HESI - part 6

The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? a. Diabetic ketoacidosis and titrated IV insulin infusion b. Emphysema extubated 3 hours ago receiving heated mist c. Subdural hematoma with an intracranial monitoring device d. Acute coronary syndrome treated with vasopressors

A

The nurse is preparing to discharge an older adult female client who is at risk for hyPOCALCEMIA nurse include with this client's discharge teaching? a- Report any muscle twitching or seizures b- Take vitamin D with calcium daily c- Avoid seafood, particularly selfish d- Low fat yogurt is a good source of calcium e- Keep a diet record to monitor calcium intake

ABDE Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish.

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. c- Position client on abdomen to provide organ stability d- Encourage an increased intake of clear oral fluids e- Review client's abdominal ultrasound findings.

ABE

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

Achieve satisfactory pain control.

A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? a- Schedule a home visit in the afternoon to assess the son and client role as caregiver. b- Acknowledge the client's stress and suggest that she consider respite care. c- Provide feedback to the client about her atonement for guilt about her son's impairment. d- Teach the client to problem-solve for herself and establish her own priorities.

Acknowledge the client's stress and suggest that she consider respite care. Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care.

A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks: a. Administer Oxygen via face mask b. Apply an internal fetal heart monitor c. Notify the healthcare provider d. Use a vibroacoustic stimulator

Administer Oxygen via face mask Rationale: The nurse should administer oxygen to increase the amount of oxygen available for the fetus, because is presenting characteristics of late decelerations, caused by uteroplacental insufficiency.

A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement? a. Encourage the child to cough b. Obtain a throat specimen for culture c. Administer nebulized epinephrine d. Collect blood for arterial blood gasses

Administered Nebulized Epinephrine

The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take? a. Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP. b. Stop the UAP before the procedure and explain to the client that some discomfort may be felt c. Interject that while the procedure is not extremely painful, the client will feel a prick on the finger. d. Report the incident to the education director and request additional instruction for the UAP.

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement? a. Feed the infant when he cries b. Allow the infant to rest before feeding c. Weigh before and after feeding. d. Insert a nasogastric feeding tube.

Allow the infant to rest before feeding

A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement? a. Turn the client to a lateral position b. Apply counter-pressure to the sacral area c. Notify the scrub nurse to prepare the OR d. Ambulate the client between contractions

Apply counter-pressure to the sacral area Rationale: B provides pain relief during labor.

The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? a- Stroke the inner thigh below the perineum to initiate urinary flow b- Contract, hold, and then relax the pubococcygeal muscle c- Pour warm water over the external sphincter at the distal glans d- Apply downward manual pressure at the suprapubic regions.

Apply downward manual pressure at the suprapubic regions. Rationale: The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.

A client present at the clinic with blepharitis. What instructions should the nurse provide for home care? a- Use bilateral eyes patches while sleeping to prevent injury to eyes. b- Wear sunglasses when out of doors to prevent photophobia c- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo d- Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo.

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo Rationale: This condition is an inflammation of the eyelids edges that occurs in older adults. Is controlled with eyelid care using warm moist compresses followed by gently scrub eyelids.

A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? a- Prepare the client for an emergency cesarean birth b- Encourage the client to move to a hands-and-knees position. c- Assist the client to sharply flex her thighs up again the abdomen. d- Lower the head of the bed an apply suprapubic pressure.

Assist the client to sharply flex her thighs up again the abdomen.

A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? a. Adhere to a bland diet whenever planning to eat out b. Decrease fluid intake at meal times c. Avoid foods that caused gas before the colostomy d. Eliminate foods high in cellulose

Avoid foods that caused gas before the colostomy

595. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a. Beta blockers b. Bronchodilators c. Corticosteroids d. Beta-adrenergic

B

In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? a- Urinalysis b- Serum creatinine c- Serum osmolarity d- Liver enzymes.

B Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level can monitor the renal function.

