HESI REVIEW FUNDAMENTALS
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
Put bed rails up on the side of bed opposite from the nurse.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access?
Right cephalic vein Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?
Sodium Rationale:Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids
HOw to clean a 3 year old uncircumcised
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria.
WHen it asks for the nurses next action on what to do next what is the response
Think if APIE!! you ALWAYS assess first
The nurse is at a teen event. Which teen's statement would cause the nurse to input some safety tips? (Select all that apply.)
1. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." 2. I never use my seatbelt while I am driving. I hate the way it feels."
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will cause the nurse to intervene for this client?
1. A florist delivering fresh flowers Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these clients. The remaining options pose a low risk for infection.
The nurse is working with one LPN and two aides on a 20 bed unit. Which are the appropriate tasks to delegate to the appropriate person?
1. Feeding an elderly and confused client to the aide 2. Reinforcing the discharge teaching instructions to the LPN 3. Administering a po pain medication to the LPN 4. Performing the routine dressing change 5 days after surgery to the LPN Rationale: the right task, circumstances, person, direction, and supervision. The aide can perform routine tasks, the LPN can deliver skilled care, the RN performs the assessment and does the teaching. Toileting the client for the first time requires the assessment of the RN. The bathroom supplies can be delegated to the aide. The remaining selections are appropriate. The LPN can reinforce teaching; the initial teaching must be done by the RN.
The nurse is orienting a new graduate to the reporting regulations often seen in the emergency department. Which clients will the nurse need to report to the nurse manager/supervisor to alert the proper authorities? (Select all that apply.)
1.A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. 2. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." 3.A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way." Rationale: Nurses are mandatory reporters and must notify in the event of child and elder abuse, domestic violence, animal bites, gun shot and stab wounds, assault, and homicides.
The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's suggestions to quench the client's thirst?
1.Infuse your water with fresh citrus fruits to quench your thirst. 2. Freeze strawberries and water together in popsicle mold. 3. Keep a few pieces of hard candy with you to suck on. Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in them that draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming frozen liquids. Hard candy can produce moisture in the mouth.
The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN?
1.Remove the PN from the refrigerator 30 minutes before infusing. 2.Assure the infusion time for the PN does not exceed 24 hours. 3.Return amber and cloudy solutions of PN to the pharmacy.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate will the nurse document?
16 Rationale:The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise will the nurse select to prepare the medication?
3 mL needleless syringe Rationale:Accuracy is most important when delivering small amounts of medication to a child. The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of tenths.
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test?
7:00 am Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.
The nurse is preparing to administer 0.32 mL of medication subcutaneously. What supplies will the nurse need to deliver the medication? (Select all that apply.)
A 1 mL syringe Alcohol prep pads A 24-gauge ¾″ needle Rationale: The best syringe is a 1 mL syringe as it is marked in 100ths; 3 mL syringes are marked off in 10ths. Clean, not sterile gloves are needed. For sub-q, the 3/4″ needle is sufficient and less painful for the client.
A. Mode of transmission
A red and swollen peripheral IV site Starting the infusion without an infusion devise Starting the infusion without an infusion devise Rationale:Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV site would need to be changed before starting the solution. Potassium solutions must infuse with an infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not lemon yellow.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
A. Mode of transmission
The nurse is talking with the spouse of a client admitted to the long-term care center. The client has end-stage renal cancer and is admitted for palliative care while awaiting hospice placement. The client often moans and groans, but is otherwise non-communicative and somnolent. What will the nurse include in the spouse's teaching regarding the care of the client?
A. Repositioning every 2 hours B. Round-the-clock pain medication administration C. Assessment for skin breakdown D. Back rubs three times a day The goal of palliative care is to make the client comfortable, and not treat the cause of the condition.
The nurse is performing an intake interview for a newly admitted client to the rehabilitation unit. Which questions will the nurse include in the interview?
A. When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?" Rationale: The goal of the intake interview is to understand the client's daily routines so those routines can be observed and upheld while residing on the rehabilitation unit. Asking about how long the client will be on the rehabilitation unit helps the nurse to understand the client's expectations of the duration of the stay. Urinary and bowel patterns are important to understand, but the issue with this assessment is the frequency of urination. The better question is, "How often do you urinate when you are awake?"
The postoperative client states to the nurse, "When I had surgery last year I got constipated. It was miserable. What can I do to avoid constipation after this surgery this time?" (Select all that apply.)
