HESI-practice exam fundamental
The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.)
32 Rationale: Use the following calculation: Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min
A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother?
"Did your daughter also start her menstrual period at 12 years of age?" Rationale: Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is worried that something is wrong with her son physically. Option B has less to do with stature than growth and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without known causes).
In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma?
"Does anyone in your family have glaucoma?" Rationale: Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member. Options A and C are not related to glaucoma. Glaucoma rarely causes pain, which is why screening is so important.
Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis?
"Has your child had an ear infection recently?" Rationale: Osteomyelitis can be caused by internal infections, such as otitis media. Options B and C are normal developmental findings for a 2-year-old. Osteomyelitis is caused by a bacterial infection, so option D is not relevant.
The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." D. "I observe my skin daily to see if I have an allergic rash to the medication."
"I take aspirin for my pain." Rationale: The client should be taught to avoid aspirin because the ingestion of aspirin or diuretics can precipitate an attack of gout. Options B, C, and D are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation. Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate. Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs.
A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?"
"Tell me more about how you're feeling." Rationale: It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings. Option A is a leading response, and the client may not be feeling sad. Options C and D are closed-ended questions that do not facilitate communication.
The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. 1. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." 2. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." 3. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." 4. "Would you like to make a change in his pharmacologic regimen?"
2, 3, 1, 4 Rationale: SBAR: S = Situation and includes introduction of the nurse and client/setting (option B). B = Background and includes the presenting complaint and relevant history (option C). A = Assessment and includes current vital signs and other information (option A). R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (option D).
The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. 1. Gently insert the catheter without suction using sterile technique. 2. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). 3. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. 4. Apply suction intermittently while withdrawing the catheter.
3, 2, 1, 4 Rationale: Equipment should be set up and adjusted prior to beginning the procedure. Hyperoxygenation using an MRB should be completed prior to inserting the catheter. After preoxygenation, the catheter can be inserted and suction can be applied intermittently.
The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN?
A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) Rationale: Option C requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic, and careful assessment is essential. Options A, B, and D could all be cared for by a PN under the supervision of the RN.
The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A.A client who is 2 days postoperative with a right total knee replacement B.A client who is scheduled for a sigmoid colostomy surgery today C.A client who has a surgical abdominal wound with dehiscence D.A client who is 1 day postoperative following a right-sided mastectomy
A client who is 2 days postoperative with a right total knee replacement Rationale: Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse.
The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide?
A client with normal vision can read at 100 feet what this client reads at 20 feet. Rationale: The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet. Options A, B, and D are inaccurate.
Which client is best to assign to a graduate PN who is being oriented to a renal unit?
A client with renal calculi whose urine needs to be strained Rationale: The client with renal calculi (kidney stones) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. Options A, B, and C require careful assessment from an experienced nurse because of the potential for significant complications.
Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci
A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) Rationale: The client with colonized MRSA is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy, which makes recovery very difficult. Positive blood cultures indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer at high risk for poor healing and bone infection.
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP?
A woman who had a hip replacement and may be transferred to the home care unit Rationale: A hip replacement is considered a clean case, and transferring the client to another unit is likely to involve physically moving the client and her belongings. The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs. The adolescent client is infected, and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit. This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support. This may require skills beyond the level of this UAP.
The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A. 50 mg/dL B. 80 mg/dL C. 110 mg/dL D. 140 mg/dL
A. 50 mg/dL Rationale: The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140 mg/dL, do not require immediate intervention.
The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours
A. Blood pressure of 90/56 mm Hg Rationale: Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose.
A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A. Help the client dangle his legs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times a day.
A. Help the client dangle his legs. Rationale: The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling, which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. Option B is indicated for venous insufficiency and indicated for bed rest. Ambulation is indicated to facilitate collateral circulation and may improve long-term complaints of pain.
