hesi practice

The primary health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse would plan to administer how many tablet(s) to the client?

1.5 tablets

The nurse provides discharge instructions to a client suspected of having an intervertebral disc problem following myelography. Which instructions would the nurse provide? Select all that apply. 1. restrict fluid intake 2. avoid bending over 3. avoid strenuous exercise 4. rest w/ HOB elevated 5. expect some clear drainage from dressing site

2, 3, 4

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

C. resp acidosis The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? a) Side-lying with a pillow under the hip b) Prone with a pillow under the abdomen c) Prone in slight Trendelenburg's position d) Side-lying with the legs pulled up and the head bent down onto the chest

D. Side-lying with the legs pulled up and the head bent down onto the chest rationale: This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? a) Deflate the cuff on the tube. b) Place the inner cannula into the tube. c) Ensure that the client is able to speak. d) Ensure that the client is able to swallow.

a - Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client? a) "Take a deep breath when I tell you, and hold it while I remove the tube." b) "Take a deep breath when I tell you, and bear down while I remove the tube." c) "Take a deep breath when I tell you, and slowly exhale while I remove the tube." d) "Take a deep breath when I tell you, and breathe normally while I remove the tube."

a - The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions would the nurse plan to include in performing this procedure? Select all that apply. a) Explaining the procedure to the client b) Clamping the tubing of the drainage bag c) Obtaining the specimen from the urinary drainage bag d) Aspirating a sample from the port on the drainage tubing e) Wiping the port with an alcohol swab before inserting the syringe

a, b, d, e - A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? a) Check for an air leak. b) Document the findings. c) Notify the primary health care provider. d) Change the chest tube drainage system.

b - Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? a) Continue to suction. b) Stop the procedure and reoxygenate the client. c) Ensure that the suction is limited to 15 seconds. d) Notify the primary health care provider immediately.

b - During suctioning, the nurse would monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? a) Do nothing because this is an expected finding. b) Check for an air leak because the bubbling needs to be intermittent. c) Increase the suction pressure so that the bubbling becomes vigorous. d) Clamp the chest tube and notify the primary health care provider immediately

b - Fluctuation with inspiration and expiration, not continuous bubbling, would be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this would decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse would check for an air leak.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse would plan to limit the suctioning time to a maximum of which time period? a) 5 seconds b) 10 seconds c) 30 seconds d) 60 seconds

b - Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest feeding? Select all that apply. a) 1% milk b) Egg yolk c) Dried beans d) Hard cheeses e) Green leafy vegetables

b, c, and e - Breast-feeding or chest-feeding parents with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the parent include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? a) Notify the surgeon. b) Clamp the surgical drain. c) Change the dressing as prescribed. d) Remove and replace the perineal packing.

c - Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? a) Bradycardia and hyperactivity b) Decreased respiratory rate and depth c) Headache, restlessness, and confusion d) Bradypnea, dizziness, and paresthesias

c - When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias

The nurse is monitoring the chest tube drainage system in a client with a pneumothorax. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? a) Continue to monitor. b) Document the findings. c) Change the chest tube drainage system. d) Perform a focused respiratory assessment.

d - Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment needs to be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema

The nurse is assisting a primary health care provider with the removal of a chest tube in a client with a resolved pneumothorax. The nurse would instruct the client to take which action? a) Stay very still. b) Exhale very quickly. c) Inhale and exhale quickly. d) Perform the Valsalva maneuver.

d - When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath and hold it, bear down, and exhale