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a- Your baby is gaining weight right on schedule b- What food does your baby usually eat in a normal day? c- The baby is below the normal percentile for weight gain What was the baby's weight at the last well-baby clinic visit

B Rationale: The normal weight gain in the first year of life is approx. twice the birth weight

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply) a- Administer a PPD test b- Schedule the client for the chest radiograph c- Obtain sputum for acid fast bacillus (AFB) testing d- Place a mask on the client until he is moved to isolation. e- Send the client home with instructions for a prescribe antibiotic.

BCD Rationale: Client with history of TB a chest x-ray and sputum are indicated. The client sign and symptoms indicate the pt should wear mask to protect others.

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply) a- Discontinue medication when palpitation subside. b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow e- If a dose is missed, the next dose should be double.

BCD Rationale: Side effects can increase if the client consume grapefruit. OTC medications or herbal should be reported for possible drugs interactions. Hepatic injury can occur, and the client should report sign of jaundice or itching, or right upper quadrant pain.

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

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness

Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? a. Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema b. A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS c. Functional residual capacity and lung compliance increase as the disease progresses d. Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema.

Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? a. Initiate a perineal pad count b. Catheterize for residual urine after next voiding c. Assess for a perineal hematoma d. Determine the client's usual voiding pattern

Catheterize for residual urine after next voiding

The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? a. Finger stick blood glucose 120 mg/dL post exchange b. Arteriovenous (AV) graft surgical site pulsations. c. Anorexia and poor intake of adequate dietary protein d. Cloudy dialysate output and rebound abdominal pain

Cloudy dialysate output and rebound abdominal pain

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy... Which action should the nurse instruct the parents to take if the child begins to vomit? a. Continue giving ORS frequently in small amounts b. Withhold all oral intake c. Supplement ORS with gelatin or chicken broth d. Provide only bottle water.

Continue giving ORS frequently in small amounts

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases? a. Contraction pattern b. Blood pressure c. Infusion site d. Pain level

Contraction pattern

The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress? a- Contractions of the sternocleidomastoid muscle. b- Respiratory rate of 20 breath/mints c- Downward movement of diaphragm with inspiration d- A pulse oximetry reading of SpO2 95%

Contractions of the sternocleidomastoid muscle Rationale: Force inspiration needs to use accessories muscle and rib cage.

Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? a- Decrease abdominal girth b- Increased blood pressure c- Clear breath sounds d- Decrease serum albumin.

Decrease abdominal girth

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take? a. Notify the healthcare provider immediately b. Increase the temperature of the radiant warmer c. Assess the infant's heart rate. d. Determine the infant's blood sugar level.

Determine the infant's blood sugar level

The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP? a- Replace the NG tube as prescribed by the healthcare provider b- Secure the NG tube if it slides out of the client's nasal passage c- Disconnect the NG suction so the client can ambulate in the hallway. d- Reconnect the NG suction when the client returns form ambulating.

Disconnect the NG suction so the client can ambulate in the hallway

A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client? a- Refrain from eating foods containing eggs for 24 hors b- Breast feeding is recommended to prevent ovulation. c- Do not get pregnant for at least 3 months. d- Avoid exposure to the sunlight for 36 hours.

Do not get pregnant for at least 3 months Rationale: The rubella vaccine can be harmful to an unborn child who is conceived within 3 month of the vaccination.

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? a- Notify the pediatrician immediately. b- Teach the parents about congenital heart defects. c- Document the finding in the infant's record. d- Apply oxygen per nasal cannula at 3 L/min.

Document the finding in the infant's record

A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend? a. Eat food high in garlic with the evening meal b. Drink chamomile tea at breakfast and in the evening. c. Increase cocoa in the diet and drink before bedtime d. Join a yoga class that meets at least weekly

Drink chamomile tea at breakfast and in the evening. Rationale: Chamomile tea is used to aid with digestion and is in fact sometimes used for indigestion. C should not be used by breastfeeding woman or at night when trying to go to sleep. D is for improve circulation, stimulate the internal organs, stretch the body, restore....

