HESI Practice Test

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test? The right eye is tested, followed by the left eye, and then both eyes are tested. Both eyes are tested together, followed by the testing of the right and then the left eye. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale:Visual acuity is tested in one eye at a time, and then in both eyes together, with the client comfortably seated. Begin with the right eye while the left eye is covered, and then test the left eye with the right eye covered, followed by testing both eyes together. Visual acuity is measured with or without corrective lenses, with the client standing at a distance of 20 feet from the chart.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply. Discourage reminiscing. Make the decisions for the family. Encourage expression of feelings, concerns, and fears. Explain everything that is happening to all family members. Extend touch, and hold the client or family member's hand if appropriate. Be honest and truthful, and let the client and family know that you will not abandon them.

Encourage expression of feelings, concerns, and fears. Extend touch, and hold the client or family member's hand if appropriate. Be honest and truthful, and let the client and family know that you will not abandon them. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. It is important to extend touch and to hold the client or family member's hand if appropriate.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply. Discourage reminiscing. Make the decisions for the family. Encourage expression of feelings, concerns, and fears. Explain everything that is happening to all family members. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale:The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The licensed practical nurse (LPN) is obtaining a client's signature on an informed consent for a total knee replacement surgery. The client has many questions and seems reluctant to sign the consent. Which best action would the LPN take? Ask the registered nurse to explain the procedure. Notify the supervisor that the client has not signed the form. Explain the procedure in detail answering the client's questions. Notify the surgeon that the client has many questions about the procedure.

Notify the surgeon that the client has many questions about the procedure. Rationale: For the client to have sufficient information for informed consent, the person must have been advised of risks, benefits, alternatives, and consequences of refusing the treatment. A client has the right to have all questions answered. The primary health care provider is responsible for obtaining informed consent. Nurses may obtain client signatures and serve as witnesses to the signature as agency policy permits. The nurse should ask the client if he or she understands the procedure. If the nurse suspects the client lacks decision-making capacity or does not fully understand the implications of the consent form, the primary health care provider should be contacted. The supervisor can be notified about the situation.

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? Provide safety for the client and other clients on the unit. Provide the clients on the unit with a sense of comfort and safety. Assist the staff with caring for the client in a controlled environment. Offer the client a less-stimulating area to calm down and gain control.

Provide safety for the client and other clients on the unit. Rationale:Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client centered. Option 4 addresses the client's needs.

The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse would plan which as a final measure to determine correct tube placement? Hyperoxygenate the client. Tape the tube securely in place. Listen for bilateral breath sounds. Verify placement by a chest x-ray.

Verify placement by a chest x-ray. Rationale: The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on which information? The object of the crisis The client's coping mechanisms The presence of support systems The physical condition of the client

The physical condition of the client Rationale :The initial data collection of a client in a crisis state would focus on the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed to care for the client.

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan? A dietary diary Food preferences The presence of food allergies Medical history of conditions related to nutritional deficits

The presence of food allergies Rationale: The presence of food allergies is critical to know before developing a nutritional plan. Dietary diary results, food preferences, and medical history provide good information but are not as crucial as the presence of food allergies.

The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions? "If I develop a fever, I will call my doctor." "When getting out of bed, I should sit up straight." "I will lift nothing heavier than 30 pounds for 2 weeks." "I can start doing abdominal exercises as soon as I get home."

"If I develop a fever, I will call my doctor." Rationale: The client should not lift anything heavier than the baby for 2 weeks. When getting out of bed, the client should turn on the side and push up with the arms. The client should call the doctor if a fever develops. Abdominal exercises should not be started following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? Slow the intravenous flow rate. Continue the oxytocin drip if infusing. Place the client in a high-Fowler's position. Administer oxygen, 8 to 10 L/minute, via face mask.

Administer oxygen, 8 to 10 L/minute, via face mask. Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume.

A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate? Skip the dose and try again at a later time. Crush the tablet and mix it with applesauce. Give the client a large glass of water to aid in swallowing. Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change.

Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change. Rationale: Time-released medications are film-coated and designed to dissolve later in the gastrointestinal tract. The contents are not made to be dissolved in the mouth or esophagus and should not be crushed or broken open. The LPN should consult with the RN because if the client has extreme difficulty swallowing, the PHCP should be notified. Offering large volumes of water and a capsule to a client with impaired swallowing could result in aspiration.

