hesi exam version 1 2022

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

1.5

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

10

The health care provider prescribes a low dose heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium two 25,000 units in 5% dextrose injection 250 ml. The nurse should program the pump to deliver how many ml/hr?

12

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior? 1. Evaluate the UAP for signs of improvement 2. Plan for scheduled break times 3. Discuss the issue privately with the UAP 4. Note date and time of the behavior

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

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

40

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin that is initiated. In what order should the nurse implement these interventions? (arrange the actions in order of priority, with highest priority first, and least priority last or at the bottom.) 1. Document reaction to the drug 2. Initiate an adverse event report 3. Contact the health care provider 4. Assess vital signs 5. Stop the infusion

5. Stop the infusion 4. Assess vital signs 3. Contact the health care provider 1. Document the reaction to the drug 2. Initiate an adverse effect report the client is exhibiting a drug reaction and quick action is required. when a drug reaction is suspected, first the infusion should be stopped. then vital signs and airway compromise should be assessed and the findings reported to the healthcare provider. documentation of the occurrence, including a description of the rash and details of the reaction should be completed after the healthcare provider is notified. finally, an adverse drug reaction or adverse event report should be completed

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

5.625

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty in concentrating at work. Which coping strategy should the nurse include in the plan of care? A. Analyze past hurts and resentments to identify the source B. Focus on small achievable tasks, not taxing problems C. Concentrate on and ventilate emotions when distressed D. Relax and reduce the amount of effort to solve the problem

B. Focus on small achievable tasks, not taxing problems This strategy helps in several ways. Breaking tasks into smaller, more manageable parts can reduce feelings of being overwhelmed, which is common in anxiety disorders. It allows the individual to experience a sense of accomplishment and control, which can boost self-esteem and decrease anxiety. Focusing on achievable tasks can also redirect attention away from distressing thoughts and provide a structured way to approach daily activities.

A client who is admitted to the intensive care unit with the right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complaints of difficulty breathing. The nurse determines that the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A. Continuous bubbling in the water seal chamber B. Tracheal deviation toward the left lung C. Decreased bright red bloody drainage D. Tachypnea with difficulty breathing

B. Tracheal deviation toward the left lung tracheal deviation toward the left lung is a significant finding that suggests the development of a tension pneumothorax; in tension pneumothorax, air accumulates in the pleural space and cannot escape, causing increasing pressure on the affected side; this increased pressure can push the mediastinum and trachea away from the affected side, leading to tracheal deviation

An infant is unresponsive and gasping for breath period prior to starting CPR, which site should the nurse palpate for a pulse?

Brachial commonly assessed in infants during CPR because it is a central pulse site, easily accessible in emergency situations

A client with acute renal failure (ARF) is admitted for uncontrolled type one diabetes mellitus and hyperkalemia. The nurse administers and IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this clients plan of care? A. Evaluate hourly urine output for return of normal renal function B. Assess glucose via fingerstick every four to six hours C. Monitor the client's cardiac activity via telemetry D. Maintain venous access with an infusion of normal saline

C. Monitor the client's cardiac activity via telemetry insulin administration can rapidly shift potassium from the extracellular fluid into the cells, potentially causing the sudden drop in serum potassium levels; this shift can lead to hypokalemia, which may have adverse effects on cardiac function, including arrhythmias; monitoring the client's cardiac activity via telemetry is essential to detect any changes or abnormalities in the heart's rhythm promptly

An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 b. 0800, 1200, 1600, 2000 c. Administer with meals and a bedtime snack d. Given equally divided doses during waking hours

a. 1000, 1600, 2200, 0400 this schedule spaces the doses 6 hours apart, providing consistent medication levels in the body throughout the 24 hour period; it's important for antibiotics to be given at regular intervals to maintain effective drug levels in the bloodstream, which is crucial for treating infections effectively

The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching? a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child b. Only foil balloons will be used for the child's birthday party c. Rubber-free toys, such as wooden building blocks, are good choices for the child d. An epinephrine auto-injector will be on hand to treat allergic reactions

a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child bananas and kiwis are fruits, and while kiwi does contain some proteins similar to those found in latex, it is not typically associated with cross-reactivity in individuals with latex allergies

The nurse is caring for a client who reports experiencing pain. The client reads the pain as two out of 10 on the numeric 1-10 pain scale. Which prescription should the nurse administer? a. Acetaminophen b. Hydrocodone c. Ketorolac d. Morphine sulfate

a. Acetaminophen 2/10 = mild pain; less potent pain reliever = acetaminophen; it's important to consider the client's medical history, allergies, and any contraindications before administering any medication

A client diagnosed with calcium kidney stones has a history of gout. The new prescription for aluminum hydroxide is scheduled to begin at 0730. Which medication should the nurse bring to the health care providers attention? a. Allopurinol b. Furosemide c. Aspirin, low dose d. Enalapril

a. Allopurinol allopurinol is a xanthine oxidase inhibitor used in the treatment of gout; it works by reducing the production of uric acid; allopurinol can increase the risk of aluminum hydroxide toxicity by decreasing the excretion of aluminum

An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Ask if the mother is experiencing any pain with urination b. Encourage increased intake of high protein foods c. Instruct the daughter to check her mother's temperature d. Review the client's current food and medication allergies e. Determine if the mother has recently experienced a fall

a. Ask if the mother is experiencing any pain with urination c. Instruct the daughter to check her mother's temperature e. Determine if the mother has recently experienced a fall urinary tract infections can cause sudden changes in behavior and confusion in older adults; pain with urination is a symptom of uti fever can be a sign of infection, which can contribute to confusion in older adults falls can lead to head injuries or fractures; which may result in changes in mental status; it is important to assess for any trauma

An older male client is admitted with a medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? a. Ask the wife to stop and assess the client swallowing reflex b. Give the wife a straw to help facilitate the clients drinking c. Assist the wife and carefully give the client small sips of water d. Obtain thickening powder before providing any more fluids

a. Ask the wife to stop and assess the client swallowing reflex this will help determine the client's ability to swallow safely and prevent the risk of aspiration; if the swallowing reflex is impaired, further interventions are necessary such as thickening liquids or adjusting the diet may be necessary

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a. Auscultate bilateral breath sounds b. Review the heart rhythm on cardiac monitor c. Administer PRN dose of lorazepam d. Check urinary catheter for obstruction

a. Auscultate bilateral breath sounds restlessness in a mechanically ventilated client may indicate a respiratory issue; auscultating bilateral breath sounds would help assess for any signs of respiratory distrss or complications related to mechanical ventilation; once respiratory concerns are addressed, other assessments, such as reviewing the heart rhythm or checking the urinary catheter, can be carried out if needed

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a. Check for a distended bladder b. Review the hemoglobin to determine hemorrhage c. Massage the uterus to decrease atony d. Increase intravenous infusion

a. Check for a distended bladder the nurse should first check for a distended bladder; a distended bladder can displace the uterus and cause atony, leading to increased lochia and a higher-than-expected uterine position; if the bladder is distended, emptying it will often result in the uterus returning to a more normal position and the reduction of lochia

The nurse request a food tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply. a. Chicken broth b. Apple juice c. Hot chocolate d. Black coffee e. Orange juice

a. Chicken broth b. Apple juice mormon beliefs often include restrictions on the consumption of hot drinks (including hot chocolate and black coffee)

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

a. Determine the client's vital signs after major abdominal surgery, the nurse's priority is to assess the client's vital signs; these provide essential information about the client's physiological status, and any significant changes may indicate potential complications such as hemorrhage or shock

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. What action should the nurse implement? a. Encourage family members to cook meals outdoors and bring the cooked foods inside b. Advise the client to replace cooked foods with a variety of different nutritional supplements c. Assess the clients' mucous membranes and report the findings to the health care provider d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting

a. Encourage family members to cook meals outdoors and bring the cooked foods inside cooking odors can trigger nausea in some individuals; encouraging family members to cook outdoors can help minimize the exposure to cooking odors, allowing the client to enjoy meals without triggering nausea

An older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (SATA) a. Encourage family to participate in the client's care b. Play classical music in room while client is awake c. Suction oral cavity every four hours d. Place a bedside commode next to bed e. Measure neurological vital signs every four hours

a. Encourage family to participate in the client's care d. place a bedside commode next to bed in the convalescence and rehabilitation phase following an ischemia CVA, involving the client's family in care and support is crucial; support from family can contribute significantly to the client's emotional well-being, motivation, and rehabilitation progress; encouraging family involvement fosters a collaborative approach to care and helps address the holistic needs of the client during recovery. A bedside commode can be very helpful for clients who have mobility issues following a stroke. It reduces the risk of falls and the effort needed to go to the bathroom, thereby promoting independence and safety.