A."Drink approximately 3000 mL of non-caffeinated fluid per day." B."I will make sure that you get out of bed an walk for 10 minutes, six times per day." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables." Side note: When postoperative, it may take up to 48 hours after a general diet is started to have a bowel movement.
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
ANA's Scope and Standards of Nursing Practice Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice.
The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?
Administer water between the doses of the two liquid medications. Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube.These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.
The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.)
Apple juice Popsicles Black coffee gelatin Full liquid is tomato soup and puddings
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite following the same routine every night." Which action should the nurse take next?
Ask the client to describe the routine he is currently following. Rationale:The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.
The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps must the nurse take? (Select all that apply.)
Ask the client, "Did your surgeon explain the procedure to you?" Ask the client, "Do you have any questions?" Witness the signature. Rationale; It is the surgeon's responsibility to review the procedure with the client until the client has no further questions. The nurse can verify the review by the surgeon and ask if the client has any further questions. If the client has questions, the nurse must call in the surgeon. When the nurse signs the consent form, the nurse is witnessing the signature only.
A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action?
Assess the client's medical record to determine the client's normal bowel pattern. Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. What is the priority nursing action for this client?
Assist the client to walk to the bathroom and do not leave the client alone. Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action?
Auscultate the client's lung Rationale:The client may show signs of fluid overload, such as crackles. Other respiratory signs are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first and then proceed with notifying the charge nurse and the health care provider.
The client 12 hours after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse reviews the medication orders and it is another hour before the client can have another dose of pain medication. What actions can the nurse take to assist the client? (Select all that apply.)
B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
B. Note any obstruction or absence of breathing. C. Deliver five backslaps between the shoulder blades. D. Place the infant over the nurse's arm.
For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply.)
Bacon, egg, and cheese biscuit . Chinese chicken and vegetables, with rice and soy sauce Grilled hot dog on a bun with ketchup and mustard Rationale: Patient is hyponatremic so will need foods high in sodium
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client?
Broiled fish, green beans, and an apple Rationale:Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B
The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.)
Call the health care provider. Observe for restlessness/confusion. Administer oxygen by re-breather mask. Observe the abdominal bandage. Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency. The head of bed may need to be lowered or placed in Trendelenburg position to increase circulation to the brain. The remaining selections are correct.
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
Check the bath water temperature. Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. This is important for safety
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
Contact the health care provider to renew the prescription for the medication. Rationale:Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions.
The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is your child playing with now?" Which response indicates to the nurse that further teaching is needed? (Select all that apply.)
"A marble run race track is set up in the playroom." "We got a golf set because my other children play golf." Rationale:Avoid small objects that can be a choking hazard during the toddler stage. The remaining play toys are appropriate for toddlers.
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?
"Compress the inhaler while slowly breathing in through your mouth." Rationale:The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect.
The client reports to the clinic nurse, "I sleep for about 2 hours and then I have to get up to use the bathroom. I repeat that pattern about three to four times per night." What questions will the nurse include in this client's assessment? (Select all that apply.)
"How much fluid do you drink after 8:00 in the evening?" "What time of day do you take your water pill?" "Do you drink any alcoholic beverages in the evening?" "When did this pattern of urination start?" "Do you have any itching or burning when you urinate?" Rationale: Asking if the spouse also gets up at night does not relate to the clients' pattern of frequency of urination at night. The goal of the assessment is to try and understand the client's urinary usual patterns and to determine if there are any modifiable factors that can decrease the frequency of urinating at night. Urinary frequency is also a sign of a urinary tract infection.
An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When reviewing the client's pre-fracture routine the client states, "I usually get up around 0800 and have breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch around 1300; then a nap from 1400 to 1600. I generally eat supper around 1900." What is the nurse's best response to the client's schedule?
"Is there any way you could say your prayers between 1230 and 1300?" Rationale: The elderly have a routine that generally fits around their sleep-wake cycle, or their circadian rhythm. The flexibility is around prayer time, since it is during the wake time. If the rehabilitation therapy can be scheduled in the am, that is generally the time when they have more energy.
The nurse notes in the client's plan of care altered sleep patterns related to nocturia. Which nursing actions are important for the nurse to provide?
Decrease intake of fluids after the evening meal. Assess the client's usual sleep pattern.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's concern?