A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen is not very effective. Which is the best suggestion by the nurse? Increase the dose of the acetaminophen. Encourage the child to lie on the left side. Encourage the child to lie on the right side. Increase the frequency of the acetaminophen.

Encourage the child to lie on the right side. Rationale:Splinting of the affected side by lying on that side may decrease discomfort. It is inappropriate to advise the mother to increase the dose or frequency of the acetaminophen. Lying on the left side will not be helpful in alleviating discomfort.

A client is admitted to a general medical-surgical unit with an upper gastrointestinal (GI) bleed. The nurse would expect which condition to be the primary cause? Esophagitis Hemorrhoids Hyperemesis Chronic constipation

Esophagitis Rationale: A GI bleed is bleeding that occurs at some area within the GI tract. Causes of upper GI bleeds include peptic ulcers, stress-related erosion, esophageal varices, tearing caused by trauma, esophagitis, gastric cancer, aortoenteric fistula, and angiodysplasia.

The nurse employed in a neighborhood health care clinic notes that the primary health care provider has prescribed oseltamivir. The nurse would reinforce teaching the client specific home care measures after determining this medication was prescribed for which condition? Herpes zoster Influenza virus Herpes simplex Varicella zoster

Influenza virus Rationale:Oseltamivir is an oral antiviral medication used to treat influenza A and B virus. It is not used to treat herpes simplex, herpes zoster, or varicella zoster.

Carbamazepine is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history knowing that this medication is contraindicated if which disorder is present? Headaches Liver disease Hypothyroidism Diabetes mellitus

Liver disease Rationale:Carbamazepine is contraindicated in liver disease, and liver function tests are routinely prescribed for baseline purposes and are monitored during therapy. It is also contraindicated if the client has a history of blood dyscrasias. It is not contraindicated in the conditions noted in the incorrect options.

The nurse assigned to care for a client with mild preeclampsia would anticipate which specific nursing intervention for this client? Monitoring fetal movement Maintaining complete bed rest Monitoring daily blood glucose Restricting maternal fluid intake

Monitoring fetal movement Rationale: A client with mild preeclampsia can be managed at home. The expectant mother is asked to keep a record of fetal movements. Bed rest with bathroom privileges is prescribed. Urine is checked for protein. A blood glucose test is not necessary. The client usually follows a regular diet that does not restrict fluids.

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action? Ignore the delusion. Take the client to a quiet room. Support the client's denial of illness. Privately confront the client with reality.

Privately confront the client with reality. Rationale:The nurse's best action is to privately confront the client with reality.

The nurse is giving a client a bed bath and drops the towel on the floor. The nurse would take which action? Use a bath blanket as a towel. Borrow a towel from the client's roommate. Wash the hands, pick up the towel, and shake it off. Wash the hands and go to the linen room to obtain another towel.

Wash the hands and go to the linen room to obtain another towel. Rationale:In order to avoid spreading the client's microorganisms, the nurse's hands must be washed before leaving the client's room. It is never appropriate to borrow other clients' supplies because it is not consistent with general principles of infection control. It is not appropriate to use a bath blanket as a towel. The nurse should never use a supply that was dropped on the floor. Additionally, shaking linen spreads microorganisms.

The nurse determines that an adolescent client with diabetes mellitus needs further teaching about A1c levels and their purpose if the client made which statement when told that a level will be drawn? "Last time this test was taken the result was 13. I hope it will be lower this time." "I have followed my diet these past 3 months, so hopefully the test result will be OK." "I already had a complete blood cell count drawn an hour ago, so this test is not necessary." "Most of my recent blood glucose levels were close to 170 mg/dL, so this result will probably be a little high."

"I already had a complete blood cell count drawn an hour ago, so this test is not necessary." Rationale:A1c reflects the average blood glucose levels during the previous 3 to 4 months. It assesses glucose control in the client with diabetes mellitus. Glucose molecules attach to the hemoglobin A molecules found in red blood cells (RBCs) and remain there for the lifetime of the RBCs, approximately 120 days.

A film-coated form of diflunisal has been prescribed for a client for the treatment of chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which initial instruction would the nurse reinforce to the client? "Crush the tablets and mix them with food." "Open the tablet and mix the contents with food." "Swallow the tablets with large amounts of water or milk." "Notify the primary health care provider for a medication change."