A newly hired unlicensed assisted personnel (UAP) is assigned to a home health care team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care b. Assign the newly hired UAP to clients who require the least complex level of care c. Ask the most experienced UAP on the team to partner with the newly hired UAP d. Review the UAP's skills checklist and experience with the person who hired the UAP

a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care observing the newly hired AP delivering care allows the home health nurse to assess their level of competency firsthand; this direct evaluation helps ensure that the UAP is capable of providing adequate care to clients; it allows the nurse to identify areas where additional training or support may be needed

An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factor should the nurse explore further with the client? Select all that apply. a. Family health history b. Homosexual lifestyle c. History of hypertension d. Vegetarian diet e. Excessive aerobic exercise

a. Family health history c. History of hypertension e. excessive aerobic exercise while family health history and hypertension are known risk factors for cardiovascular disease, excessive aerobic exercise may also contribute to the symptoms the client experienced during jogging

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problem should the nurse include in the client's plan of care? Select all that apply. a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion d. Fluid volume deficit e. Fatigue

a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion e. Fatigue heart failure can lead to fluid retention, causing an excess of fluid in the body; the combination of heart failure, coronary artery disease, and atrial fibrillation can contribute to reduced cardiac output; reduced cardiac output and impaired circulation can lead to altered perfusion in peripheral tissues; the client is experiencing respiratory distress, which can contribute to fatigue

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of medication? a. Hypertension b. Difficulty locating the uterine fundus c. Saturation of more than one pad per hour d. Excessive lochia

a. Hypertension methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary hypertension. the nurse should withhold the medication if the client's blood pressure is elevated (c) and notify the health care provider (a, b, & d) are signs of uterine atony and are indications for use of the medication

A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply. a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions

a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. schedule rest periods between activities d. maintain a record of fluid intake and output infective endocarditis can lead to complications such as emboli, and monitoring the cardiac rhythm is important to detect any arrhythmias or changes changes in heart murmurs can indicate further damage to the heart valves and may be indicative of complications related to infective endocarditis Rest is important to reduce cardiac workload and promote healing Monitoring fluid balance is crucial, especially if the client is experiencing heart failure or complications related to infective endocarditis

During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review period which food choices included in the clients less should the nurse encourage? Select all that apply. a. Natural whole almonds b. Cheddar cheese cubes c. Lightly salted potato chips d. Plain, air-popped popcorn e. Canned fruit in heavy syrup

a. Natural whole almonds d. Plain, air-popped popcorn almonds are a good source of healthy fats and can be included in moderation; popcorn is whole grain and a good source of fiber

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. Babinski test that reveals fanning out of the toes c. Plum line test indicates fetal position curvature d. Moro test precipitating the startle response

a. Ortolani maneuver causing a click at the hip joint this may suggest the presence of developmental dysplasia of the hip; a click during the ortolani maneuver could indicate the femoral head slipping back into the acetabulum, suggesting instability

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? a. Potassium b. Calcium c. Protein d. Hemoglobin

a. Potassium when administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential to monitor the serum potassium levels closely; insulin therapy, especially in the initial phases of DKA treatment, can lead to a rapid shift of potassium from the extrecellular space into the cells, potentially causing hypokalemia; hypokalemia can be dangerous and may lead to cardiac dysrhythmias

A female child is brought into the emergency department after awakening with a bark-like cough and stridor. Upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? a. Prepare for emergency tracheostomy b. Assess the child for dehydration c. Collect midstream urine specimen for culture d. Examine oropharyngeal area for foreign body

a. Prepare for emergency tracheostomy the child is presenting with signs and symptoms of coup, a viral infection that causes inflammation of the upper airway, leading to airway obstruction; the bark-like cough, stridor, and drooling are indicative of significant airway involvement; emergency tracheostomy may be necessary to secure the airway in severe cases of croup

A low-risk primigravida at 28-weeks gestation arrives for her regular antenatal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? a. Pulse increase of 10 beats/minute b. Fundal height of 22 centimeters c. Glucosuria d. Proteinuria

a. Pulse increase of 10 beats/minute it's normal for a woman's pulse rate to increase due to the increased cardiac output required to support the growing fetus; an increase of about 10-15 beats per minute compared to pre-pregnancy rate is typically considered within normal limits

The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment? a. RN completes the two admission assessments. 1 PN completes the blood glucose measurements, and 1 PN completes the post-operative visit b. RN completes the postoperative visit in two blood glucose measurements. Each PN completes one admission assessment c. RN completes 1 admission and the postoperative visit. 1 PN completes the blood glucose measurements, 1 PN completes an admission assessment d. RN completes the postoperative visit. Each PN completes one admission assessment and one blood glucose measurement

a. RN completes the 2 admission assessments. 1 PN completes the blood glucose measurements and 1 PN completes the post-operative visit

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? Select all that apply. a. Report serum albumin and globulin levels b. Provide diet low in phosphorus c. Increase oral fluid intake to 1500 ml daily d. Note signs of swelling and edema e. Monitor abdominal girth

a. Report serum albumin and globulin levels d. Note signs of swelling and edema e. Monitor abdominal girth monitoring serum albumin and globulin levels is important in assessing liver function and nutritional status; swelling and edema are common manifestations of cirrhosis, and monitoring for these signs helps in assessing fluid balance; monitoring abdominal girth helps assess for the presence of ascites, which is a common complication of cirrhosis

An adult client who was admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the health care provider? a. Serum lithium level of 1.6 meq/L or mmol/l (SI) b. Six hours of sleep in the past three days c. Weight loss of 10 pounds in the past month d. Blood alcohol level of 0.09%

a. Serum lithium level of 1.6 meq/L or mmol/l (SI) a level of 1.6 meq/L is above the therapeutic range for lithium, which is typically 0.6 to 1.2 meq/L. elevated lithium levels can lead to lithium toxicity, which is associated with symptoms such as slurred speech, unsteady gait, confusion, and tremors

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

a. Teach techniques for scanning the environment for a client experiencing scotomas due to multiple sclerosis, teaching techniques for scanning the environment is a relevant intervention; scanning involves systematically moving the eyes to explore the visual field, compensating for blind spots and improving overall awareness

A school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow up. The teacher should be instructed to report which situations to the school nurse? Select all that apply. a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility c. Bruises on both knees after the weekend d. Refuses to complete written homework assignments e. Sunburn with blisters on the face, arms, and hands

a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility e. Sunburn with blisters on the face, arms, and hands these situations may indicate potential health concerns or issues that require further assessment by the school nurse; thirst and frequent bathroom breaks may suggest issues related to hydration or diabetes; shaking that affects handwriting legibility could be a sign of tremors or other neurological concerns; sunburns with blisters may require medical attention to address potential skin damage

A client with peptic ulcer disease receives a prescription for an intermittent suction via a Salem Sump nasogastric tube (NGT). After inserting the NGT and obtaining coffee ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complaints of nausea. Which action should the nurse implement first? a. Connect the NGT to low intermittent suction b. Irrigate the NGT with sterile normal saline c. Provide oral suction using a Yankauer tip d. Administer a prescribed antiemetic agent

a. connect the NGT to low intermittent suction the client's complaint of nausea after leaving the unit suggests that gastric contents may have accumulated in the stomach since the NGT was clamped; to relieve nausea and prevent further accumulation, the nurse should reconnect the NGT to low intermittent suction; this will help drain gastric contents and provide relief for the client

The nurse instructs and unlicensed assistive personnel (UAP) to turn an 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. Assess the breath sounds c. Offer the client oral fluids d. Feed the client a snack

a. empty the urinary drainage bag emptying the urinary drainage bag is essential to prevent urinary stasis and ensure proper urine drainage; frequent emptying of the drainage bag helps prevent complications such as urinary tract infections and maintains the integrity of the urinary catheter system

Client with end stage renal disease (ESRD) is refusing all treatment and requests that no life saving measures be implemented. The health care provider refuses to write do not resuscitate instructions. Which action should the nurse take? a. Initiate a review of the situation by the hospital's ethics committee b. Remind the client that new treatments are being developed daily c. Facilitate a palliative care meeting with the client and health care provider d. Provide the health care provider with a copy of the clients Bill of Rights

a. initiate a review of the situation. by the hospital's ethics committee when a client with ESRD refuses treatment and requests no life-saving measures, and the healthcare provider is unwilling to write a DNR instruction, it becomes an ethical dilemma; involving the hospital's ethics committee can help address the ethical, legal, and medical aspects of the case; the ethics committee can provide guidance and facilitate communication among the client, healthcare provider, and other involved parties to reach a resolution that respects the clients autonomy and values while considering the ethical principles of beneficence, non-maleficence, and justice

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluids as prescribed b. Remove the catheter and apply direct pressure for five minutes c. Notify the health care provider of the need to reposition the catheter d. Secure the catheter using aseptic technique

a. initiate intravenous fluids as prescribed This action is appropriate because the placement of the CVC in the superior vena cava is considered correct and safe for use. The nurse can proceed with the administration of prescribed intravenous therapies, which may include fluids, medications, or nutrition.

A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client? a. Is it possible that you will be in direct contact with the children at school? b. Do you realize that you will be exposed to many different types of germs? c. Are you aware that you do not have a fully functioning immune system? d. Have you ever considered that you are putting yourself at risk for developing infections?

a. is it possible that you will be in direct contact with the children at school? this question is open-ended and invites the client to discuss the nature of her volunteer work, which will help the nurse assess her risk of exposure to infections; chemotherapy can weaken the immune system, increasing the risk of infections; understanding the level and type of interaction she will have with children is crucial for the nurse to provide appropriate guidance and precautions; this approach is non-judgmental and focuses on assessing the situation to provide individualized advice

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on the data contained in the record, what action should the nurse take before assisting the client with ambulation? a. Remove sequential compression devices b. Apply PRN oxygen per nasal cannula c. Reinforce the surgical wound dressing d. Administer a PRN dose of an antipyretic

a. remove sequential compression devices Sequential compression devices (SCDs) are used to prevent deep vein thrombosis (DVT) in bedridden or immobile patients. They would need to be removed before ambulating the client, as they are bulky and connected to a machine, making walking difficult or unsafe.