The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit? a- Dyspnea, cough, and fatigue. b- Hepatomegaly and distended neck veins c- Pain over the pericardium and friction rub. d- Narrowing pulse pressure and distant heart sounds.

Dyspnea, cough, and fatigue.

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take? a. Elevate the foot and leg on two pillows b. Measure the client's capillary glucose c. Ask the client to dorsiflex the right foot. d. Encourage the client to describe the pain.

Encourage the client to describe the pain. Rationale: Neuropathic pain is caused by damage within the nervous system. Description of the pain such as burning or numbness helps identify the pain as neuropathic, allowing appropriate treatment to be initiated. Elevation is to unlikely to impact the pain. Persons with diabetes mellitus may develop peripheral neuropathy, nut there is no immediate need to measure this client's capillary glucose. (C) is not a useful intervention in assessing or managing neuropathic pain.

The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate? a. Ask the client to remove shoes before stepping on the scale b. Ensure that the scale is calibrated before a weight is obtained. c. Slide the balancing weights until the scale is at zero. d. Compare client's weight at various time of the day.

Ensure that the scale is calibrated before a weight is obtained

A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement? a- Evaluate the urine osmolality and the serum osmolality values. b- Obtain blood pressure and assess for dependent edema c- Measure oral secretions suctioned during last hours d- Obtain capillary blood samples q2 hours for glucose monitoring.

Evaluate the urine osmolality and the serum osmolality values. Rationale: With a known head injury, sudden inadequate secretion of antidiuretic hormone (ADH) can cause excessive output of diluted urine. Evaluating laboratory results should de determined to identify findings of neurogenic diabetes insipidus (DI0, such as low urine osmolarity and normal serum osmolarity (A) prior to notify the healthcare provider so that these finding can be included in the report. Massive diuresis, dehydration, and thirst manifest hypotension, irregular tachycardia, decrease skin turgor, but B or C are not related to DI.

The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? a- Exercise at least three times weekly b- Monitor blood glucose levels daily c- Limit intake of foods high in saturated fat d- Learn to read all food product labels

Exercise at least three times weekly

A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment? a- Tell the mother to keep a twenty- four-hour food diary for the child. b- Explain that a protruding abdomen is typical for toddlers. c- Discuss way to increase the child's daily activity level d- Ask the mother is she has weight problems when she was a child.

Explain that a protruding abdomen is typical for toddler

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests? a- Expresses an understanding of the procedure. b- NPO for 6 hrs. c- No known drug allergies d- Intravenous access intact.

Expresses an understanding of the procedure

Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? a. Arterial ischemia b. Tissue necrosis c. Fat embolism d. Nerve damage

Fat embolism

The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus? a. Push the NGT beyond the oropharynx gently yet swiftly. b. Offer the client sips of water or ice and coax to swallow c. Elevate the bed 90 degree and hyperextend the head. d. Flex the client's head with chin to the chest and insert.

Flex the client's head with chin to the chest and insert.

When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? a- Check for any abrasions or bruises. b- Help the client to stand. c- Get a blood pressure cuff. d- Report the fall to the nurse-manager.

Get a blood pressure cuff.

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority? 545. a- Clean the perineal are to prevent infection b- Assess the mother's blood pressure to check for signs of preeclampsia c- Assess the mother temperature to check for development of sepsis. d- Have a meconium aspirator available at delivery.

Have a meconium aspirator available at delivery

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care? a- Speak clearly and face the clients for lip reading b- Provide written instructions for eyes drop administration c- Ensure that someone will stay with the client for 24 hours. d- Have the client vocalize the instructions provided.

Have the client vocalize the instructions provided. Rationale: A client with both hearing and visual sensory deficit should be repeat the instruction provided so the nurse needs to be sure the clients understand the self-care instructions.