"Swallow the tablets with large amounts of water or milk." Rationale:The initial instruction the nurse would reinforce to the client is to swallow the tablets with large amounts of water or milk. Taking the medication with a large amount of water or milk should be tried before contacting the primary health care provider. Diflunisal may be given with water, milk, or meals. The tablets would not be crushed or broken open.

The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values would the nurse expect to note in this client? Sodium of 145 mEq/L Potassium 5.4 mEq/L Magnesium 2 mEq/L Phosphorus 2.3 mEq/L

Potassium 5.4 mEq/L Rationale:Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering. In acidosis, extracellular hydrogen ion content increases, and hydrogen ions then begin to move into intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions must leave the cell, creating a relative hyperkalemia. Sodium, magnesium, and phosphorus would remain within normal range.

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? "The uterus weighs about 2 ounces." "The uterus weighs about 2.2 pounds." "The uterus has a capacity of about 50 milliliters." "The uterus is round in shape and weighs approximately 1000 grams."

"The uterus weighs about 2 ounces." Rationale: Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb), and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.

The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse would prepare how many tablet(s) to administer the dose? Fill in the blank.

2

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse would expect that the infusion line on the IV bag would be at which point? Refer to figure. 1 2 3 4

2 Rationale:If an IV is to infuse at 100 mL/hr, in a 5-hour period (0700 to 1200) a total of 500 mL would have infused. The infusion line is connected to the IV bag and catheter hub; the fluid line will be at the 500 mL position of the time tape strip.

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group? Al-Anon Fresh Start Families Anonymous Alcoholics Anonymous

Al-Anon Rationale:Al-Anon is a support group for families of alcoholics. Fresh Start is a self-help group for those with addiction to nicotine. Families Anonymous is a support group for parents of children who abuse substances. Alcoholics Anonymous is a major self-help organization for those who suffer from alcoholism.

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? Advancing uremia Phosphate overdose Folic acid deficiency Aluminum intoxication

Aluminum intoxication Rationale:Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

The nurse is caring for a client with muscle spasticity characterized by heightened muscle tone, spasm, and loss of dexterity caused by multiple sclerosis. Which centrally acting skeletal muscle relaxants might be prescribed for this client? Select all that apply. Baclofen Diazepam Ibuprofen Dantrolene Trazadone

Baclofen Diazepam Dantrolene Rationale:Baclofen, dantrolene, and diazepam may be prescribed for this client with muscle spasticity. Centrally acting skeletal muscle relaxants are prescribed as an adjunct to rest and physical therapy for relief of discomfort associated with acute, painful musculoskeletal disorders such as multiple sclerosis, cerebral palsy, spinal cord lesions, and CVA. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). Trazadone is given for anxiety and depression.

Latanoprost drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which finding noted in the client indicates a side effect associated with the use of these eye drops? Periorbital edema Cardiac dysrhythmias Elevated blood pressure Brown pigmentation of the iris

Brown pigmentation of the iris Rationale:Latanoprost is a topical medication used to lower intraocular pressure in clients with open-angle glaucoma and ocular hypertension. The most significant side effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation stops progressing when the medication is discontinued but does not regress. Options 1, 2, and 3 are inaccurate and not associated side effects of the medication.

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma? Changes in vital signs Signs of heavy bruising Complaints of a tearing sensation Complaints of lower abdominal discomfort

Changes in vital signs Rationale:Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply. Increase the rate of the IV fluid. Call the primary health care provider. Administer a 250-mL bolus of normal saline (0.9%). Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency. Rationale:Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is a decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. The nurse needs to check that the catheter is draining properly and is not kinked besides reviewing the intake and output. Increasing the rate of the IV fluid and administering a bolus of normal saline are not implemented without a prescription from the primary health care provider. The primary health care provider is called by the registered nurse (RN) once the nurse has gathered all necessary assessment data and has reported the information to the RN, including the overall fluid status and vital signs.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test? Checks for glaucoma Checks for color blindness Examines pupil constriction Examines visual fields or peripheral vision

Examines visual fields or peripheral vision Rationale: The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information would the nurse provide to the client about Leopold's maneuvers? The maneuvers measure the height of the maternal fundus. The maneuvers determine the "lie" and "attitude" of the fetus. The maneuvers are a systematic method for palpating the fetus through the maternal back. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall. Rationale:Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect descriptions.