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the client to discuss the medication side effects with the health care provider B. Inform the client that gradual tapering must be used to discontinue the medication C. Remind the client that feeling better is the therapeutic side effect of the medication D. Tell the client that the medication side effects will most likely dissipate overtime

a. tell the client to discuss the medication side effects with the healthcare provider This approach is most appropriate because it encourages open communication between the client and the healthcare provider. Discussing concerns about side effects and the desire to discontinue the medication is crucial for safe and effective care. The healthcare provider can address the client's concerns, provide information about the side effects, and potentially adjust the medication or its dosage if necessary. It's important for clients to understand that changes in medication, especially antidepressants, should not be made without professional guidance due to the risk of relapse or withdrawal symptoms.

The nurse asked the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? a. Use soothing statements to facilitate cooperation b. Examine the genitalia as the last part of the total exam c. Allow the child to keep underpants on to examine the genitalia d. Work slowly and methodically so not to stress the child

a. use soothing statements to facilitate cooperation using soothing statements can help calm the toddler and make the examination process more comfortable; the nurse can provide reassurance, explain the procedure in a child-friendly manner, and use positive language to encourage cooperation

A male client with COPD smokes 2 packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? a. "I always shake the inhaler several times before I start." b. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away." c. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best." d. "I never use the inhaler unless I am feeling really short of breath."

b. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away." using an inhaler involves inhaling the medication, not swallowing it; the client should be instructed to coordinate the actuation of the inhaler with a slow, deep inhalation, hold the breath for 10 seconds, and then exhale slowly; swallowing the medication does not deliver it effectively to the lungs

A client's morning assessment includes bounding peripheral pulses, weight gain of two pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? a. Restrict daily fluid intake to 1500 ml b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning

b. Administer prescribed diuretic the client's assessment findings, including bounding peripheral pulses, weight gain, pitting ankle edema, and moist crackles bilaterally, are indicative of fluid volume excess and potential heart failure exacerbation. administering a prescribed diuretic is crucial to help the client eliminate excess fluid and manage symptoms of congestive heart failure

Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis

b. Allergic rhinitis d. Contact dermatitis antihistamines are commonly used to alleviate symptoms such as sneezing, itching, and runny nose associated with allergic rhinitis antihistamines may help relieve itching and some symptoms associated with contact dermatitis

An older adult client us having photocoagulation for macular degeneration. Which intervention should the nurse implement during the post-procedure care in the outpatient surgical unit? a. Arrange food on the plate in clockwise order b. Apply bilateral eye patches while sleeping c. Verbally identify self when entering the room d. Use white board to communicate ideas

b. Apply bilateral eye patches while sleeping after photocoagulation for macular degeneration, it is important to protect the eyes from bright light and to minimize eye movement; applying bilateral eye patches during sleep helps prevent exposure to light and reduces eye movement, promoting optimal healing and recovery

An older client comes to the clinic with a family member. When the nurse attempts to take the clients health history, the client does not respond to the questions in a clear manner. What action should the nurse implement first? a. Provide a printed healthcare assessment form b. Assess the surroundings for noise and distractions c. Ask the family member to answer the questions d. Defer the health history until the client is less anxious

b. Assess the surroundings for noise and distractions when an older client has difficulty responding to health history questions, the nurse should first assess the surroundings for potential factors that may contribute to the communication barrier; noise and distractions in the environment can interfere with the client's ability to concentrate and respond clearly; addressing these environmental factors may improve the client's ability to communicate effectively

A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer a unit of packed red blood cells as seen in the picture. Which action should the charge nurse take? a. Verify that a 22-gauge intravenous catheter is used for the transfusion b. Assist the nurse in changing the intravenous tubing attached to the blood c. Tell the nurse to take the clients vital signs and then start the transfusion d. Assume responsibility for the care of the client during the blood transfusion

b. Assist the nurse in changing the intravenous tubing attached to the blood this ensures that the correct tubing is used for the blood transfusion, following established protocols and maintaining patient safety; it's an opportunity for education and correction, supporting the new nurse in learning the proper procedures

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Continued development of the brain lesion determines the child's outcome b. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation

b. Brain damage with CP is not progressive but it does have variable course cp is a non-progressive neurological disorder caused by damage to the developing brain. the brain damage itself does not worsen over time, but the impact of the damage on motor function and associated symptoms can vary and change as the child grows. the course of cp is influenced by factors such as the severity and location of the brain injury, early intervention, therapy, and overall health

A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? a. Administer and non-steroidal anti-inflammatory drug for pain b. Check neurovascular status of the distal digits c. Change the dressing if drainage increases d. Position the arm in a sling for discharge

b. Check neurovascular status of the distal digits checking the neurovascular status is important to ensure that there is adequate blood flow and nerve function in the hand and fingers after the procedure. this assessment includes evaluating capillary refill, sensation, and motor function. changes in neurovascular status could indicate complications, such as compression of nerves or impaired blood flow, that need to be addressed before discharge

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? a. Administer IV atropine b. Defibrillate with one shock c. Give a dose of amiodarone IV d. Prepare for external pacing

b. Defibrillate with one shock ventricular fibrillation is a life-threatening arrhythmia that requires prompt defibrillation to restore a normal heart rhythm; defibrillation is the standard treatment for VF, and it should be initiated as quickly as possible to increase the chances of successful restoration of normal cardiac rhythm

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed c. Document why the blood pressure cannot be accurately measured at the present time d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses

b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed palpating the popliteal pulse can be an alternative method for estimating blood pressure when traditional methods are not feasible; demonstrating this technique to the unlicensed assistive personnel allows for an indirect assessment of blood pressure in the absence of traditional measurements

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number

b. Determine type of chemical exposure Rationale: once the type of chemical is determined, poison control should be called even if the chemical is unknown. if lavage is recommended by poison control, intubation, and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested.

The nurse is preparing to administer 1.6 ml of medication intramuscularly to a four-month-old infant. Which action should the nurse include? a. Is a quick dart like motion to inject into the dorsogluteal site b. Divide the medication into two injections with volumes under 1 ml c. Administer into the deltoid muscle while the parent holds the infant securely d. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection

b. Divide the medication into two injections with volumes under 1 ml for intramuscular injections in infants, the vastus lateralis msucle in the thigh is commonly used; the recommended needle length for intramuscular injections in infants is usually shorter than 1 1/2 inches

The nurse is planning care for a 16 year old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Perform passive range of motion exercises twice daily b. Exercise in a swimming pool c. Splint affected joints during activity d. Begin a training program lifting weights and running

b. Exercise in a swimming pool for a 16 year old with juvenile idiopathic arthritis, engaging in exercises in a swimming pool is an appropriate and beneficial physical therapy regimen; swimming and water exercises are often recommended for individuals with arthritis because the buoyancy of the water reduces the impact on joints while providing resistance to help strengthen muscles; this form of exercise can improve joint mobility, reduce pain, and enhance overall function without putting excessive stress on the affected joints

The nurse is preparing to send the client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? a. Reports left chest wall pain prior to admission b. Experiences facial swelling after eating crab c. Verbalizes a fear of being in a confined space d. Drink a glass of water in the past two hours

b. Experiences facial swelling after eating crab facial swelling after eating crab is indicative of a potential allergic reaction, which can be severe and life-threatening; allergies, especially to substances like contrast dye used in angioplasty, can lead to anaphylaxis; anaphylaxis is a serious and rapid allergic reaction that can cause a drop in blood pressure, difficulty breathing, and other life-threatening symptoms

The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? a. Hypertonic saline solution at 100 ml/hr until all edema disappears b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L)

b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg emergency treatment for acute adrenal insufficiency (addisonian crisis) is IV infusion of hydrocortisone and saline solution. the client is usually given a dose containing hydrocortisone 100 mg IV in normal saline every 6 hours until the client's blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemia. The client needs normal- not hypotonic- saline solution

A female client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurses on duty now." Which response is best for the nurse to provide to this clients dichotomous tendency? a. Tomorrow I will talk to that nurse about how you were treated last night b. I am happy that you are getting better and will be able to go home c. I am glad you like me. Which nurse was acting aloof to you? d. What did the night nurse do that makes you think she is aloof?

b. I am happy that you are getting better and will be able to go home this response focuses on the positive aspect of the client's progress and impending discharge without directly engaging in discussion about the night shift nurse or reinforcing negative feelings about the previous interaction. it encourages a more balanced perspective and avoids getting drawn into the splitting behavior

A client in menopause reports being lactose intolerant. She exercises three times a week, drinks wine one to three times a month, and drinks a cup of coffee daily. Which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis? a. Increase weekly exercise b. Increase calcium intake c. Decrease wine consumption d. Decrease coffee consumption

b. Increase calcium intake lactose intolerance may limit the client's intake of dairy products, which are a significant source of calcium; increasing calcium intake through other sources or supplements becomes crucial to support bone health and reduce the risk of osteoporosis