The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indications best support the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A. Hourly urine output B. Bladder distention C. Urinary incontinence D. Intraoperative bladder decompression E. Urine sample for culture
A. Hourly urine output B. Bladder distention D. Intraoperative bladder decompression Rationale: Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output, bladder distention, and bladder decompression related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence or midstream collection of urine for culture, are not indicated based on the client's description.
A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A. Move objects out of the child's immediate area. B. Quickly slip soft restraints on the child's wrists. C. Insert a padded tongue blade between the teeth. D. Place in the recovery position before going for help.
A. Move objects out of the child's immediate area. Rationale: The first priority during a seizure is to provide a safe environment, so the nurse should clear the area to reduce the risk of trauma. The child should not be restrained because this may cause more trauma. Objects should not be placed in the child's mouth because it may pose a choking hazard. Although option D should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the clienT? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited.
A. Oral hygiene should be performed before the medication. Rationale: HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Mycostatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated.
Which nursing interventions should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status.
A. Report lithium level of 2.0 mEq/L to the primary health care provider. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status. Rationale: A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity. Consistent salt levels are important when taking lithium to maintain a therapeutic level. Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, the client should be assessed. Noncompetitive physical activities should be encouraged because of the risk for agitation, and decreased environmental stimuli is therapeutic for the manic phase.
A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity.
A. Save the next urine sample Rationale: The nurse should instruct the client to save the next urine sample for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated. Option C is only necessary if a calculus (stone) is suspected. Option D is not indicated by this client's symptoms.
The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which interventions would the nurse expect to implement after the procedure? (Select all that apply.)
A. Monitor maternal vital signs for hemorrhage. D. Monitor fetal heart rate for 1 hour after the procedure. B. Instruct the woman to report any contractions Rationale: These are safe measures to implement during an amniocentesis to monitor for and prevent complications. During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward. The woman should be placed in a supine position with her hands across her chest.
Which interventions are most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36-month-old child? (Select all that apply.)
A. Record wet diapers. C. Examine skin turgor. D. Observe mucous membranes. E. Record dietary intake Rationale: Options A, C, D, and E can be used to evaluate fluid status in children and are helpful assessment functions, but the age of the child makes a fontanel check impractical. The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.
Which nursing interventions should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.)
A. Report lithium level of 2.0 mEq/L to the primary health care provider D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status. Rationale: A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity. Consistent salt levels are important when taking lithium to maintain a therapeutic level. Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, the client should be assessed. Noncompetitive physical activities should be encouraged because of the risk for agitation, and decreased environmental stimuli is therapeutic for the manic phase.
Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which actions should the nurse take when preparing the client for this type of pain relief? (Select all that apply.)
A. Shave the area where the TENS will be placed. C. Place the TENS unit directly over or near the site of pain. E. Describe the use of TENS for postoperative procedures such as dressing changes. Rationale: The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain, and hair or skin preparations should be removed before attaching the electrodes. The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings. Electrodes are used, not needles, and unlike with opioids, pain relief is achieved without drowsiness.
What instructions related to foot care are appropriate for the client with type 1 diabetes mellitus? (Select all that apply.)
A. Use lanolin to moisturize the tops and bottoms of the feet. C. Wash feet daily and dry well, particularly between the toes. E. Wear leather shoes that fit properly. Rationale: Options A, C, and E are therapeutic interventions for foot care in the diabetic client. Options B and D are contraindicated and could cause foot infection or injury.
Prior to administering an oral suspension, which intervention is most important for the nurse to implement?
Assess the client's ability to swallow liquids Rationale: An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used. If a food product is used to thicken the liquid, option C would be beneficial. Option D may also be warranted, but only if the client is at risk for aspiration, determined by option A.
The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members?
Assign the UAPs to take vital signs and obtain daily weights. Rationale: A UAP can take vital signs and daily weights on stable clients. UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN. All team members can answer call lights, and PNs can administer some of the medications, so assigning the RN these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds, and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.
The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN?
Assist the client with toileting. Rationale: The PN can implement nursing care, such as option B. The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. Options A, C, and D are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.