A primary health care provider prescribes auranofin for a client with rheumatoid arthritis. Which data would indicate to the nurse that the client is experiencing toxicity related to the medication? Joint pain Constipation Ringing in the ears Complaints of a metallic taste in the mouth

Complaints of a metallic taste in the mouth Rationale:Early symptoms of toxicity of auranofin include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth. Auranofin is the one gold preparation that is given orally rather than by injection. Gastrointestinal reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy, but these usually subside in the first 3 months of therapy.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse would reinforce which information to the mother? Select all that apply. The CD4+ count is used to determine the child's immune status. The CD4+ count identifies the specific diagnosis of HIV infection. The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

The CD4+ count is used to determine the child's immune status. The CD4+ count is used to identify the risk for disease progression. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered. Rationale:The CD4+ count is the measurement of a specific subset of T lymphocytes used to monitor clients who are HIV positive. CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for pneumonia prophylaxis after 1 year of age. These counts are measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered. The CD4+ is not used by itself to specifically diagnose the HIV-positive client.

A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected? The primary health care provider will utilize clean aseptic technique. An antipyretic medication will be administered before the procedure. A local anesthesia will be administered to the proposed aspiration site. The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.

The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure. Rationale:A bone marrow aspiration is done on a client suspected of having leukemia to establish the diagnosis and the specific type. The bone marrow is taken from the sternum or iliac crest. Before bone marrow aspiration, the site is cleansed with an antiseptic solution and allowed to air dry. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The primary health care provider will use strict sterile technique, not clean technique, to perform the procedure. Antipyretic medication may be given for comfort to a febrile client but this will not affect the risk for infection. A local anesthetic will be administered, but this will decrease the pain involved with the procedure and not decrease the risk for infection.

A client who is taking hydrochlorothiazide has also been prescribed triamterene. The client asks the nurse why both medications are required. Which response is the most accurate to give to the client? Both are weak potassium-excreting diuretics. The combination of these medications prevents renal toxicity. Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost-effective. Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic.

Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic. Rationale:Potassium-retaining (sparing) diuretics include amiloride, spironolactone, and triamterene. They are weak diuretics that are used in combination with potassium-excreting diuretics. This combination is useful when medication and dietary supplement of potassium is not appropriate. The use of two different diuretics does not prevent renal toxicity. Hydrochlorothiazide is an effective and inexpensive generic form of the thiazide classification of diuretics.

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response? "That doesn't sound like the real you talking!" "I'm sure you have someone if you think hard enough." "It sounds as though you are feeling all alone right now." "I don't believe that, and I really don't think you do either."

"It sounds as though you are feeling all alone right now." Rationale:The client is experiencing loss due to the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is, "It sounds as though you are feeling all alone right now." This response is the one that attempts to translate words into feelings. Options 2 and 4 deny the client's feelings. Option 1 puts distance between the nurse and client because it does not address the client's concerns.

A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question would the nurse ask next? "Was the tick small or large?" "When were you bitten by the tick?" "Did you save the tick for inspection?" "Did the tick bite anyone else in the family?"

"When were you bitten by the tick?" Rationale:There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage? 22.5% 31.5% 36% 40.5%

22.5% Rationale:According to the rule of nines, the posterior side of the head equals 4.5%, the upper half of the posterior trunk equals 9%, and the back of both arms equals 9%, totaling 22.5%.

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate? Bleeding Infection Renal colic Normal, expected pain

Bleeding Rationale:If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding. Signs of infection should not appear immediately after a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.

A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply. Diarrhea Tinnitus Tachycardia Photophobia Red, macular rash Positive Kernig's sign

Tachycardia Photophobia Red, macular rash Positive Kernig's sign Rationale: Meningitis is an infection or inflammation of the membranes covering the brain and spinal cord. Signs and symptoms can include a positive Kernig's sign, tachycardia (heart rate greater than 100 beats per minute), a red macular-type rash, and photophobia. Other signs and symptoms include severe headache, stiffness of the neck, irritability, malaise, and restlessness. Diarrhea and tinnitus are not usually associated with meningitis.

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which data finding best indicates adequate location of the tube? Bowel sounds are absent. The aspirate from the tube has a pH of 7.45. The aspirate from the tube has a pH of 6.5. The tube can be palpated to the right of the umbilicus.

The aspirate from the tube has a pH of 7.45. Rationale:The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube.

