Hesi test
The client has a new prescription for an appetite stimulant. Question 15 of 26 Which information about the drug should the nurse obtain prior to educating the client regarding the time the medication will be administered
Onset of action. The nurse should determine when the drug will start to take effect, so that the medication can be taken when the greatest therapeutic effect can be achieved.
The client's husband states that his wife loves applesauce and asks if this is a good snack choice. Which response by the nurse is best?
"Offer her applesauce since she likes it, along with higher calorie snacks." To improve the client's nutrition, the nurse needs to consider the likes and dislikes of the client in addition to the needed nutrients. Combining applesauce, which the client likes, but which is not a high calorie snack, with snacks that contain more calories, best meets the needs of the client.
The client's spouse inquires about the newly prescribed medication, which is a brand name drug, and states, "When we fill this prescription, I hope we can get this in a generic form. Maybe it won't be as expensive." Question 16 of 26 How should the nurse respond?
"Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand name drug. Although brand name and generic medications are bioequivalent, the inert ingredients may vary, sometimes resulting in differing effects. Therefore, the healthcare provider must approve the substitution of a generic form for a prescribed brand name medication.
Dietary InstructionThe health care provider prescribes an appetite stimulant and asks the nutritionist to consult with the client and her family regarding her dietary needs. The nurse and nutritionist collaborate to develop a plan of care to improve the client's nutritional status. The nurse teaches the client and her spouse about foods that are high in protein and provides them with sample menus. Question 13 of 26 Which breakfast selection(s) are good sources of protein? (Select all that apply.)
1-Scrambled eggs and sausage. Both eggs and sausage are good sources of protein.Raymond, J., Egg, potato and onion omelet. 2-An egg, potato, and onion omelet is a good source of protein and also provides minerals and vitamins.
Nutritional Assessment Three days later the nurse assesses the client's nutritional status.Which data indicates the need for the nurse to evaluate the client further for altered nutrition? (Select all that apply.)
1-the skin over the sternum tents when pinched. This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit. 2-the lips are dry and cracked. This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration. 3-The conjunctival sac is pale in appearance when exposed. The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia.
The client tells the nurse that she has had 5 to 7 liquid diarrhea stools a day for the last 2 days. Question 26 of 26 What is the sequence of nursing actions? (Place in numerical order from first action through last action.)
1.Tell the spouse to hold the remaining feeding. 2. Auscultate for the presence of bowel sounds. 3. Assess the elasticity of the client's skin. 4. Notify the HCP of the diarrhea. First initial action is to tell the spouse to hold the remaining feeding until further assessment can be obtained. Second, auscultate for bowel sounds to determine if there are hyperactive or hypoactive bowels. Third, assess elasticity to determine whether the client is dehydrated and will need further hydration. Finally, notify the HCP about the assessment findings for further instruction for the client.
Client has been placed in her hospital bed upon arrival to the medical-surgical unit. Which intervention is most important for the charge nurse to verify as completed for her within the first hour?
A registered nurse (RN) performs and documents a comprehensive assessment. This assessment is required immediately after a hospital admission takes place and must be performed by an RN.
The nurse has confirmed that client understands the pain rating scale and where the call light is located. The healthcare provider has written three orders for pain management: Acetaminophen 650 mg by mouth (PO) every 6 hours as needed for mild pain Acetaminophen 1000 mg by mouth (PO) every 8 hours as needed for moderate pain Acetaminophen/hydrocodone 500 mg/5 mg by mouth (PO) 1 or 2 tablets every 6 hours as needed for moderate to severe pain Client reports to the nurse that her pain scale level is a 6 on a 0 to 10 scale. Which PRN medication should the nurse give her?
Acetaminophen/hydrocodone 500 mg/5 mg by mouth (PO) 1 tablet. The client's pain rating of a 6 of 10 is considered moderate to severe. Opioid analgesics are most effective for relief of moderate to severe pain. Giving one tablet gives the nurse the ability to give another in 30 minutes to an hour, if the pain has not resolved satisfactorily. Acetaminophen/hydrocodone tablets take 30 to 60 minutes to take effect and have a half-life of 4 hours.