The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? a- Administer the Tropol immediately and monitor the client until the heart rate increases. b- Provide the dose of Tropol as scheduled and assign a UAP to monitor the client's BP q30 minutes. c- Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. d- Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Rationale: Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third-degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a- Hypernatremia b- Excessive thirst c- Elevated heart rate d- Poor skin turgor

Hypernatremia

A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? a. Hypotension. b. Fever and chills c. Dizziness d. Headache

Hypotension

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis? a- I couldn't get my son's socks and shoes on this morning" b- My son has been on amoxicillin/clavulanate for 2 days for an ear infection c- My son has had a red rash over his entire body for the past 4 days. d- I couldn't get my son calm down and sleep last night.

I couldn't get my son's socks and shoes on this morning"

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? a- Initiation of the impulses from a location outside the SA node b- Inability of the SA node to initiate an impulse at the normal rate c- Increased conduction time from the SA node to the AV junction Interference with the conduction through one or both ventricles

Inability of the SA node to initiate an impulse at the normal rate Rationale: A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first-degree heart block.

A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement? a- Infuse sodium chloride 0.9% (normal saline) b- Prepare an emergency dose of glucagon c- Determine the last time the client ate d- Check urine for ketone bodies with a dipstick

Infuse sodium chloride 0.9% (normal saline) Rationale DKA an increase in glucose and ketone bodies, result in hyperosmolar dehydration, so is necessary to restore fluid balance.

An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? a- Ask a family member to sit with the client b- Apply bilateral soft wrist restraints c- Assign staff to check client q15 minutes d- Install a bed exit safety monitoring device

Install a bed exit safety monitoring device

A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant? a- Give ampicillin 25 mg/kg slow IV push b- Deliver 1:10,000 epinephrine 0.1 ml/kg per endotracheal tube c- Administer digoxin 20 mcg/kg IV d- Instill beractant 100 mg/kg in endotracheal tube.

Instill beractant 100 mg/kg in endotracheal tube

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement? a- Document the observation in the client's medical record b- Instruct the scrub nurse to re-drape the client c- Ensure that the client in unaware of the surrounding. d- Consult with operating room manager.

Instruct the scrub nurse to re-drape the client

During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client? a. Elevate the head with two pillows while sleeping b. Lie on the left or right side when sleeping or resting. c. Increase intake of foods that are high in iron d. Decrease the amount of carbohydrates in the diet.

Lie on the left or right side when sleeping or resting

A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement? a- Encourage the parents to stay at the bedside b- Use distraction techniques to reduce pain. c- Maintain strict aseptic technique d- Place a drape over the pubic area.

Maintain strict aseptic technique.

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? a. White blood count of 19,000 mm3 b. Oral temperature of 100.2 F (37.9 C) c. Moderate amount of foul-smelling lochia. d. Blood pressure 122/74 mm Hg

Moderate amount of foul-smelling lochia.

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement? a- Send stool specimen to the lab b- Measure abdominal girth c- Encourage increased fiber in diet. d- Monitor mental status.

Monitor mental status. Rationale: Administer lactulose to a patient hepatic encephalopathy to lower serum ammonia level, so mental status should be improving.

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a JacksonPratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? a- Monitor urine output hourly. b- Assess for back muscle aches c- Record drainage from drain d- Obtain body weight daily

Monitor urine output hourly. Rationale: When one kidney is removed the remained kidney must do all the volume filtering, so A is immediate to postoperative period.

A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? a- Insomnia b- Muscle cramping c- Increase appetite d- Anxiety.

Muscle cramping Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.

The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? a- Low bioavailability b- Rapid onset of action c- Short half life d- Narrow therapeutic index.

Narrow therapeutic index.

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement? a. Negative pressure environment b. Contact precautions c. Droplet precautions d. Protective environment

Negative pressure environment

The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse? a- Notify nursing supervisor and hospital chaplain of the child's impending death. b- Verify that the no resuscitate forms are in the child's medical record c- Ask the parents if they have made arrangements with a funeral home d- Provide staff coverage to sit with them as the child's death approaches.

Notify nursing supervisor and hospital chaplain of the child's impending death.