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? The transfusion will begin as prescribed. The transfusion will begin after the administration of an antihistamine. The transfusion will begin after the administration of 650 mg of acetaminophen. The blood will be held, and the primary health care provider (PHCP) will be notified.

The blood will be held, and the primary health care provider (PHCP) will be notified. Rationale:If the client has a temperature of 100° F (37.7° C) or more, the unit of blood should be held until the primary health care provider (PHCP) is notified and has the opportunity to give further prescriptions. The other options are incorrect actions.

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which is associated with this type of cancer? The reticuloendothelial system is affected. Reed-Sternberg cells are found on biopsy. Normal bone marrow is replaced by blast cells. Red blood cells (RBCs) and platelet production become affected.

Reed-Sternberg cells are found on biopsy. Rationale:In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually RBC and platelet production is affected and the child becomes anemic and thrombocytopenic. The reticuloendothelial system is affected, thus disturbing the body's defense system and rendering these children unable to fight infections normally. The Reed-Sternberg cell is found in Hodgkin's disease.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? Begin to teach relaxation techniques. Encourage the client to discuss the assault. Remain with the client until the anxiety decreases. Place the client in a quiet room alone to decrease stimulation.

Remain with the client until the anxiety decreases. Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

A client has been prescribed valproic acid for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching? "I need to take the pills whole and not crush them." "I need to take the medication with food so that I won't get an upset stomach." "I am so glad that I won't lose any of my hair. I was worried what my friends would think." "I know that I might gain weight with the medication, so I need to be careful to not eat a lot of sweets and to eat more fruits and vegetables."

"I am so glad that I won't lose any of my hair. I was worried what my friends would think." Rationale:Side effects of valproic acid include nausea and vomiting, tremors, weight gain, and hair loss. It is important to take the medication whole and not crush or cut the medication

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching? "I will avoid excessive amounts of alcohol." "I'm glad I can still drink as much coffee as I want." "I must make sure I include fruits and vegetables in my daily diet." "I need to make sure I have adequate amounts of calcium and vitamin D."

"I'm glad I can still drink as much coffee as I want." Rationale:There is a need for further teaching when a client with osteoporosis says "I'm glad I can still drink as much coffee as I want." The nurse needs to teach clients to avoid excessive alcohol and caffeine consumption and about the need for adequate amounts of calcium and vitamin D for bone remodeling. The nutritional considerations for the treatment of a client with a diagnosis of osteoporosis are the same as those for preventing the disease. The nurse needs to help the client develop a nutritional plan that is most beneficial in maintaining bone health. The plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine.

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply. Clients are better educated about health care. Clients are better informed about their rights. Clients do not trust nurses and primary health care providers. Clients have a higher expectation about the care they receive. Clients are aware that lawsuits result in payment of large sums of money.

Clients are better educated about health care. Clients are better informed about their rights. Clients have a higher expectation about the care they receive. Rationale:The reasons that health care-related litigation involving nurses is common is because clients are more educated, more aware of their rights, and have a higher expectation regarding the care they receive. Lawsuits involving nurses are not common because of an expectation of monetary gain or because nurses are not trusted.

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which is the least realistic goal for this client? The client will develop adaptive coping patterns. The client will identify a realistic perception of stressors. The client will stop blaming himself for the lack of insurance. The client will express and share feelings regarding the present crisis.

The client will stop blaming himself for the lack of insurance. Rationale: The least realistic goal for this client is that the client will stop blaming himself for the lack of insurance. The other goals identify a positive movement toward increased self-esteem and problem solving. Option 3 places undue pressure on the client by implying that the client was negligent and contributed to the loss.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays? Nosebleeds are common. The protective mechanism of the nose may be damaged. It is acceptable to double the dose if one dose is ineffective. Fungal infections of the nose may occur because of container contamination.

The protective mechanism of the nose may be damaged. Rationale:The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers but not nasal sprays. Nosebleeds are uncommon. The client should not double-dose medications to increase their effect.

The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching? "I need to use a water-soluble lubricant." "I will insert a glycerin suppository before the dilation." "I will insert the dilator no more than 1 to 2 cm into the anus." "I need to use only dilators supplied by the primary health care provider."