An adult woman who was recently diagnosed with type 2 diabetes mellitus (DM) is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modification should the nurse recommend? Select all that apply. a. Reduce daily fat intake to 10% of total calories b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet d. Eliminate alcohol intake except for special occasions e. Restrict protein to 10% of total calories in diet

b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet these recommendations focus on promoting a diet that includes complex carbohydrates, particularly those with high fiber content (such as whole grains); increasing dietary fiber can help regulate blood sugar levels; additionally, reducing processed carbohydrates can contribute to better glycemic control in individuals with diabetes

A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's 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. Furosemide b. Lactulose c. Loperamide d. IV human albumin

b. Lactulose lactulose is a medication commonly used to treat hepatic encephalopathy, a condition associated with elevated serum ammonia levels in patients with liver disease; it works by promoting the excretion of ammonia in the form of ammonium ions through the stool; by reducing ammonia levels, lactulose helps alleviate confusion and other symptoms of hepatic encephalopathy

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility b. Names 3 home safety hazards to be resolved immediately c. States 4 risk factors for the development of osteoporosis d. Lists five calcium rich foods to be added to her daily diet

b. Names 3 home safety hazards to be resolved immediately home safety is a critical consideration for individuals with osteoporosis, as they are at an increased risk of fractures due to decreased bone density. identifying and addressing home safety hazards can help prevent falls and minimize the risk of fractures, which is a significant concern for individuals with osteoporosis

A client with cellulitis of the right great toe has been taking an antibiotic for seven days. Which assessment should the nurse complete to determine the effectiveness of this medication? a. Note any thickening, scarring, or ridge lines present on the toe b. Observe for signs of inflammation on and surrounding the toe c. Determine the length of the capillary refill time of the toe d. Compare the fetal pulse volumes of the right and left feet

b. Observe for signs of inflammation on and surrounding the toe to determine the effectiveness of the antibiotic treatment for cellulitis, the nurse should observe for signs of inflammation on and surrounding the affected toe; improved redness, swelling, warmth, and tenderness would indicate a positive response to antibiotic therapy

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

b. PaCO2 in respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream; the partial pressure of carbon dioxide in arterial blood is elevated, leading to decrease in pH

The nurse is feeding a client who is admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals b. Provide nectar thickened liquids c. Allow small amounts of liquids with meals d. Perform oral care before meals

b. Provide nectar thickened liquids given the client's history of aspiration, providing nectar thickened liquids can help reduce the risk of aspiration; nectar-thick liquids are easier to control while swallowing and are less likely to be aspirated into the airway

Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complaints of a headache. Which intervention should the nurse implement first? a. Teach the client to recognize symptoms of dysreflexia b. Relieve any kinks or obstruction in the client's Foley tubing c. Administer or prescribe PRN dose of hydralazine d. Assess the client's blood pressures every 15 minutes

b. Relieve any kinks or obstruction in the client's Foley tubing autonomic dysreflexia can be triggered by issues such as a distended bladder, so addressing any potential cause related to the foley catheter is a priority; after relieving the obstruction, the nurse should assess the client's blood pressure to determine if it resolves the symptoms

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? a. Check your pulse rate every day b. Report unusual bruising or bleeding c. Monitor your blood pressure regularly d. Elevate your feet if swelling occurs

b. Report unusual bruising or bleeding this is because anticoagulants can increase the risk of bleeding, and its crucial for the client to promptly report any signs of unusual bruising or bleeding to the healthcare provider

The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? a. Collect a sputum specimen immediately b. Request a consultation to confirm dysphasia c. Offer the client additional clear liquids frequently d. Encourage the client to do deep breathing exercises daily

b. Request a consultation to confirm dysphasia dysphagia can lead to aspiration, where foods or liquids enter the airway, causing coughing or respiratory symptoms. confirming the presence of dysphagia through a consultation with a speech therapist or a healthcare provider specializing in swallowing disorders can conduct a thorough assessment, including a swallow study, to evaluate the client's ability to swallow safely

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Check the client's hemoglobin level b. Review the clients current list of medications c. Assess the client for the presence of hemorrhoids d. Administer prescribed PRN anti-emetic

b. Review the clients current list of medications clear, watery diarrhea can be associated with various causes, including infectious agents, certain medications, dietary factors, or other underlying conditions; reviewing the client's current list of meds is important to identify any drugs that may be contributing to or causing the diarrhea

A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the health care provider? a. Volume of each voiding is more than 300 ml b. Serum potassium level is elevated c. Relief of flank pain that is radiating to the groin d. Hematuria that is beginning to turn pink

b. Serum potassium level is elevated An elevated serum potassium level can be a significant concern, particularly in a client with urolithiasis. Kidney stones can potentially impair kidney function, and the kidneys are responsible for regulating potassium levels in the body. Hyperkalemia (high potassium levels) can lead to serious cardiac complications and must be addressed promptly.

The nursing staff on the medical unit uses a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which tasks should the charge nurse assigned to the RN? a. Transport a client who's receiving IV fluids to the radiology department b. Supervise a newly hired graduate nurse doing an admission assessment c. Complete ongoing focus assessments of a client with wrist restraints d. Administer PRN oral analgesics to a client with a history of chronic pain

b. Supervise a newly hired graduate nurse doing an admission assessment tasks that involve assessment, supervision, and complex nursing judgment are typically assigned to the registered nurse; supervising a newly hired graduate nurse during an admission assessment aligns with the RN's scope of practice

After receiving a report on an inpatient acute care unit, which client should the nurse assess first? a. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid b. The client with a bowel obstruction due to a volvus who is experiencing abdominal rigidity c. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds d. The client with an obstruction of the large intestine who was experiencing abdominal distention

b. The client with a bowel obstruction due to a volvus who is experiencing abdominal rigidity the client with a bowel obstruction due to a volvulus (twisting of the bowel) who is experiencing abdominal rigidity should be assessed first; abdominal rigidity is a concerning sign that may indicate bowel ischemia or perforation, which are serious complications

The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendation should the nurse provide this client? Select all that apply. a. Avoid range of motion exercises b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness e. Apply alcohol to the stump after bathing

b. Use a residual limb shrinker c. Wash the stump with soap and water d. Inspect skin for redness a residual limb shrinker is a compression garment designed to control swelling and shape the residual limb, promoting proper healing and fitting of a prosthesis regular skin inspection is essential to monitor for any signs of irritation, pressure points, or infection. early detection can help prevent complications cleaning the stump with soap and water is important for maintaining hygiene and preventing infection. however, it's crucial to use mild soap and avoid harsh chemicals

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. Aerobic exercise b. Weight bearing exercise c. Muscle stretching and toning d. Core strengthening

b. Weight bearing exercise weight-bearing exercises are particularly beneficial for bone health and can help prevent osteoporosis; these activities include walking, jogging, dancing, and resistance training; weight-bearing exercises stimulate bone formation and increase bone density, which is important for maintaining bone strength and reducing the risk of fractures associated with osteoporosis

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations for the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply. a. A bedside commode is positioned near the bed b. A full pitcher of water is on the bedside table c. A low sodium diet tray was brought to the room d. The client is lying in the supine position in bed e. A saline lock is present in the right forearm

b. a full pitcher of water is on the bedside table d. The client is lying in the supine position in bed For option B, heart failure patients often need to manage their fluid intake to prevent fluid overload, which can exacerbate heart failure symptoms. Having a full pitcher of water easily accessible might encourage excessive fluid intake, so it's important to monitor and potentially limit the amount of fluid available to the client, based on their specific fluid restriction orders. For option D, lying flat in a supine position can exacerbate breathing difficulties in patients with heart failure and COPD due to increased pressure on the diaphragm and potential fluid accumulation in the lungs. Elevating the head of the bed can help ease breathing and reduce the workload on the heart. This position adjustment is a crucial intervention for patients with both heart failure and COPD.

The nurse who is working on a surgical unit received change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? a. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson Pratt drain b. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills c. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container d. Gunshot wound 3 hours ago with dark drainage of 2 cm noted on the dressing

b. adbominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills The presence of fever and chills in a postoperative client, particularly following a major surgery like an abdominal-perineal resection, is concerning for a possible infection. The absence of drainage on the dressing does not rule out internal complications. This client's symptoms suggest a potential postoperative infection, which requires prompt evaluation and intervention.