Description of the family's home environment Rationale:School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action?
Determine if pain is causing the client's tachypnea. Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate).
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
Discuss the client another time. Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others.
The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
Do not give the medication and document the reason. Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications.
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Dorsiflex and plantarflex the feet 10 times each hour. Rationale:To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion.
While conducting an intake assessment of an adult client at a community mental health clinic, the nurse notes that the client's affect is flat, responds to questions with short answers, and reports problems with sleeping. At the end of the intake assessment, the client reveals the loss of a life partner 1 month ago. What is the nurse's best action for this client?
Encourage the client to see the clinic's grief counselor. Rationale:The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. . An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?
Explain the relationship to the charge nurse and ask for reassignment. Rationale:Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.
The nurse worked with a client to alleviate pain with aroma and relaxation therapy. Twenty minutes after working with the client, the nurse returns to the room and finds the client's eyes are closed and breathing deeply. What is the best entry for the nurse to document this finding?
Eyes closed, deeply breathing Rationale: The purpose of charting is to document the client's response to care. Charting must be objective. The client could still be awake, and in a calm state
What do you do when the iv rate by gravity has slowed even though venous access is healthy?
First check the tube for any kinks and then you would raise the IV pole
The nurse is preparing to administer a new medication through an existing IV line containing a vasopressor. What action must the nurse take first?
Flush the line with normal saline at the same rate as the vasopressor.
The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.)
Heals without redness bilaterally Skin intact on the back Elbow joint fully flexes and extends. Ankle joint rotates 360 degrees freely.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?
How will this affect your present sexual activity? Rationale: Open ended questions are more relevant to clients statements.
The health care provider diagnoses metastatic cancer and recommends a gastrostomy for an elderly client in stable condition. The client's adult child is concerned and states to the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information will guide the nurse's response?
If informed consent is withheld from a client, health care providers could be found guilty of negligence. Rationale:Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
Inform the surgeon the client has questions about the surgery. Rationale:It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse take next? (Select all that apply.)
Instruct the client not to get out of bed. Place the call bell within the client's reach. Place the side rails up, according to institutional policy. Rationale:Diazepam is a common preoperative medication. Close observation by placing the client close to the nurse's station is not necessary. The medication has a sedative effect and the client should not get out of bed, even with assistance. The remaining selections are correct.
The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement?
K 5.3 mEq/L Rationale:Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
Leave the catheter in place and reattempt with another catheter. Rationale:It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours.
The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What supplies will the nurse take into the room for this procedure? (Select all that apply.)
Normal saline in a 10 mL syringe Clear plastic sterile bandage Skin preparation antiseptic swab
A 75-year-old client states to the nurse, "I am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the past 4 months. Which snacks will the nurse recommend to the client? (Select all that apply.)
Nuts Milkshakes Peanut butter and crackers Glass of whole fat milk Rationale: The nurse must recommend high calorie/high nutrition foods for this client who is unintentionally losing weight. The candy bar is high calorie, but empty in nutritional value. The remaining selections are high calorie/high nutrition.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which action should be included in this instruction?
Perform range-of-motion exercises to prevent contractures.
The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client's room?
Pillow Rationale: The purpose of splinting an incision is to offer additional support to the wound. The client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items do not offer the level of support necessary to splint the wound.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which nursing actions are correct? (Select all that apply.)
Place the client in a high Fowler position. Instruct the client to swallow after the tube has passed the pharynx.
Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply.)
Place the client in a side-lying position. Pull the auricle upward and outward. Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).
The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider?
Pulse: 80 beats/min Rationale:A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the normal range.
The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.)
Raise the head of the bed 30 to 45 degrees. Elevate her right arm under two pillows.
A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.)
Raise the head of the bed to no less than a 45 degrees angle. Have the client use an incentive spirometer 10 times every hour while awake. Ask the client to take deep breaths and cough five times every hour while awake. Rationale: As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting at the side of the bed is not a replacement for ambulating. Having the client sit up helps expand the lungs. Taking deep breaths, through coughing or incentive spirometry, helps expand the lungs and decrease atelectasis.
During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?
Remind the client to walk carefully down the stairs until reaching a lower floor.
The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I know your children want to come over and say goodbye before we call the funeral home. Just let me know when you are ready for me to prepare the body." What steps will the nurse include in the postmortem care? (Select all that apply.)