"I will insert a glycerin suppository before the dilation." Rationale: Following this surgery, anal dilation at home by the parents is necessary to achieve and maintain bowel patency. Inserting a glycerin suppository before dilation is not a component of this procedure. Options 1, 3, and 4 are accurate instructions and will prevent damage to the rectal mucosa.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? Call the client's family. Persuade the client to stay a few more days. Contact the primary health care provider (PHCP). Tell the client that discharge is not possible at this time.

Contact the primary health care provider (PHCP). Rationale:Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option 1 violates client confidentiality. Option 2 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. Respiratory impairment Anorexia and weight loss Pallor, weakness, irritability Supraorbital ecchymosis and periorbital edema Firm, nontender, irregular mass in the abdomen Urinary frequency or retention from compression on the bladder

Firm, nontender, irregular mass in the abdomen Urinary frequency or retention from compression on the bladder Rationale:The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

A client with Parkinson's disease is beginning treatment with carbidopa/levodopa. Which statement made by the client indicates the need for further teaching? "I will need to change positions slowly." "I should take my medication after a full meal." "Hard candy may help if I experience dry mouth." "I should notify my primary health care provider if I have difficulty sleeping."

"I should take my medication after a full meal." Rationale: Carbidopa/levodopa should be taken on an empty stomach with a full glass of water to enhance absorption. Because the medication can cause orthostatic hypotension, clients should be taught to change positions slowly. To ease the side effect of dry mouth, sugarless chewing gum, hard candy, and frequent mouth rinses are indicated. The side effect of sleep difficulty should be reported. In addition, the client is taught to avoid high-protein meals because it affects the effectiveness of the medication.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which would the nurse instruct the mother to do? Give the child children's aspirin for the discomfort. Be sure that the child is resuming normal activities. Give the child acetaminophen for the discomfort as per discharge instructions. Speak to the primary health care provider because the child should not be having any discomfort.

Give the child acetaminophen for the discomfort as per discharge instructions. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present.

A client has been given a prescription for chloral hydrate for short-term use. The nurse includes which nursing intervention in caring for this client? Monitor the vital signs every 4 hours. Leave the lights on in the client's room. Perform a neurological assessment every 4 hours. Instruct the client to call for help to get out of bed.

Instruct the client to call for help to get out of bed. Rationale:Chloral hydrate is a sedative-hypnotic. This medication promotes sleep, and the client is at risk for falls due to sedative effects. The nurse should instruct the client to ask for assistance getting out of bed. It is not necessary to leave the room lights on; this would interfere with sleep. Awakening the client for vital sign measurement and neurological assessment is unnecessary and interferes with sleep as well.

A client uses the call system to notify the nurse to say that "the IV hurts and my left hand is swollen." The nurse assesses the site and determines infiltration has occurred. In order of priority, which actions would the nurse take? Arrange the actions in the order they should be performed. All options must be used. 1.Stop the infusion. 2.Apply a compress to the site. 3.Remove the intravenous catheter. 4.Notify the registered nurse to start a new IV on the right extremity.

1.Stop the infusion. 3.Remove the intravenous catheter. 2.Apply a compress to the site. 4.Notify the registered nurse to start a new IV on the right extremity. Rationale:Continuing to infuse the solution will increase the amount of fluid in the tissues, leading to further swelling and pain. Therefore, the first action is to stop the infusion. Since the infiltration has occurred, the nurse would remove the intravenous catheter, apply a compress to the site (the temperature of the compress is determined by the primary health care provider and agency procedure), and notify the registered nurse to start a new IV on the right extremity.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions? Select all that apply. Collect data to determine factors for fall risk. Close the blinds and turn off the overhead light. Instruct the client to ask for assistance when getting up to walk. Teach the client to lift legs high while walking, as if walking over planks. Ensure the client is upright when eating and swallows twice after each bite.

Collect data to determine factors for fall risk. Instruct the client to ask for assistance when getting up to walk. Rationale: In the Romberg test, the client is asked to stand with the feet together and the arms at the sides, close the eyes, and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking. Decreasing the light in the environment is done if a client has photophobia (sensitivity to light). Clients with a shuffling gait as with Parkinson's disease should lift their legs high when walking. Clients experiencing dysphagia, which often occurs with stroke, should eat sitting upright and perform double swallowing.

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions would the nurse use for communicating with the client? Select all that apply. Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Avoid the use of body language when talking to the client. Give the client directions using short phrases and simple terms. Phrase what was said differently the second time, if there is a need to repeat it.