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action? a. Determine why the UAP did not notify the nurse of the change in the client's condition b. Advise the UAP stop providing care so the nurse can assess the client's condition c. Explain to the UAP that changes in the client's condition should be reported immediately d. Ask the UAP to position the client so the oral medications can be administered

b. advise the UAP stop providing care so the nurse can assess the client's condition the nurse should immediately intervene to assess the client's deteriorating condition and prioritize the client's well-being

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. Which response should the nurse provide? a. Complete a list of alternative medications that are effective in curing parksinson's disease b. Explain there are no known conventional, alternative, or complementary therapies that cure Parkinson's disease c. Encourage the wife to ventilate her feelings about having a husband with Parkinson's disease d. Tell the wife that her husband's neurologist just would know more about alternative treatments to cure Parkinson's

b. explain there are no known conventional, alternative, or complementary therapies that cure parkinson's disease while some treatments and medications can help manage symptoms and improve quality of life for individuals with parkinson's disease; none have been proven to cure the condition

Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis? a. Blood in urine cultures b. Glucose and calcium levels c. Renal and liver function tests d. Electrolytes and hemoglobin

b. glucose and calcium levels thyrotoxic crisis is a severe and potentially life-threatening complication of hyperthyroidism; it can cause significant metabolic disturbances, including alterations in glucose and calcium metabolism; monitoring glucose levels is important because hyperthyroidism can cause hyperglycemia; similarly, calcium levels can be affected, as hyperthyroidism can lead to increased bone turnover and calcium release into the bloodstream

An older client arrives to the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute, respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which intervention is most important for the nurse to implement? a. Maintain strict intake and output b. Monitor blood glucose level c. Keep head of bed raised 45 degrees d. Assess warmth of extremities

b. monitor blood glucose level given the client's symptoms and vital signs, they are likely experiencing shock, possibly due to dehydration from severe vomiting; monitoring blood glucose is crucial as hypoglycemia can exacerbate or mimic shock symptoms; additionally, severe vomiting can disrupt glucose balance, making it essential to regularly monitor and manage blood glucose levels in this situation

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which finding should the nurse include as indicators to begin implementing the detoxification medication protocol? a. Excessive eating, constipation, headache b. Nausea, vomiting, diaphoresis, anxiety, tremors c. Dilated pupils, tachycardia, elevated blood pressure, elation d. Mood lability, poor hand coordination, fever, drowsiness

b. nausea, vomiting, diaphoresis, anxiety, tremors these symptoms are indicative of alcohol withdrawal and may require detoxification to manage the withdrawal symptoms safely. nausea, vomiting, diaphoresis, anxiety, and tremors are common manifestations of alcohol withdrawal, and appropriate medications, such as benzodiazepines, may be prescribed to help alleviate these symptoms and prevent complications

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are: temperature 99.6 degrees F, Heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement? a. Prepare client for endotracheal intubation b. Place the client in a forward-leaning position c. Apply a non-rebreather mask at 100% oxygen d. Obtain a sputum sample for culture and sensitivity

b. place the client in a forward leaning position This position, often called the "tripod" position, can help improve breathing in clients with COPD. Leaning forward with support, such as on a table or with the arms on the knees while sitting, can help decrease the work of breathing and increase lung expansion. This position is a non-invasive, immediate intervention that can help alleviate shortness of breath.

A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone? a. Complaints of increasing flank pain b. Unresponsive to verbal or tactile stimuli c. Statements about visual hallucinations d. Respiratory rate of 12 breaths/minute

b. unresponsive to verbal or tactile stimuli unresponsiveness to verbal or tactile stimuli suggests a more profound level of sedation or respiratory depression, which could be indicative of opioid overdose; naloxone is an opioid antagonist used to reverse the effects of opioid toxicity; if the client is unresponsive and there are concerns about opioid overdose, naloxone administration may be necessary to reverse the opioid's effects and improve respiratory function

During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse? a. "It should be alright as long as you can find your skiing to the easier trails." b. "Go for it. Skiing should provide you with a terrific aerobic workout." c. "Cold weather may constrict your blood vessels raising your blood pressure'" d. "Skiing might produce too much exertion. How about sledding?"

c. "Cold weather may constrict your blood vessels raising your blood pressure'" in individuals with hypertension, exposure to cold weather can lead to vasoconstriction, potentially elevating blood pressure; it's important for the client to be aware of this risk and take appropriate precautions; while the client may still engage in downhill skiing, they should be cautious about exposure to cold temperatures and stay mindful of the potential impact on blood pressure

What might the nurse suggest to a client with fibrocystic breasts in the attempt to help relieve her symptoms? a. "Increase high calcium foods in your diet b. "Eat a low carbohydrate, high protein diet" c. "Eliminate caffeine from your diet" d. "Avoid vigorous physical exercise immediately after your menstrual period"

c. "Eliminate caffeine from your diet" caffeine is believed to contribute to breast tenderness and discomfort in individuals with fibrocystic breasts; reducing or eliminating caffeine intake may help alleviate symptoms

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? a. "What would you like to see me do to protect you?" b. "You are in a safe place. No one can get you here." c. "You seem quite frightened right now." d. "There is no one who will hurt you."

c. "You seem quite frightened right now." this response acknowledges the client's emotional state and expresses understanding without reinforcing or agreeing with the delusional content

Which class of drugs is the only source of cure for septic shock? a. Anticholesteremics b. Antihypertensives c. Antiinfectives d. Antihistamines

c. Antiinfectives septic shock is caused by a severe infection, and the primary treatment involves antiinfective drugs, such as antibiotics; these drugs target the infectious microorganisms and aim to eliminate or control the infection, addressing the underlying cause of septic shock

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? a. Anticipatory grieving b. Pain (acute) c. Anxiety d. Knowledge deficit

c. Anxiety the client's expression of fear and doubt about handling the pain indicates a high level of anxiety; addressing anxiety is crucial to help the client cope with the upcoming surgery and manage pain effectively; anxiety can impact the client's ability to cope with pain, follow through with pain management techniques, and participate in their own care

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this clients plan of care for today? a. Schedule client for a group that focuses on self esteem b. Help client to develop a list of daily affirmations c. Assist client in identifying goals for the day d. Encourage client to participate for one hour in a team sport

c. Assist client in identifying goals for the day encouraging the client to identify daily goals is an important intervention to promote activity and engagement; setting achievable goals helps the client regain a sense of purpose and accomplishment, which can be especially beneficial in managing depression; it is a step towards increasing daily activities and breaking the cycle of inactivity and lethargy

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he has difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Advise him to take his own food with him on going to fast food restaurants with his friends b. Encourage him to find activities to do with his friends that do not involve eating c. Assist him in identifying popular fast foods that are within his meal plan for diabetes d. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet

c. Assist him in identifying popular fast foods that are within his meal plan for diabetes this intervention involves providing education and support to help the client make informed choices while still participating in social activities with friends; identifying fast food options that align with his prescribed diet for diabetes allows him to enjoy socializing without compromising his health

The mother of a 12 month old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instruction should the nurse provide? a. Perform CPT only in the morning, but increase frequency when appetite improves b. Perform CPT after meals to increase appetite and improve food intake c. CPT should be performed more frequently, but at least an hour before meals d. Stop using CPT during the daytime until the child has regained and appetite

c. CPT should be performed more frequently, but at least an hour before meals performing chest physical therapy more frequently can help manage the increasing congestion associated with cystic fibrosis; performing CPT at least an hour before meals can prevent any potential discomfort or nausea during mealtime; CPT is often recommended to be done multiple times a day to help clear mucus from the airways in individuals with cystic fibrosis

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply. a. Weeping serosanguinous fluid from wounds b. Sloughing tissue around wound edges c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure

c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure a change in the quality of peripheral tissues may suggest compromised circulation, requiring immediate assessment and intervention; increased pain and pressure may indicate infection or inadequate pain control, necessitating prompt evaluation and intervention

A nurse who was working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? a. Low grade fever, headache, and malaise for the past 72 hours b. One inch bleeding laceration on the chin of a crying 5 year old c. Chest discomfort one hour after consuming a large, spicy meal d. Unable to bear weight on the left foot, with swelling and bruising

c. Chest discomfort one hour after consuming a large, spicy meal chest discomfort, especially after consuming a large, spicy meal, raises concerns about possible cardiac issues, such as angina or a myocardial infarction; this requires immediate attention to assess the client's cardiac status and initiate appropriate interventions

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 client's discharge teaching plan? Select all that apply. a. Cross legs at knee but not at ankle b. Maintain the bed flat while sleeping c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting

c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting compression stockings help improve venous blood flow and reduce edema; prolong standing or sitting can worsen venous insufficiency; elevating legs can reduce swelling and improve venous return

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. History of intravenous drug abuse b. Conversion of the client's PPD test from negative to positive c. Current diagnosis of hepatitis B d. Length of time of the exposure to tuberculosis

c. Current diagnosis of hepatitis B isoniazid (INH) is known to have potential hepatotoxic effects; it is crucial to assess for pre-existing liver disease, such as hep B, the nurse should collaborate with the healthcare provider to determine the appropriateness of INH therapy and consider alternative treatment options

The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit which initial symptoms? a. Rigid board like abdomen and elevated white blood cell count b. Dull, left lower cramping pain and a low-grade fever c. Diarrhea, abdominal pain, and weight loss d. Change in bowel habits, blood and stool, and unexplained anemia

c. Diarrhea, abdominal pain, and weight loss in regional enteritis, also known as crohn's disease, the initial symptoms often include diarrhea, abdominal pain, and weight loss; this chronic inflammatory bowel disease can affect any part of the gastrointestinal tract, leading to a range of symptoms related to inflammation, ulceration, and scarring

A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits? a. Teach parents about poison prevention in young children b. Lavage activated charcoal before giving acetylcysteine dose c. If dose is vomited within one hour of administration, repeat that oral dose d. Obtain blood samples to monitor liver function

c. If dose is vomited within one hour of administration, repeat that oral dose if the child vomits within one hour of administration of N-acetylcysteine, the dose should be repeated; N-acetylcysteine is the antidote for acetaminophen overdose, and its effective is crucial in preventing liver damage; if the child vomits the dose, it may have been fully absorbed, and repeating the dose helps ensure adequate treatment; however, if the vomiting occurs more than one hour after administration, repeating the dose is not necessary