Remove the existing Foley catheter. Close the client's eyes. Remove soiled padding under the client. Rationale:Postmortem care includes making the client ready for the family to view prior to the client's transfer to the mortuary. The nurse need to make sure the client's body is completely washed, and all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the client may excrete contents from the bowel and the bladder during the dying process, remove all soiled pads and bedding from under the client and replace with fresh items. Make sure the client's eyes are closed.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing action is best for this client?
Review the schedule of outdoor breaks with the client Rationale:The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule.
After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take next?
Select another sterile needle. Rationale: After a needlestick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.
The postoperative nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan?
Sit in an upright position. Cough deeply three times .Place mouth securely around the mouthpiece of the spirometer. Rationale:After the spirometer is used the nurse can encourage deep coughing. The client should exhale through pursed lips. The remaining steps are correct.
Which action should the nurse implement when providing wound care instructions to a client who does not speak English?
Speak directly to the client, with an interpreter translating. Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. F
The nurse is preparing to change the bed of a client who is non-responsive, and receiving continuous enteral tube feedings. What step must the nurse take prior to changing the bed?
Stop the feeding for 15 minutes prior to changing the bed. Rationale: This client is at risk for aspiration during the bed change as the head of the bed must be lowered. Stopping the feeding will help decompress the stomach and decrease the risk. The client should not be leaking fluid out of the mouth. Check the feeding for residual. If the feeding is not moving out of the stomach, notify the healthcare provider.
The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority?
Take the client's temperature every 4 hours. Rationale:Indwelling urinary catheters are a major source of infection.
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?
Taking anticoagulants for the past year Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs.
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse take first?
Talk to the client and attempt to find out why the client is crying. Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide?
Talk with the client about thoughts and feelings about death. Rationale:The nurse should first assess the client's feelings about death and determine the extent to which this statement expresses the client's true feelings.
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?
Teach the importance of personal hygiene during menstruation with the client. Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP's approach?
The UAP auscultates the popliteal pulse with the cuff on the lower leg. Rationale:When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first?
The victim who is heavily bleeding bright red blood from a thigh wound. Rationale:The client hemorrhaging from the leg wound is the priority as of the severely injured clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to the wound site. When there is only one health care provider on the scene, the nurse must provide care to those who are most likely to survive. The client without a pulse and respirations is dead. The client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head trauma. The victim with arm pain and crying is the lowest priority.
Which action is most important for the nurse to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway.
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first?
Turn off the intermittent suction device. Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications.
The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The nurse should be alert for which findings?
Weakness in the hands and feet +1 reflexes to the patella Headache Nausea This patient is hyponatremic and these are all signs and symptoms
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response?
"When I watched you give yourself the injection, you did it correctly." Rationale:The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive.
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection?
handwashing Rationale: Careful hand washing technique is the single most effective intervention for the prevention of contamination to all clients.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
normal saline Rationale: only drug that is used with normal saline
The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.)
1. Ask the client, "Have you considered completing the paperwork for an AD?" 2. Tell the client, "An AD helps the staff provide care according to your wishes."
What is indicative of infiltration?
1.Area around the insertion site is swollen 2. Insertion site is cool to touch 3. Client complains of a burning pain 4. Redness is noted in the area of insertion site
The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to administering the feeding?
1.Aspirate the stomach contents. 2. Assess bowel sounds. 3. Warm the feeding to room temperature. 4. Assess the pH of the stomach contents. Rationale: The client needs to be in high Fowler's position to decrease the risk of aspiration. Irrigation of the lumen is only necessary if there is an obstruction. The contents were replaced, so there is no suspicion of obstruction.
The nurse is providing care to clients at a day treatment center. One of the clients who is usually talkative and eats well is now confused and did not eat lunch. The nurse learns these are new findings as of today. What are the next nursing actions? (Select all that apply.)
A.Obtain a clean catch urine sample. B.Take the client's vital signs. C.Assess for the initiation of any new medications. D. Obtain an oxygen saturation. Rationale:Until the assessment is complete, there is no need to contact the client's children. With the client's state of confusion, the nurse cannot dismiss the client to home. The client is exhibiting signs of an infection with the confusion and anorexia. The remaining assessments will help the nurse determine if the client has an infection or if there is another reason for the confusion.
A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first?
A.Pulse characteristics Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority.
client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse take next?
Assess the clients neurological status