Face the client when talking. Speak slowly and maintain eye contact. Use gestures when talking to enhance words. Give the client directions using short phrases and simple terms. Rationale:A client who is aphasic has difficulty expressing or understanding language. The nurse should face the client when talking, establish and maintain eye contact, and speak slowly and distinctly. The nurse should use gestures and pantomime when talking to enhance words and use body language to enhance the message. The nurse should give the client directions using short phrases and simple terms, and phrase questions so that they can be answered with a yes or no. If there is a need to repeat something, the nurse should use the same words a second time.

The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? Pain Inadequate knowledge Neurological dysfunction Difficult family coping processes

Neurological dysfunction Rationale: Neurological dysfunction is the priority client care concern for the child with meningitis. Pain related to meningeal irritation may also be a concern, but it is not the priority. There are no data in the question to indicate that there are psychosocial issues.

A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting? Septic Neurogenic Cardiogenic Anaphylactic

Anaphylactic Rationale: Injection of contrast media may result in anaphylaxis and most likely occurs as a result of mast cell degranulation. If not recognized and treated immediately, the client will progress to anaphylactic shock. Septic shock is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock occurs when there is loss of sympathetic tone. Cardiogenic shock occurs when the heart fails as a pump.

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position? Trendelenburg's with the legs in stirrups Supine with a wedge under the right hip Prone with the legs separated and elevated Semi-Fowler's with a pillow under the knees

Supine with a wedge under the right hip Rationale:Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this should be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? The mother administered the iron with milk. The mother administered the iron with water. The mother administered the iron with apple juice. The mother administered the iron with orange juice.

The mother administered the iron with milk. Rationale:Milk may affect absorption of the iron. Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Water will not assist in absorption.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse would make which therapeutic response to the client? "Why do you think this way?" "Here, I'll taste the food for you." "It must be frightening to you. Has something made you feel that your food is poisoned?" "Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people."

"It must be frightening to you. Has something made you feel that your food is poisoned?" Rationale: The response, "It must be frightening to you. Has something made you feel that your food is poisoned?" validates the client's feelings. Asking the client "Why do you think this way?" may place the client on the defensive and is not a facilitative technique. The response, "Here, I'll taste the food for you," involves the nurse in the client's delusion. Finally, the statement, "Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people," is an incorrect response because the statement is defensive and therefore nontherapeutic.

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time? "You sound very unhappy. Are you thinking of harming yourself?" "Have you talked to anyone specifically about what is bothering you?" "Those feelings will go away once your medication really takes effect." "I know what you mean; everyone gets that way when they are depressed."

"You sound very unhappy. Are you thinking of harming yourself?" Rationale: The appropriate response by the nurse at this time is "You sound very unhappy. Are you thinking of harming yourself?" The best method is to ask the client directly about whether a specific plan has been formed. Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The other responses do not directly focus on the client's statement.

The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply. 1 Maintaining bed rest 2 Elevating the affected extremity 3 Administering anticoagulants daily 4 Administering anti-inflammatory agents every 4 hours 5 Applying warm compresses to the affected area as prescribed

1 Maintaining bed rest 2 Elevating the affected extremity 5 Applying warm compresses to the affected area as prescribed Rationale:Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when signs/symptoms disappear, the woman may gradually begin to ambulate.

The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. Fluorescein dye is used to detect which conditions? Select all that apply. Cataracts Glaucoma Foreign object Corneal abrasion Macular degeneration

Foreign object Corneal abrasion Rationale:Fluorescein is a water-soluble dye that produces an intense green color. This agent is applied to the surface of the eye to detect lesions of the corneal epithelium; intact areas of the cornea remain uncolored but abrasions and other defects turn bright green. The dye will also collect around a foreign object

The nurse is reinforcing instructions to a client taking phenytoin for seizure control. Which statement would the nurse make to the client regarding the administration of this medication? "If you miss a dose of medication, wait until the next dose and take both doses." "If you develop a sore throat, it is necessary to notify the primary health care provider." "If you have difficulty swallowing the capsules, open them and mix the contents with applesauce." "You need to cancel your next dentist visit and plan dentist appointments yearly rather than twice a year."

"If you develop a sore throat, it is necessary to notify the primary health care provider." Rationale:Phenytoin is an anticonvulsant. Gingival hyperplasia, bleeding, and swelling and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not miss medication doses because this could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity.

The nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further teaching? "I need to allow my infant time to swallow." "I need to use a nipple with a small hole to prevent choking." "I need to stimulate sucking by rubbing the nipple on the lower lip." "I need to allow my infant to rest frequently to provide time for swallowing what has been placed in the mouth."

"I need to use a nipple with a small hole to prevent choking." Rationale:The mother should be taught the ESSR method of feeding the child with a cleft palate: ENLARGE the nipple by cross-cutting a hole so that food is delivered to the back of the throat without sucking; STIMULATE sucking by rubbing the nipple on the lower lip; SWALLOW; then REST to allow the infant to finish swallowing what has been placed in the mouth.

The nurse working in the emergency department is assisting with an initial assessment on a client who is complaining of severe upper abdominal pain that spreads throughout the abdomen and radiates to the back and shoulders. The client has tried taking antacids with no relief. On assessment the abdomen is rigid and bowel sounds are absent. Which data in the client's history would the nurse be most concerned about in connection with these assessment findings? Colon cancer Diverticulosis Peptic ulcer disease Chronic pancreatitis

Peptic ulcer disease Rationale: Given the clinical presentation for this client, the nurse would be most concerned about a reported history of peptic ulcer disease, because a complication of this disease is bowel perforation from an ulcer. With the findings of severe upper abdominal pain spreading through the abdomen and radiating to the back and shoulders, unrelieved by antacids, and rigid abdomen with absent bowel sounds, the nurse would suspect an acute abdomen problem. Colon cancer, diverticulosis, and chronic pancreatitis are chronic conditions that have less of a risk of causing an acute abdomen condition when compared to peptic ulcer disease. In addition, colon cancer and diverticulitis are most likely to cause lower abdominal pain. Chronic pancreatitis is more likely to cause left sided mid-abdominal pain.

A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Sixty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply. Failure to replace body fluids Increased risk of hypotension Lack of follow-up nursing actions Increased need to protect the client Failure to teach the client adequately Excessive bumetanide administration

Increased risk of hypotension Lack of follow-up nursing actions Increased need to protect the client Failure to teach the client adequately Rationale:To prove malpractice against the nurse, the plaintiff must prove that the nurse owed a duty to the client; that the nurse breached the duty; and that as a result, harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide. This is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response? State they have no questions Request to hold the infant following delivery Refuse a footprint and picture of the infant to take home Are surprised by the appearance of the infant following delivery

Request to hold the infant following delivery Rationale:The nurse should explain to the parents the expected events following delivery of the fetus and should tell the parents that they can hold their infant following delivery. Viewing and holding the dead infant can alleviate any negative images the mother or her partner may have. Providing a picture or other mementos will help preserve the memory of the infant. If the parents refuse a picture, most hospitals will keep a picture and copy of the footprints on file for parents to access later. Parents should be encouraged to verbalize their feelings, ask questions about the process, and make their own decisions about care as much as possible.

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location? Penicillin, ears Neomycin, eyes Silver nitrate, ears Erythromycin, eyes

Erythromycin, eyes Rationale:Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the baby's passage through the birth canal. Ophthalmia neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria, and the ears is not the correct location.

A client who underwent kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply. Oliguria Swelling of the lips Tachypnea with wheezing Elevation of blood pressure over baseline Abdominal tenderness on the side of the kidney transplant Elevation of serum blood urea nitrogen (BUN) and creatinine

Oliguria Elevation of blood pressure over baseline Abdominal tenderness on the side of the kidney transplant Elevation of serum blood urea nitrogen (BUN) and creatinine Rationale: Acute rejection occurs 1 week to 2 years after a kidney transplant. Antibodies and white blood cells cause inflammation and vasculitis within the transplanted organ. Diagnosis is made by laboratory tests demonstrating impaired function of the organ and by changes in the donated organs found upon biopsy. Acute rejection is treated with increased immunosuppressant medication. Signs/symptoms of acute rejection of a transplanted kidney include abdominal tenderness over the transplanted kidney and decrease in organ function. Signs of decreased kidney function include oliguria (urine output between 100 and 400 mL in 24 hours), elevation in blood pressure, and elevation in the BUN and creatinine levels. Swelling of the lips is a sign of angioedema that occurs with an acute hypersensitivity reaction or anaphylaxis. Tachypnea (rapid breathing) with wheezing, the sound resulting from airway inflammation, occurs with many types of respiratory distress. It is not specific to acute rejection in a transplanted kidney.