A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone per PRN protocol b. Obtain a serum drug screen c. Initiate seizure precautions d. Instruct the family about withdrawal symptoms

c. Initiate seizure precautions withdrawal of cns depressants, such as xanax, results in rebound over-excitation of the cns. since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client

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's discharge teaching? a. Use of topical applicants to manage pruritis b. Need for maintaining good oral hygiene c. Instructions regarding a restricted protein diet d. Strategies to promote independent self-care

c. Instructions regarding a restricted protein diet for a client with chronic renal insufficiency, one of the most important aspects of managing the condition is dietary management, particularly restricting protein intake; the kidneys play a vital role in excreting waste products from protein metabolism, and in renal insufficiency, the ability to do so is compromised; limited protein intake helps reduce the accumulation of waste products, managing the progression of kidney disease

The nurse is assessing a 4-year-old child with eczema. The child skin is dry and scaly, in the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Be the child daily with bath oil b. Apply baby lotion to the skin twice daily c. Keep the nails trimmed short d. Allow the child to wear only 100% cotton clothing

c. Keep the nails trimmed short keeping the child's nails trimmed short is an important guideline to prevent excessive scratching and further damage to the skin; scratching can worsen eczema and lead to complications such as infection

A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement? a. Log roll and place adult disposable briefs b. Insert an indwelling urinary catheter c. Maintain traction while client uses the urinal d. Release traction so client can use bedpan

c. Maintain traction while the client uses the urinal this approach ensures that the client's traction remains intact while addressing the immediate need for urination

A client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? a. Encourage mobilization to prevent pulmonary embolism b. Assess blood pressure and heart rate at least every four hours c. Observe for bleeding side effects related to heparin therapy d. Measure each calf's girth to evaluate edema in the affected leg

c. Observe for bleeding side effects related to heparin therapy heparin is an anticoagulant that helps prevent the formation of blood clots, but it also increases the risk of bleeding; monitor for signs of bleeding, such as easy bruising, petechiae, hematuria, or black/tarry stools, is crucial to ensure the client's safety

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? a. Encourage the mother to breastfeed b. Wrap tightly in a warm blanket c. Obtain a capillary glucose level d. Feed 30 ml of 10% dextrose in water

c. Obtain a capillary glucose level jitteriness and tachypnea is a newborn may be indicative of hypoglycemia; obtaining a capillary glucose level is a priority to assess and address the possibility of low blood sugar

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids." What nursing intervention is most useful in assisting the resident to meet this goal? a. Increase fluids provided with the client's meals b. Record the client's intake and output every shift c. Offer a glass of fluid every hour while awake d. Maintain a full pitcher of water at the bedside

c. Offer a glass of fluid every hour while awake offering a glass of fluid every hour while the resident is awake is the most useful nursing intervention to encourage increased daily intake of fluids; this approach helps ensure that the resident has frequent opportunities to drink and may contribute to maintaining adequate hydration levels; it is a proactive strategy to prevent dehydration, especially in older adults who may be prone to urinary tract infection

The client is admitted to the hospital after experiencing a stroke or a cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? a. Unilateral facial drooping b. Abnormal responses for cranial nerves I and II c. Persistent coughing while drinking d. Inappropriate or exaggerated mood swings

c. Persistent coughing while drinking the client who exhibits persistent coughing while drinking is showing signs of dysphagia, which is difficulty swallowing; dysphagia is a common consequence of a stroke or cerebral vascular accident; speech therapy is often involved in the assessment and management of dysphagia, as they can provide strategies and exercises to improve swallowing function and prevent complications such as aspiration pneumonia

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

c. Position the infant in a supine position while sleeping this recommendation is based on the "back to sleep" campaign, which encourages placing infants on their backs to sleep as the safest sleep position to reduce the risk of SIDS

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? a. Observe the stool for a clay-colored appearance b. Obtain a specimen for culture and sensitivity analysis c. Send a stool sample to the lab for guaiac test d. Assess for fatty yellow streaks in the client stool

c. Send a stool sample to the lab for guaiac test thrombolytic medications, such as tPA, can increase the risk of bleeding; if a client who has received a thrombolytic medication has a bowel movement, the nurse should assess for the presence of occult blood in the stool

A mother brings her four-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter supposed to fix her child hernia. Which explanation should the nurse provide? a. The quarter should be secured with an elastic bandage wrap b. An abdominal binder can be worn daily to reduce protrusion c. This hernia is a normal variation that resolves without treatment d. Restrictive clothing will be adequate to help the hernia go away

c. This hernia is a normal variation that resolves without treatment the mother's belief that taping a quarter over the child's umbilicus will fix a hernia reflects a misunderstanding; the condition described is likely an umbilical hernia, which is a common and usually benign condition in infants; umbilical hernias occur when there is a small opening in the abdominal muscles near the belly button, allowing a portion of the intestines or abdominal lining to protrude slightly; in most cases, umbilical hernias resolve on their own as the child grows and the abdominal muscles strengthen

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less than the input flow. Which action should the nurse implement first? a. Irrigate the dialysis catheter b. Check the client's blood pressure and serum bicarbonate c. Change the client position d. Continue to monitor and take an output with next exchange

c. change the client's position A difference between input and output volumes during peritoneal dialysis can sometimes be due to the positioning of the patient or catheter. Changing the client's position can help facilitate the flow of the dialysis solution, potentially resolving issues with inadequate drainage. The patient can be repositioned to a side-lying position or encouraged to move or walk if able, as these changes can help the dialysis fluid distribute and drain more effectively.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Prepare the client for spinal anesthesia b. Prepare the coach to accompany the client to delivery c. Empty the client's bladder using a straight catheter d. Convey to the client that birth is imminent

c. empty the client's bladder using a straight catheter emptying the client's bladder is a priority during the second stage of labor because a full bladder can obstruct the descent of the fetal head and prolong labor; it is essential to ensure the bladder is empty to facilitate the descent of the baby and prevent complications

The husband of an older woman, diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? a. Encourage the husband to bring the client to the clinic for a complete blood count b. Determine if the client is taking iron and folic acid supplements c. Explain that memory loss and confusion are common with vitamin B12 deficiency d. Ask if the client is experiencing any change in bowel habits

c. explain that memory loss and confusion are common with vitamin B12 deficiency Pernicious anemia is a type of anemia caused by vitamin B12 deficiency, often due to the body's inability to absorb this vitamin. This condition can lead to neurological problems, including memory loss, confusion, and even changes in behavior. These symptoms are related to the effect of vitamin B12 deficiency on the nervous system. It's important to educate the husband that these symptoms are associated with the client's current diagnosis and not necessarily indicative of Alzheimer's disease. However, it should also be noted that while cyanocobalamin (vitamin B12) treatment can improve these symptoms, it may take some time for cognitive symptoms to resolve after starting treatment.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply. a. Take out dentures and place in a labeled cup b. Apply a body shroud c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes

c. place a small pillow under the head d. remove resuscitation equipment from the room e. gently close eyes this helps to position the head in a natural resting position, providing a more peaceful appearance this is important to create a more serene and less clinical environment for the family; removing reminders of the resuscitation attempt can help the family to focus on saying goodbye this is a common practice to give the decreased a more restful and peaceful appearance, which can be comforting for the family

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child anxiety, what action is best for the nurse to implement? a. Provide dolls and equipment to re-enact feelings associated with painful procedures b. Give the child syringes or hospital masks to play with at home prior to hospitalization c. Provide a family tour of the preoperative unit one week before the surgery is scheduled d. Include the child and play therapy with children who are hospitalized for similar surgery

c. provide a family tour of the preoperative unit one week before the surgery is scheduled school age children gain satisfaction from exploring and manipulating their environment, thinking about objects, situations, and events, and making judgments based on what they reason. a tour of the unit allows the child to see the hospital environment and reinforces explanations and conceptual thinking.