While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take? a. Complete a usual incident report b. Start prophylactic treatment c. Seek psychological resources d. Notify the employee health nurse.

Notify the employee health nurse.

A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take? a. Obtain a pulse oximeter reading b. Assess the child blood pressure c. Perform a neurological assessment d. Initiate peripheral intravenous access.

Obtain a pulse oximeter reading

In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? a- High urinary PH b- Abdominal Ascites c- Orthopnea d- Fever.

Orthopnea Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).

To obtain an estimate of a client's systolic B/P. What action should the nurse take first? a. Palpate the client's brachial pulse b. Pump up the blood pressure cuff c. Position the stethoscope diaphragm d. Release the blood pressure cuff valve

Palpate the client's brachial pulse

The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse? a- Peak and through levels has not been drawn since the tobramycin was started b- Today labs report indicates a white blood cell count of 13,000 cell/mm3 or 13 x 10777/L (S1) c- A serum creatinine level of 1.0 mg/dl or 88 mcmol/L (S1) is documented on yesterday flowsheet. d- The culture growth form the burn areas is sensitive to aminoglycosides.

Peak and through levels has not been drawn since the tobramycin was started

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? a- Allow the client to use a bedpan. b- Assist the client to the bathroom c- Perform a sterile vaginal exam d- Explain the fetal head is descending.

Perform a sterile vaginal exam Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.

The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first? a. Place client in Trendelenburg position on the left side. b. Administer precordial thump c. Monitor the client with a 12-lead electrocardiogram d. Request a STAT portable chest x-ray.

Place client in Trendelenburg position on the left side

After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next? a. Vigorous rub both hands together under running water b. Path both hands dry keeping the fingers lower that the arm c. Place one hand on top of the other and interlace the fingers d. Hold both hand with the fingers pointing upward until dry.

Place one hand on top of the other and interlace the fingers

Which intervention should the nurse implement for a client with a superficial (first degree) burn? a. Spray an anesthetic agent over the burn every 3 to 4 hours b. Position the burn victim in front of a cool fan to decrease discomfort c. Apply ice pack for 30 mints to lower surface temperature d. Place wet clothes on the burned areas for short periods of time.

Place wet cloths on the burned areas for short periods of time. Rationale: D provides comfort and helps to relive the pain of a first degree burn, which involves only the epidermal layer of the skin.

A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result...dealing with the healthcare provider. What action should the nurse manager implement? a- Confront the health care provider about the perceived lack of respect for the staff nurses. b- Plan an interdisciplinary staff meeting to develop strategies to enhance client care c- Request an investigation about the perceived incivility of the healthcare provider interaction. d- Remind the staff that avoidance behavior is not a professional way to handle the problem.

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? a. Administer epinephrine IV b. Give an IV bolus of amiodarone c. Provide immediate defibrillation d. Prepare for synchronized cardioversion

Provide immediate defibrillation

While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? a- Tinea corporis b- Herpes zoster c- Psoriasis d- Drug reaction

Psoriasis Rationale: Psoriasis is typically located on the elbow and knees

Which interventions should the nurse include in a long-term plan of care for a client with COPD? a- Reduce risk factors for infection b- Administer high flow oxygen during sleep c- Limit fluid intake to reduce secretions d- Use diaphragmatic breathing to achieve better exhalation

Reduce risk factors for infection Rationale: Interventions aimed at reducing the risk factors of infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection of infections are necessary

When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? a. Doubt b. Observation c. Confrontation d. Reflection

Reflection

A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond? a- Determine how the client is administering the medication b- Confirm that this is a common symptom of osteoporosis c- Report the client's jaw pain to the healthcare provider. d- Advise the client to gargle with warm salt water twice daily.

Report the client's jaw pain to the healthcare provider. Rationale: Bisphosponates, including alendronate, can cause osteonecrosis of jaw, which should be reported to the healthcare provider © for evaluation. Incorrect administration (A) such as failing to remain upright after taking the medication, can contribute to esophageal reactions, but does not causes haw pain. Jaw pain is not a symptom of osteoporosis and is not relieved with saline throat gargles.

