosage as prescribed by their healthcare provider. This typically involves a "stress dosing" plan that outlines specific circumstances, such as illness, surgery, or injury, when additional steroids are needed to prevent an adrenal crisis.

What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with and HIV infection? a. Increase ability to carry out activities of daily living b. Promote a feeling of general well-being c. Prevent spread of infection to others d. Improve function of the immune system

d. Improve function of the immune system HIV (Human Immunodeficiency Virus) infection attacks the immune system, specifically CD4 cells (T cells), which are crucial for the immune response. The goal of promoting good nutrition, rest, exercise, and stress reduction is to support and enhance the function of the immune system in clients with HIV. A strong immune system can help the body better fight off infections and diseases, including opportunistic infections associated with advanced HIV/AIDS.

The mother of a 7-month-old brings the infant to clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Tell the mother to cleanse with soap and water at each diaper change b. Encourage the mother to apply lotion with each diaper change c. Ask the mother to decrease the infants intake of fruits for 24 hours d. Instruct the mother to change the child's diaper more often

d. Instruct the mother to change the child's diaper more often The most appropriate nursing intervention for an excoriated and red diaper area without blisters or bleeding in a 7-month-old infant is to instruct the mother to change the child's diaper more often. Prolonged exposure to urine and feces can irritate the skin and lead to diaper dermatitis. Keeping the diaper area clean and dry by changing diapers frequently is essential in preventing and managing diaper rash. Soap and water should be used for cleaning during diaper changes, but excessive use of lotions or creams may exacerbate the problem. There's no need to restrict the infant's intake of fruits unless a specific dietary issue is suspected.

A client who is hypotensive is receiving dopamine, and adrenergic agonist IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a. Initiate seizure precautions b. Assess pupillary response to light hourly c. Monitor serum potassium frequently d. Measure urinary output every hour

d. Measure urinary output every hour Dopamine is used to increase blood pressure and cardiac output in hypotensive clients. Monitoring urinary output is important to assess the effectiveness of the medication and ensure that the client is responding appropriately to the treatment. Measuring urinary output hourly helps assess renal perfusion and ensures that the medication is not causing excessive vasoconstriction that could impair renal function. It is a critical parameter to monitor when administering dopamine.

A client is receiving a hypertonic solution for bladder irrigation in as at risk for dilutional hyponatremia. The nurse should plan to observe for which common sign of hyponatremia? a. Irregular heartbeats b. Bradycardia c. Muscle spasms d. Mental status changes

d. Mental status changes Hyponatremia, which is a low sodium level in the blood, can lead to various symptoms, including mental status changes such as confusion, agitation, and even seizures. Monitoring for mental status changes is crucial when a client is at risk for dilutional hyponatremia.

The father of a four-year-old has been battling metastatic lung cancer for the past two years. After discussing the remaining options with his health care provider, the client request that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Provide the client written information about end-of-life care b. Reassure the client that his child would be allowed to visit c. Mark the chart with the clients request for no heroic measures d. Obtain a detailed report from the nurse transferring the client

d. Obtain a detailed report from the nurse transferring the client A detailed report from the transferring nurse will provide critical information about the client's current condition, medical history, preferences, and any specific care considerations. This information is essential for the palliative care team to provide appropriate and compassionate care aligned with the client's wishes and needs.

A client with a history of upper respiratory symptoms is admitted with chest tightness, productive cough, and difficulty breathing period the client's arterial blood gases indicate respiratory acidosis. An increase in which laboratory test result supports this finding? a. HCO3 b. Arterial pH c. PaO2 d. PaCO2

d. PaCO2 Respiratory acidosis is characterized by an increase in arterial carbon dioxide (PaCO2) levels. This occurs due to impaired lung function, which leads to the retention of carbon dioxide in the bloodstream, resulting in a decrease in pH (acidosis). The other laboratory values may also be affected, but an elevated PaCO2 is the primary indicator of respiratory acidosis.

When teaching a group of school age children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? a. Wash hands frequently b. Avoid drinking lake water c. Do not share personal products d. Wear long sleeves and pants

d. Wear long sleeves and pants Lyme disease is primarily transmitted through the bite of infected ticks, particularly black-legged ticks (also known as deer ticks). To reduce the risk of contracting Lyme disease, individuals, especially those in areas where Lyme disease is prevalent, should wear protective clothing such as long sleeves and pants when outdoors in wooded or grassy areas. This helps to minimize skin exposure to ticks and makes it more difficult for ticks to attach to the skin. Additionally, using insect repellent on exposed skin and conducting thorough tick checks after being outdoors can further reduce the risk of Lyme disease.

The healthcare provider prescribes an antibiotic cefdinir 300 mg PO Every 12 hours for a client with a postoperative wound infection. Which food should the nurse encourage this client to eat? a. Avocados and cheese b. Green leafy vegetables c. Fresh fruits d. Yogurt or buttermilk

d. Yogurt or buttermilk Cefdinir is an antibiotic, and taking it can sometimes lead to gastrointestinal upset, including diarrhea. Eating yogurt or buttermilk with live active cultures can help maintain the balance of beneficial bacteria in the gut and may reduce the risk of antibiotic-associated diarrhea. Avocados, cheese, green leafy vegetables, and fresh fruits are all healthy foods, but they are not specifically recommended to counteract the potential gastrointestinal side effects of the antibiotic.

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. Prevention through nutrition and exercise b. Avoidance of foods containing purine c. Immobilization of affected joints d. Application of heat and cold therapy

d. application of heat and cold therapy This is a relevant and practical health promotion strategy for clients with rheumatoid arthritis. Heat therapy can help relax muscles and alleviate joint stiffness, while cold therapy can reduce joint swelling and pain. Clients should be taught how to safely use heat and cold therapy.

The nurse inserts and indwelling urinary catheter as seen in the video. What action should the nurse take next? a. Remove the catheter and insert into urethra opening b. Insert the catheter further and observe her discomfort c. Observe for urine flow and then inflate the balloon d. Leave the catheter in place and obtain a sterile catheter

d. leave the catheter in place and obtain a sterile catheter

A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the streptococcus bacteria? A. High, protracted fever B. Flaky, peeling skin C. White coating on the tongue D. Red bumps across chest

d. red bumps across the chest Scarlet fever is characterized by a red, bumpy rash that typically starts on the chest and spreads to other parts of the body. This rash, often described as having a sandpaper-like texture, is a direct response to the toxins released by the streptococcus bacteria. It's one of the earliest and most distinctive signs of scarlet fever.