When the nurse demonstrates the use of the feeding equipment, the client's spouse looks away. The nurse observes that he is crying. Question 24 of 26 Which action should the nurse implement?
Acknowledge the stressful nature of the situation and ask him if he feels ready to continue. This is a therapeutic response, offering support and allowing the spouse to feel in control of the situation.
Ethical-Legal ConsiderationsThe client gradually weakens and is admitted to the medical unit. Her HCP recommends the insertion of a feeding tube, by means of a percutaneous esophageal gastrostomy (PEG). She signs the consent form, and the procedure is scheduled for the next day. That evening, the nurse notes that the client's medical record contains an advance directive requesting that she not be resuscitated in the event of an arrest, which is confirmed in the prescriptions written by the HCP. While the nurse is conversing with the client and her spouse they both confirm that "no heroic measures be taken to save her life." Question 17 of 26 What action should the nurse take to ensure the client's DNR status?
Advise the client that she will need to sign a form that will be placed in her chart and according to their protocol a wrist band will be placed on her identifying that she not be resuscitated. Order in the client's chart and an identifying wrist bracelet indicating that resuscitation should not be performed helps ensure that the client's wishes are known and respected.
In 20 minutes, the healthcare provider (HCP) visits client and orders one tablet of hydrocodone/acetaminophen 5 mg/300 mg by mouth (PO) to be given now as a preliminary pain medication. Which data in the client's medical record is important for the nurse to review before administering hydrocodone/acetaminophen? (Select all that apply.)
Allergies. Drug allergies are very important to identify when administering this medication Home medications. Home medications need to be reviewed to avoid contraindications, such as other prescribed pain medications that can cause a drug overdose Liver enzymes. This combination drug contains acetaminophen, which cannot be administered to a client with elevated liver enzymes because it could result in drug toxicity. Vital signs. This combination drug contains an opioid (hydrocodone), which can cause respiratory depression, therefore, vital signs are essential to review and to measure before administering this medication.
While the registered nurse (RN) is performing the admission assessment, the nurse notices that client has a large bag full of her home medications, a suitcase full of clothes, a purse, and a cane. The practical nurse (PN) and the unlicensed assistive personnel (UAP) have come to assist the nurse. Which intervention is the best action for the nurse to take?
Ask the PN to record and verify which medications the client has been taking. While the RN finishes the comprehensive admission assessment, the PN can list the medications the client brought with her to the hospital and verify them with the client so that the healthcare provider can review the list and decide if they should be continued during the hospitalization.
The nurse's assessment findings include right-sided weakness, slurred speech, and dysphagia. The nurse identifies that the client is at high risk for several problems. which of the highest priority problem
Aspiration. Aspiration, or the entry of foreign substances such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client's plan of care.
The nurse takes client to the triage area and performs a focused assessment of his nontraumatic, mid-lower flank pain. If a client has symptoms of tenderness at the costovertebral angle (CVA), what should be the nurse's priority?
Assess for bladder distention. Urinary tract obstruction that contributes to pain is an emergency that can result from a stone blocking the bladder neck or urethra and it must be treated immediately to preserve kidney function.
Client's MRI report says that she has an incomplete left transverse sub-trochanteric hip fracture. Her community healthcare provider says that she has community-acquired methicillin-resistant staphylococcus aureus (MRSA) cellulitis.Client tells the nurse that she is having some pain in her left hip. Which action is most important when responding to the client's stated need?
Assure the client that her pain experience will be respected and believed. When caring for clients with pain, it is the nurse's duty to recognize and relieve their pain. The nurse should advocate for and empower the client, and show compassion and respect for the client's experience.