A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A. "I will avoid coughing, sneezing, and forceful nose blowing." B. "Swimming can begin on the tenth postoperative day." C. "Any mild discomfort can be managed with acetaminophen." D. "Drainage from my ears is expected after the surgery."
B. "Swimming can begin on the tenth postoperative day." Rationale: The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims or allows water to enter the external ear. Options A, C, and D reflect correct responses.
The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction? A. "I should balance my daily exercise with my dietary intake and insulin dosages." B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C. "I should inject my insulin into a different site to reduce the development of scar tissue." D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."
B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." Rationale: Aspiration is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the absorption of the insulin. Options A and D are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight serum glucose level control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.
A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A. Flex the hips and knees and align the knees with the client's knees for safety. B. Allow the client to sit on the side of the bed for a few minutes before transferring. C. Place the client's weight-bearing or strong leg forward and the weak foot back. D. Grasp the transfer belt at the client's sides to provide movement of the client.
B. Allow the client to sit on the side of the bed for a few minutes before transferring. Rationale: A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt provides a secure hold to prevent sudden falls.
Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes.
B. Assess the client for pain and administer pain medication as prescribed. Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.
The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication.
B. Take the vital signs to determine the client's response for a potential blood loss. Rationale: After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment.
An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished.
B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. Rationale: A priority goal for the client with infectious diarrhea caused by C. difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission. Options A and C are goals dependent on the return of the client's normal bowel pattern.
The nurse recognizes which behaviors in a client as warning signs of an impending suicide attempt? (Select all that apply.)
B. Mood changes from depressed to happy. C. Begins giving away possessions Rationale: Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide. Feelings of sadness are signs of depression but not impending suicide. Options D and E are not typically indicative of impending suicide.
A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications?
Blood urea nitrogen > 25 mg/dL Rationale: Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria, an expected finding. Metabolic acidosis is the potential complication, not alkalosis. During the diuretic phase of acute renal failure, there can be a normal output volume (≈2000 mL/day), which can result from IV fluid hydration.
A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids?
Breath sounds Rationale: Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds. Options A, B, and D are important assessment data but are not specifically related to insertion of a central venous catheter.
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular self-examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones.
C. Ask about scrotal pain or blood in the semen. Rationale: Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms. Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer. Although hematuria is associated with renal disease or calculi, the client's pain is associated with ejaculate, not urine.
The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A. Parents of children with spina bifida B. High school girls in a health class C. Class of people interested in having children D. Postpartum women attending a baby care class
C. Class of people interested in having children Rationale: Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is option C. Parents with children who already have a neural tube defect such as spina bifida are not as invested in the content as option C. High school age students may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than option C. Option D may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.
A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A. Administer oxygen per nasal cannula at 2 L/min. B. Plan to check his vital signs again in 30 minutes. C. Notify the health care provider of the change in mental status. D. Ask the client why he thinks there are bugs in the bed
C. Notify the health care provider of the change in mental status. Rationale: One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status. It is important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation is normal, the administration of oxygen is not the top priority. Vital signs should be monitored frequently, but the client's confusion should be reported immediately. Option D is not a useful intervention.
Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A. Inspection of the skin B. Breath sound auscultation C. Pain scale measurement D. Mobility limitations
C. Pain scale measurement Rationale: Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority. Options A, B, and D are part of the complete assessment but do not have the priority of option C for this client.
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing actions are most likely to maintain client safety? (Select all that apply.)
C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed F. Notify the health care provider of the client's intention. Rationale: To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital and the need to take prescribed medications. This client, who is very likely self-destructive, should remain on the unit, and the health care provider should be notified. Signing a release form before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital, but pressuring clients is unethical behavior. Option E may be helpful at a later time in this client's treatment program.
The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement?
Call for the charge nurse to check the advanced directive while continuing to assess the client. Rationale: Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated.
A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?
Check the client's blood pressure. Rationale: The blood pressure should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and who have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. Options B, C, and D can be done if the blood pressure is normal.
When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take?
Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. Rationale: Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling.
The nurse performs an assessment on a client with heart failure. Which findings are consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins
Confusion; Crackles in the lungs Dyspnea Rationale: Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure.
A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take?
Consult the agency's policies and procedures manual and follow the guidelines. Rationale: The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical.
Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart?
Cover one eye while reading the chart with the other. Rationale: Each eye should be tested separately because visual acuity can vary from one eye to the other. A Snellen chart scores vision in comparison with what a person with normal vision can read at a distance of 20 feet. The Snellen chart is comprised of letters, not sentences. The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read.
According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years
D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years Rationale: The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity. The nurse uses Erikson stages of development over the lifespan to assess an older client's adjustment to aging and plans teaching strategies to assist the client to attain integrity versus despair. Options A, B, and C are normal developmental tasks of older adults.
The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received.
D. Continue with current assignments until more instructions are received. Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel.
An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A. Turn off the client's television and speak very loudly. B. Communicate in writing whenever it is possible. C. Speak very slowly while exaggerating each word. D. Face the client and speak in a normal tone of voice.
D. Face the client and speak in a normal tone of voice. Rationale: A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so option D should be implemented. Options A and C may distort the sounds and facial expressions, which alters the client's ability to interpret the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective.
A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations
D. The ventilator setting for respiratory rate and the client-initiated respirations Rationale: The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client.
A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff?
Encourage staff to participate in online in-service education. Rationale: Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census. Option B is not the responsibility of the nursing staff. Option C is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary.
After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.
Ensure that the client receives breakfast within 30 minutes. Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.
The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform?
Examine for clamp closures. Rationale: Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps first. Irrigation with a larger syringe will not alleviate the cause for the resistance and can rupture the line. A central line infection should not cause resistance while flushing the line. The CVC should be flushed with normal saline or a diluted solution of heparin (10 to 100 U/mL) after option A is completed, if necessary.
A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test?
Failure to collect all urine specimens during the period of the study will invalidate the test. Rationale: Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results will be inaccurate. As renal function decreases, the creatinine level will decrease in the urine. Dialysis is usually started when the GFR is 12 mL/min. There is no need to record the frequency and amount of each voiding during the time span of urine collection.
A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time?
Hypotension Rationale: During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension. Option A is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not option C. Option D is characteristic of chronic renal failure with multiple body system involvement.
A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting?
Inability to flex the chin to the chest Rationale: Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest. Although options A, B, and D may occur in meningitis, option A describes exaggerated spinal nerve reflex responses, option B describes opisthotonus, and option D may be related to cranial nerve pathology of the trigeminal nerve.
The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate that the drug is effective? (Select all that apply.)
Increase in T3 and T4 Decrease in periorbital edema Rationale: Levothyroxine (Synthroid) is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism. Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine. Levothyroxine does not affect urine output.
The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure
Increased oxygen saturation Rationale: Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator.
A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make?
Inform the client that the scheduled Pap test cannot be done today. Rationale: The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test.
When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include?
Instruct the client to grasp the overhead trapeze bar Rationale: The client will gain upper body strength and independence by using the overhead trapeze bar for positioning. Elevation of the residual limb is controversial because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. Option C is used for alignment following some hip surgeries. A prone position should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.
The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement?
Leave the room and discuss the incident privately with the staff member. Rationale: Discussing the incident privately promotes open communication between the charge nurse and staff member. The client is free to share unwanted food with family or friends, but the employee should not ask for the client's food. Option C is not necessary, and the charge nurse can respond to this situation without implementing option D.
A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement?
Obtain a stool specimen for culture and sensitivity Rationale: Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen. Impaction is unlikely, so option A is of less priority and may not be necessary. Option B is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort are important interventions but of less priority than determining the cause of the client's diarrhea.
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP?
Offer the client emotional support Rationale: By using therapeutic techniques to offer support, the nurse can determine any client concerns that need to be addressed. Options A, B, and C are all actions that can be performed by the UAP under the supervision of the nurse.