After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? a. Note the presence of an auscultatory gap b. Reinflate the cuff to a higher number c. Reposition the stethoscope over the brachial artery d. Continue with the blood pressure assessment

c. reposition the stethoscope over the brachial artery repositioning the stethoscope allows the nurse to detect any sounds that may have been missed during the initial assessment due to the auscultatory gap; by repositioning and carefully listening, the nurse can obtain a more accurate blood pressure leading

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client? a. Restrict oral fluid intake b. Avoid urinary catheterization c. Strain all urine d. Maintain contact isolation

c. strain all urine straining all urine is important in the care of a client with prostatitis to monitor for the presence of blood or sediment; it helps in assessing the severity of inflammation and any complications related to the prostate

The nurse working in the psychiatric clinic has phone messages from several clients. Which cost should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medications b. The mother of a child who was involved in a physical fight at school today c. A client diagnosed with depression who is experiencing sexual dysfunction d. A family member of a client with dementia who has been missing for five hours

d. A family member of a client with dementia who has been missing for five hours safety concerns take precedence, and a missing client with dementia is at risk of harm; the nurse needs to gather information about the situation, assess the urgency, and take appropriate actions to ensure the safety and well-being of the client

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

d. Achieve satisfactory pain control degenerative joint disease, also known as osteoarthritis, is characterized by the breakdown of joint cartilage and underlying bone; pain control is a crucial aspect of care for clients with DJD, as it helps improve the client's quality of life, mobility, and overall function; managing pain allows individuals with DJD to engage in activities of daily living and maintain independence

A client is admitted with a severe asthma attack. For the last three hours the client has experienced increasing shortness of breath. Arterial blood gas results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which intervention should the nurse implement? a. Space care to provide periods of rest b. Instruct client to purse lip breathe c. Position client for maximum comfort d. Administer PRN dose of albuterol

d. Administer PRN dose of albuterol the arterial blood gas results indicate respiratory acidosis, with a low pH (indicating acidosis), an elevated paco2 (indicating respiratory component), and a normal bicarbonate (indicating a compensatory response). in the context of a severe asthma attack, the client is likely experiencing inadequate ventilation, leading to an accumulation of carbon dioxide. albuterol is a bronchodilator that helps relieve bronchoconstriction, a common feature in asthma attacks. it can improve ventilation and decrease the level of carbon dioxide in the blood

While making rounds the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bedside table. The client is currently receiving oxygen at 2 liters/minute via Nasal cannula. The client is wheezing and is using purse-lip breathing. Which intervention should the nurse implement? a. Increase oxygen to 6 liters/minute b. Call for an ambu resuscitation bag c. Assist the client to lie back in bed d. Administer nebulizer treatment

d. Administer nebulizer treatment the client's position, sitting on the side of the bed and leaning over the bedside table, suggests increased respiratory effort and potential distress; the nurse should assist the client to lie back in bed to facilitate better lung expansion and ease of breathing; this position promotes optimal respiratory function and may reduce the work of breathing for the client; if the client is using purse-lip breathing, it indicates an attempt to prolong expansion and reduce airway resistance, and lying back may help support these efforts

Which client is best to assign to the practical nurse (PN) who's assisting the registered nurse (RN) with the care of a group of clients? a. An older client who is scheduled for foot amputation due to diabetes complications b. An older client who is one day postoperative with a colostomy for colon cancer c. An adult with alcoholism, cirrhosis, and hepatic encephalopathy d. An adult who is one day postoperative for a laparoscopic cholecystectomy

d. An adult who is one day postoperative for a laparoscopic cholecystectomy the client who is one day postoperative for a laparoscopic cholecystectomy is likely to have a stable condition and routine postoperative care, making it a suitable assignment for a practical nurse

A client with chronic kidney disease has an arteriovenous (AV) fistula In the left forearm. Which observation by the nurse indicates that the fistula is patent? a. Distended, tortuous veins in the left hand b. Auscultation of a thrill on the left forearm c. The left radial pulses 2+ bounding d. Assessment of a bruit on the left forearm

d. Assessment of a bruit on the left forearm a bruit is a swishing or humming sound heard on auscultation over a vascular access site, such as an AV fistula; the presence of a bruit suggests that blood is flowing through the fistula, indicating its patency

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? a. Call respiratory therapy b. Monitor oxygen saturation levels every five minutes c. Silence the alarm and call the technician d. Begin manual ventilation immediately

d. Begin manual ventilation immediately when the ventilator alarms continuously and the client's oxygen saturation level is critically low (62%), the nurse should prioritize providing manual ventilation to ensure the client is receiving adequate oxygen; the first and foremost concern is addressing the hypoxia, and manual ventilation can be initiated while further assessment and interventions are planned

The practical nurse (PN) is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the leg straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement? a. Arrange for an unlicensed assistive personnel to assist the PN during the procedure b. Acknowledged that the PN has positioned the client safely and correctly c. Assume care of the client and assign the PN to care of a different client d. Demonstrates the PN how to position the client more effectively for the procedure

d. Demonstrates the PN how to position the client more effectively for the procedure In preparing a client for a lumbar puncture, the correct positioning is crucial for the success and safety of the procedure. The correct position for a lumbar puncture is usually the fetal position, where the client lies on their side with their knees drawn up to their chest and their chin tucked down to their chest. This position helps to open up the spaces between the vertebrae, making it easier to perform the lumbar puncture. This action provides an opportunity for teaching and ensures that the client is positioned correctly for the lumbar puncture. By demonstrating the correct position, the nurse ensures the safety and comfort of the client and the success of the procedure. It also serves as a valuable educational moment for the PN.

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

d. Difficulty breathing the presence of difficulty breathing is an indication of potential air embolism, which is a serious complication that can occur with the administration of blood; an air embolism can obstruct blood vessels and interfere with oxygen delivery to tissues, leading to respiratory distress

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

d. Hematocrit of 28% considered low and indicates anemia, which is a common issue during pregnancy but requires management; anemia in pregnancy can lead to various complications, including increased risk of preterm birth, low birth weight, and postpartum depression; it's important to investigate the cause of anemia and initiate appropriate treatment, which may include iron supplements or dietary changes

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Erythrocyte sedimentation rate b. Serum calcium c. Osmolality d. Hemoglobin

d. Hemoglobin the client's ongoing stomach pain, increasing weakness, and fatigue may suggest gastrointestinal bleeding, a known adverse effect of NSAIDs; monitoring hemoglobin levels is important to assess for anemia related to potential blood loss from the gastrointestinal tract

A 46 year old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care? a. Deficient knowledge of lifestyle changes b. Decisional conflict due to stress c. Anxiety related to treatment plan d. Ineffective coping related to denial

d. Ineffective coping related to denial the client's behavior of wanting to leave the hospital 24 hours after a myocardial infarction despite the seriousness of the condition suggests ineffective coping related to denial; denial is a common coping mechanism wherein individuals may refuse to accept the reality of the situation

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 healthcare provider immediately? a. Facial numbness b. Right ear hearing loss c. Difficulty with balance d. Intensifying headache

d. Intensifying headache an intensifying headache could be indicative of increased intracranial pressure, which is a serious and potentially life-threatening condition. given that the client has an acoustic neuroma, which is a type of tumor affecting the nerve between the inner ear and the brain, changes in intracranial pressure should be taken seriously

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room period which action should the nurse take? a. Encourage the client to implement relaxation techniques b. Explain that insulin is a lifesaving drug for the client c. Refer the client to a social worker for support therapy d. Leave their clients room and return later in the day

d. Leave their clients room and return later in the day it's important to respect the client's wishes for privacy and revisit the topic at a later time when the client may be more receptive to learning

An older adult male who is in his early 70s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe, and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the clients living will. Which action should the nurse take? a. Alert the nursing staff of the clients do not resuscitate status b. Facilitate a family meeting with the palliative care team c. Place a certified copy of the living will in the client record d. Notify the healthcare provider of the client wishes

d. Notify the healthcare provider of the client wishes it is crucial to respect the client's wishes as outlined in the living will; the nurse should notify the healthcare provider about the client's living will and desire to avoid intubation; this information can guide the healthcare team in making appropriate decisions and providing care that aligns with the client's preferences

A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? a. Teach the client about the side effects of the prescribed anti-infective drug b. Assess the last 24-hour oral and intravenous fluid intake and urine output c. Administer the initial dose of the anti-infective drug as prescribed d. Obtain a urine specimen for a prescribed culture and sensitivity test

d. Obtain a urine specimen for a prescribed culture and sensitivity test obtaining a urine specimen for a culture and sensitivity test is crucial in identifying the causative organism and determining the most effective antimicrobial treatment; this helps guide appropriate antibiotic therapy, which is essential in the management of urosepsis

Which clients' vital signs indicating increased intracranial pressure (ICP) should the nurse report to the health care provider? a. P 70, BP 120/60 mmhg; P 100, BP 90/60 mmhg; rapid respirations b. P 110, BP 130/ \70 mmhg; P 100, BP 110/70 mmhg; shallow respirations c. P 130, BP 190/90 mmhg; P 136, BP 200/100 mmhg; Kussmaul respirations d. P 55, BP 160/70 mmhg; P 50, BP 194/70 mmhg; irregular respirations

d. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations This set of vital signs is suggestive of Cushing's triad, which is a classic sign of increased intracranial pressure. Cushing's triad consists of three primary signs: bradycardia (slow heart rate), hypertension (high blood pressure), and irregular respirations. In this option, the client demonstrates a significantly elevated systolic blood pressure with a relatively narrow pulse pressure, a decreased heart rate, and irregular respirations, all of which are concerning for increased ICP.