Dysphagia PrecautionsThe speech therapist is consulted to evaluate the client. The therapist determines that dysphagia precautions are needed and writes an order for pureed diet and honey thickened liquids. The nurse and the unlicensed assistive personnel (UAP) enter the client's room shortly after the therapist's evaluation is completed. The UAP prepares to assist client with her noon meal and with her personal care.What instruction should the nurse provide to the UAP?
Bathe the client first and then place the client in a high Fowler's position during and after the meal. The head of the bed should be elevated to a high Fowler's position while the client with dysphagia is eating, and it should be kept elevated for at least 1 hour following the meal to reduce the risk for aspiration
The client receives the second dose and reports a pain rating of 1 to 2 in an hour. The nurse documents the response in the electronic medical record (EMR). There are also non-pharmacological methods for reducing pain and improving comfort for clients with an incomplete hip fracture. Which orders would the nurse expect to maintain for client?
Bed rest, elevate heel, and turn every 2 hours. This client has suffered an incomplete, hairline fracture and will only need minimal body alignment for comfort.
How are gout and nephrolithiasis related in this scenario?
Both conditions are caused by uric acid crystallization. This is true. Both gout and uric acid nephrolithiasis are caused by uric acid crystallization.
The nurse observes that the dressing around the PEG tube insertion site is intact, with a small amount of serosanguineous drainage. Question 20 of 26 Which action should the nurse implement?
Circle the amount of drainage on the initial dressing. Circling this small amount of drainage allows the nurse to compare any changes in the amount of drainage at a later time.
Before notifying the healthcare provider of the data reported by the nutritionist, what information is most important for the nurse to obtain?
Client's calculated body mass index. The body mass index is calculated based on the client's height and weight and provides a picture of the client's current nutritional status regarding over- or under-nutrition.
After checking in at the ED registration desk, client's spouse notices that the waiting area is very busy. She goes to the triage desk and tells the nurse, "In the 32 years we have been married, I have never seen my husband this agitated about back pain. Is there something you can give him for his pain while we wait to be seen?"Client quietly paces in the ED waiting area with his hands on his hips and rubbing his mid-lower left side. He has a flat facial expression. Which factor is most important for the nurse to consider when interpreting this client's pain behavior?
Client's cultural identity. A common finding observed with this client's Canadian Scottish heritage cultural group includes a high value for stoicism; therefore, he is not likely to complain about his pain. It is important to note that his wife of 32 years is concerned enough to speak to the triage nurse and states that she has never seen him this agitated about back pain.
Which type of MRSA infection does client have?
Community acquired. When the client was admitted to the hospital, she already had an MRSA infection.
Client's medical record has no allergies listed. Which action is the best intervention for the nurse to perform next?
Confirm with the client if he has no food or drug allergies. The most important intervention at this stage would be to ask the client about any known food or drug allergies.
Care of a Client with a Feeding TubeThe couple discusses the decision together, and the client decides to have the procedure as scheduled. She is taken to the procedure room where a PEG tube is inserted. Following the surgery the client returns to her room following the insertion of the PEG tube. She has an IV of Lactated Ringer's Solution infusing at 50 mL/hour but does not have any feeding solution attached to the PEG tube.Click for image Question 19 of 26 Which initial actions should the nurse implement?
Continue to monitor the client without infusing any solution through the PEG tube. Feeding supplements are typically initiated when bowel sounds are present, usually within 24 hours after PEG tube insertion.
What other issue is most important for the nurse to consider when teaching client about making dietary adjustments to promote his health?
Cultural influences. The most important issue to consider when teaching a client about making dietary changes is to ask about any traditional foods the client enjoys and explore their impact on health.
The nurse receives additional prescriptions from the HCP. The UAP and the PN approach the registered nurse (RN) to offer assistance with caring for this client. Which prescriptions can the nurse safely delegate to the UAP? (Select all that apply.)