A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation?
Offer to develop an alternate solution so that the residents can continue to watch television. Rationale: The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise. The staff do not have the right to watch television while being paid to work. Option B challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. Option D is not a sound rationale for the use of the television.
Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)?
Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP. Rationale: The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP.
A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement?
Place trochanter rolls on the lateral aspects of the client's thighs Rationale: Trochanter rolls should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although options A, B, and C are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board provides increased back support, especially with a soft mattress. The footboard maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.
A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide?
Save the next urine sample Rationale: The nurse should instruct the client to save the next urine sample for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated. Option C is only necessary if a calculus (stone) is suspected. Option D is not indicated by this client's symptoms.
The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented?
Serum potassium level is 2.5 mEq/L Rationale: Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥ 2 ng/mL); Option A is within this range. Option B would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is < 60/min.
Which physiologic finding in an older adult contributes to an adverse drug reaction?
Reduced renal excretion Rationale: During the aging process, reduced renal function is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not option C, predisposes an older adult to an increase in adverse drug reactions. Option B may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders is not increased, nor does it affect drug pharmacotherapeutics.
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement?
Rest in bed with the head of the bed elevated 20 degrees and flex the knees. Rationale: Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Range-of-motion exercises can result in paravertebral muscle spasms and increased pain. Bending the knees, rather than option B, reduces stress on the lower back. Option D places stress on the lower back and increases the client's pain.
A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client?
Serum sodium level of 137 mEq/L Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema, but the higher priority outcome is the effect on serum electrolyte levels. Although options B and C are findings associated with resolving SIADH, they do not have the priority of option D.
A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client?
Sitting upright and forward with both arms supported on an over the bed table Rationale: Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler position does not allow maximum expansion of the posterior lobes of the lungs. A semi-Fowler position restricts the expansion of the anterior-posterior diameter of the thoracic cage. Positioning a client on the right side with the head of the bed elevated does not facilitate lung expansion.
When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement?
Speak privately with the nurse. Rationale: The nurse-manager should speak privately with the nurse to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. Option B might become confrontational. Option C is irrelevant. Option D is not warranted.
A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl (Symmetrel). Which action should the nurse take?
Teach client to change positions slowly. Rationale: Amantadine can cause postural hypotension, so sudden position changes should be avoided. Options A and C are contraindicated with this drug, and option D is a sign of a possible allergic reaction, not a common side effect.
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff?
Team 1: RN team leader, PN; team 2: PN team leader, UAP Rationale: Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN. Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. Options B, C, and D do not use the expertise of the nursing staff for the high-risk clients.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A. The client is noncompliant with his medications. B. = The client recently consumed large quantities of pears or nuts. C. The client's renal function has affected his potassium level. D. The client needs to be started on a potassium supplement.
The client's renal function has affected his potassium level. Rationale: The client has a normalized potassium level despite diuretic use. The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium level. There is no need for a potassium supplement because the client's potassium level is within the normal range.
A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain?
The client's usual sleeping pattern Rationale: The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained.
Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse?
The color of the dialysate outflow is opaque yellow. Rationale: Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia.
A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol). How should the nurse respond to this client's statement?
The drug is hepatotoxic and contraindicated Rationale: Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated. Although bleeding is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although option B is an indicated use for this drug, it remains contraindicated in clients with hepatic failure. Option C is inaccurate.
Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake.
The oral mucosa is pink and intact. Rationale: Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication.
A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat milk
Toasted oat cereal and low-fat milk Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D. Option A is high in fat and sugar. Options B and C are high in fat and sodium.
The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents?
Warm the child with an electric blanket prior to getting the child out of bed. Rationale: Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness. Option D is contraindicated, because joints should be exercised, not immobilized.
A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client?
With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. Rationale: With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation. Option A is not the primary reason for the changes in body structure. Option B is not indicated because loss of muscle tone and constipation are age-related changes. Option D dismisses the client's concerns and does not help her understand the changes that she is experiencing.