While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

T4 levels in newborns

A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? a. Hold the next dose of antibiotic until contacting the healthcare provider b. Teach the client how to use a dry heating pad over the painful area c. Encourage the client to practice pelvic floor exercises every hour d. Assist the client to splint the site by applying an abdominal binder

Teach the client how to use a dry heating pad over the painful area

A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? a- Supplemental hormonal therapy will probably be unnecessary b- The thyroid will regenerate to a normal size within a few years. c- The client will be restricted from eating seafood d- The remainder of the thyroid will be removed at a later date.

The client will be restricted from eating seafood

A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? a. Presence of bruising, weakness, or fatigue b. Therapeutic exercise included in daily routine. c. Average amount of protein eaten daily d. Existence of gastrointestinal discomfort

Therapeutic exercise included in daily routine

A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? a. Thready brachial pulse. b. Respirations of 24/minute c. Right foot cool to touch. d. Swelling at the site of injury

Thready brachial pulse.

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip what? a- The mother perceives and marks at least four fetal movements b- Fetal movements must be elicited with vibroacoustic stimulator c- Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. d- No FHR late deceleration occur in response to fetal movement

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk? a. Blood pressure of 100/60 b. Incontinent with blood in urine c. Unresponsive to painful stimuli d. Presence of hematemesis.

Unresponsive to painful stimuli Rationale: Eptifibatide, is an inhibitor of platelet aggregation, is administer IV for ACS, and bleeding is a significant side effect. A sudden onset of unresponsiveness may indicate intracranial bleeding, which is the life threatening finding related to bleeding. Although hypotension may indicate bleeding, it is not as significant as unresponsiveness to pain. This medication has a short half-life, so B and D are not life threatening findings.

A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider? a- Urinary output of 25mL per hour b- Hemoglobin level of 10 g/dL or 100 g/L (S1) c- Hyperactive bowel sounds d- Oral temperature of 100.4 F (38 C)

Urinary output of 25mL per hour

A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour Rational: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.

The nurse is conducting the initial assessment of an ill client who is from another culture.... What response should the nurse provide? a- Can you read the written instructions is English? b- "What practices do you believe will help you heal?" c- What prescriptions must be strictly followed to get well. d- You must believe that the medications will help you.

What practices do you believe will help you heal?"

A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? a- Review the surgical consent with the client b- Explain that vomiting can occur during surgery c- Remove the food from the client d- Withhold the preoperative medication

Withhold the preoperative medication

An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make? a. Your blood pressure indicate that you have hypertension. You need to see a physician at once. b. Your blood pressure is quite high. Go to the closest emergency room for immediate treatment. c. Your blood pressure is a little high. You need to have it rechecked within one week. d. Your blood pressure is little high, but it is within the normal range for your age group.

Your blood pressure is a little high. You need to have it rechecked within one weeK

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement? a. Encourage the client to be calm and relax for a little while b. Assist the client to identify stimuli that precipitates the activity. c. Allow time for the behavior and then redirect the clients to other activities. d. Teach the client thought stopping techniques and ways to refocus.

allow time for the behavior and then redirect the clients to other activities

In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents? a- avoid smoking in the house b- stop smoking immediately c- decrease the number of cigarettes smoke daily d- obtain nicotine patches to assist in smoking sensation

avoid smoking in the house

The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

corner of the mouth to the tip of the ear

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last) Move the crash cart to the client room Call the rapid response team to assist Inform the family of the critical situation Notify the client's healthcare provider

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

The nurse is collecting a sterile urine specimen using a straight catheter tray for culture.... (Arrange from first action to last). Use forceps and swaps to clean the urinary meatus Drape the client in a recumbent position for privacy Open the urinary catheterization tray Don sterile gloves using aseptic technique

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only)

18 Rationale: 450000/25000=18

The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2500

The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

47

A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving

700 Rationale: 25000/500x14=700