A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over the chest and back. Which intervention should the nurse implement? a. Apply an anti-itch ointment over the rash area b. Instruct the client to avoid lying on his back c. Administer scheduled dose of glucocorticoid d. Replace the transfusion with normal saline

d. Replace the transfusion with normal saline the appropriate intervention in the presence of suspected transfusion reaction is to stop the blood transfusion immediately and replace the blood tubing with normal saline

The healthcare provider prescribes a low fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? a. Roasted pork, fresh strawberries b. Pancakes, whole grain cereals c. Baked potato with skin, raw carrots d. Roasted Turkey, canned vegetables

d. Roasted Turkey, canned vegetables a low-fiber diet typically involves avoiding foods high in insoluble fiber, such as raw fruits and vegetables with skin, whole grains, and seeds; roasted turkey and canned vegetables are examples of foods that are generally lower in fiber and can be included in a low-fiber diet

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? a. White blood cell count of 12,000 mm^3 (12 x 10^9/L) b. Urine culture positive for MRSA c. Serum sodium of 145 meq/L (145 mmol/L) d. Serum creatinine of 4.5 mg/dl (398 mcmol/L)

d. Serum creatinine of 4.5 mg/dl (398 mcmol/L) an elevated serum creatinine level indicates impaired kidney function, and ciprofloxacin is primarily excreted through the kidneys; high serum creatinine levels suggests that the kidneys may not be effectively clearing the medication from the body; there is an increased risk of ciprofloxacin toxicity, which can have adverse effects on the central nervous system

A client with diabetes insipidus (DI) has an average urinary output of 500 mL of dilute urine every hour for the last four hours. Which laboratory test is most important for the nurse to monitor? a. White blood cell count b. Capillary glucose c. Urine specific gravity d. Serum sodium

d. Serum sodium in diabetes insipidus, there is an inability to concentrate urine, leading to the excretion of large volumes of dilute urine; monitoring serum sodium levels is crucial in assessing the balance of fluids and electrolytes; in DI, excessive loss of water without a proportional loss of solutes can result in hypernatremia

A client who is pregnant seems confused and presents with the onset of headache, polyurea, fatigue, and blurry vision. Which action should the nurse implement? a. Assess client for signs of Vertigo b. Palpate bladder for urinary retention c. Determine serum potassium (K) level d. Take serial blood pressure readings

d. Take serial blood pressure readings these symptoms suggest the possibility of preeclampsia, a condition that can occur during pregnancy and is characterized by high blood pressure and damage to other organs, often the liver and kidneys; serial blood pressure readings are important for monitoring and diagnosing preeclampsia

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. As the burn heels, the graft permanently attaches b. Graphs are later removed by a debriding procedure c. Grafting increases the risk for bacterial infections d. The xenograft is taken from non-human sources

d. The xenograft is taken from non-human sources xenografts are temporary grafts derived from animals (usually pig skin) and are used to provide temporary coverage while the body heals and before a more permanent graft can be applied

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but has it's been approved for surgery. Which intervention is most important for the nurse to include in this client plan of care? a. Observed for signs of depression b. Monitor for urinary incontinence c. Provide a wide variety of meal choices d. Apply sequential compression stockings

d. apply sequential compression stockings This intervention is crucial in the perioperative care of patients undergoing major surgery, such as gastroplasty. Sequential compression stockings are used to prevent deep vein thrombosis (DVT), a common risk associated with surgery and decreased mobility. Patients with obesity, diabetes, and hypertension are at a higher risk for developing blood clots, making this intervention particularly important.

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? a. Decrease in the appetite b. Weight of 227 pounds (103 kg) c. Dry mucosal membranes d. Body mass index (BMI) of 17

d. body mass index (BMI) of 17 a BMI of 17 falls below the normal range and indicates underweight, which can be a sign of malnutrition; malnutrition occurs when the body doesn't get enough nutrients from food, leading to various health problems, including being underweight

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

d. bone marrow transplantation bone marrow transplantation is considered the most effective treatment for acquired aplastic anemia, particularly in cases where severe aplasia or life-threatening complications exist; this treatment aims to replace the damaged or defective bone marrow with healthy stem cells, promoting the production of normal blood cells

An older client returns to the clinic and received refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill can be substituted for many of the others. Which instruction should the nurse implement to address the clients concerns? A. Do not take any over the counter drugs while taking medications prescribed by the health care provider B. Make certain a family member knows the name and use of all medications currently being taken C. Use a medication reminder system to prevent forgetting to take the right medications at the right time D. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment

d. bring all medications, supplements, and herbs currently being taken to the next clinic appointment it is essential for the nurse to ensure the client's safety and address concerns about medications; the nurse may conduct a medication review to allow for a comprehensive assessment of the client's current medication regimen, potential interactions, and opportunities for simplification or adjustments;

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safety? Select all that apply. a. Leans forward to pull a pan from a high shelf b. Bends from the waist to pick trash off the floor c. Locks knees while preparing food on the counter d. Brings a heavy can close to body before lifting e. Widens stance while working near the sink

d. brings a heavy can close to body before lifting e. widens stance while working near the sink this demonstrates proper body mechanics by keeping the weight close to the center of gravity, reducing the risk of injury; a wider stance provides a more stable base and can help prevent falls

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we sought treatment sooner!" Which intervention is best for the nurse to implement? a. Refer the parents to the chaplain to provide grief counseling b. Assure the parents that a terminal diagnosis was inevitable c. Tell the parents that blame each other will not change the situation d. Explain to the parents that anger is a common response to grief

d. explain to the parents that anger is a common response to grief it's important to acknowledge and validate the parents' emotions; grief can manifest in various ways, including anger and blame; explaining that these feelings are common can help the parents understand that their reactions are a natural part of the grieving process; this approach is non-judgmental and supportive, and it opens the door for further emotional support and counseling if needed

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? a. Frequently apply moisturizers to prevent dry skin b. Protect the site from getting wet during bathing c. Use a sponge to debride the affected area d. Gently pat the skin dry after rinsing with water

d. gently pat the skin dry after rinsing with water This recommendation is crucial because the skin in the area receiving radiation can become very sensitive and prone to irritation. Gently patting the skin dry minimizes friction and reduces the risk of further irritation or damage to the skin.

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Administer hypertonic IV fluids as prescribed b. Limit oral water intake c. Assess neurological status every eight hours d. Initiate seizure precautions

d. initiate seizure precautions severe hyponatremia can lead to neurological complications, including seizures; initiating seizure precautions is crucial in preventing and managing potential seizures in this client populations

A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain? a. Frequency that the child uses a rescue inhaler during the week b. Type of allergen exposure or trigger for the current episode c. Type of inhaler the child typically uses on a regular basis d. Last dose and type of rescue inhaler used by the child

d. last dose and type of rescue inhaler used by the child the child is currently experiencing a severe asthma exacerbation with signs of respiratory distress, including wheezing, anxiety, tachycardia, and labored respirations; it's crucial to determine when the last dose of the rescue inhaler was administered and the type of inhaler used; this helps assess the effectiveness of the child's current treatment and guides further interventions

The nurse is providing teaching to a client who has been recently diagnosed with gestational diabetes mellitus. Which complication poses the greatest risk to the fetus if euglycemia is not maintained? a. Cleft palate b. Preterm birth c. Low birth weight d. Macrosomic newborn

d. macrosomic newborn macrosomia refers to the condition where a newborn is significantly larger than average. in the context of gestational diabetes, maternal hyperglycemia can lead to excessive fetal growth, resulting in a macrosomic newborn. this condition increases the risk of complications during delivery, such as shoulder dystocia, and can also lead to long-term health issues for both the mother and the newborn

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration. The medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 minutes after the admission assessment, should the nurse report immediately to the emergency department health care provider? a. Client reports being anxious b. Extreme agitation with staff and family c. An apical pulse of 120 beats per minute d. No wheezing upon auscultation of the client

d. no wheezing upon auscultation of the client The sudden absence of wheezing in a client with severe asthma can be a concerning sign, especially if the client is still experiencing difficulty breathing. It can indicate that the airways have become so narrowed or blocked that not enough air is moving through them to create a wheezing sound. This can be a sign of impending respiratory failure and requires immediate medical attention.

Which assessment finding is most important when planning to provide a complete bed bath to a bed fast client? a. Right sided paralysis b. 2+ pitting edema of the feet c. Pallor d. Orthopnea

d. orthopnea Orthopnea is a condition characterized by difficulty breathing when lying flat. This is a crucial consideration when providing a bed bath, as the client's position during the bath can exacerbate respiratory difficulties. The nurse will need to ensure the client is positioned in a way that does not interfere with their breathing, such as keeping the head of the bed elevated. Managing a bed bath with a client who has orthopnea requires careful planning to maintain their comfort and respiratory status.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing in the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? a. Replace the IV site with a smaller gauge b. Apply soft bilateral wrist restraints c. Leave the lights on in the room at night d. Redress the abdominal incision

d. redress the abdominal incision since the abdominal dressing is no longer occlusive, it's important to redress the incision to prevent infection and promote healing; this should be a priority to maintain the integrity of the surgical site

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement? a. Using analgesic spray to the perennial area to reduce pain b. Apply an ice pack to the perineum for the first 24 hours c. Teach the client how to practice kegel exercises d. Review the use of sitz bath equipment with the client

d. review the use of sitz bath equipment with the client A sitz bath can be very beneficial in the postpartum period for relieving perineal discomfort, reducing inflammation, and promoting healing. Given that the client has found this method helpful in the past, it's appropriate for the nurse to review the proper use of sitz bath equipment with her, ensuring she understands how to use it safely and effectively.

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? a. Risk for infection b. Impaired physical mobility c. Self-care deficit d. Risk for impaired skin integrity

d. risk for impaired skin integrity neuropathy can lead to decreased sensation in the feet, making the client more susceptible to injuries, wounds, or pressure ulcers

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? a. Case management and screening for clients with HIV b. Regional relocation Center for earthquake victims c. Lead screening for children in low-income housing d. Vitamin supplements for high-risk pregnant women

d. vitamin supplements for high-risk pregnant women This program focuses on preventing potential health issues before they occur. Providing vitamin supplements, such as folic acid, to high-risk pregnant women can help prevent birth defects and promote the overall health of both the mother and the developing fetus.