Deliver stat samples to the laboratory. Delivering stat labs is a task that a UAP can perform.Transport to radiology for KUB x-ray. Transporting the client to radiology is a task that the UAP would be able to perform.
Over time, the continuous feeding is increased to 80 mL/hour. The nurse plans to educate the client's spouse on how to manage the continuous feeding when his wife is discharged. Question 23 of 26 Before the nurse educates the client and her spouse about managing the continuous feed, what information is most important for the nurse to collect prior to providing discharge instructions?
Determine if the client and her husband feel ready to learn the skill. Readiness to learn is essential for effective teaching. If the client's husbanc expresses a lack of readiness to learn, other resources will have to be initiated before his wife is discharged home.
The nurse is teaching client and his spouse about his prescription for tamsulosin. Which rationale explains why client is being prescribed this medication?
Dilates the ureter. Tamsulosin facilitates stone passage by relaxing the ureter, bladder, and urethral smooth muscles.
Client has an uncomplicated and uneventful procedure. Several sodium uric acid calculi were dislodged and he is sent home with prescriptions for oral tamsulosin, allopurinol, and naproxen. The nurse is evaluating client discharge teaching. Which description made by the client about allopurinol would reassure the nurse that teaching for this medication was successful?
Dissolves uric acid calculi. The xanthine oxidase inhibitor allopurinol will dissolve uric acid crystals.
Xerostomia
Dryness of the mouth caused by reduction of saliva Dry mouth could be a problem; however, that could be resolved by adding water to the masticated food. The client has spit her food out into a napkin.
When the unlicensed assistive personnel (UAP) brings a food tray to client, they notice that the client takes a very long time to finish chewing a single bite and then she spits the masticated food into a napkin. Which observation should the UAP expect to report to the nurse?
Edentulism. Having no teeth with which to chew will slow mastication significantly and some food will never quite become chewed enough for the client to feel safe about swallowing it.
Client fell and fractured her hip. Besides the fall, which progressive pathophysiological process should the nurse expect contributes to the cause of this fracture?
Enhanced osteoclast formation with reduced apoptosis. The client has a history of osteoporosis, which is a progressive process of enhanced osteoclast formation with reduced osteoclast apoptosis (programmed cell death) which leads to reduced bone density. Osteoclasts are macrophage-like cells that are specialized for bone resorption (reabsorbing bone back into circulation) and remodeling.
Bolus FeedingsThe feedings are changed to bolus feeding 3 times a day. After receiving instruction, the client's spouse demonstrates correct ability to perform the skill and states that he feels he can handle this responsibility. The client is discharged home and home healthcare services are initiated. During a home visit, the nurse observes the client's spouse administering a bolus feeding to the client, who is sitting upright in the bed. After checking the residual volume, he pours the feeding into the syringe attached to the feeding tube. He then holds the syringe upright while the feeding enters the stomach. Question 25 of 26 In observing this procedure, which action should the nurse take?
Ensure that he flushes the tubing with water after the syringe is empty of feeding. Flushing the syringe and tubing with water reduces the risk for obstruction of the tubing.
As the nurse prepares client for lithotripsy in the preoperative holding area, which actions should the nurse perform? (Select all that apply.)
Ensure the client understands the procedure. This is an important safety precaution and an element of informed consent.Check that the informed consent has been signed. This is an essential part of preparing the client for the procedure.Start an IV and measure the client's vital signs. Baseline vital signs and IV access are important tasks to perform before the procedure.Initiate administration of the prescribed IV fluids. Administering IV fluids as ordered is an important task to perform before the procedure.
After establishing priorities, the nurse should take which action next in developing the client's plan of care?
Establish outcomes. The nurse should first complete the assessment, then analyze the assessed data to identify problems, and then establish outcomes. After the expected outcomes are established, the nurse plans and implements interventions, which are then evaluated to determine if the expected outcomes were accomplished.
The nurse recalls that client is originally from an area of Canada that is largely of Scottish heritage. When discussing his usual dietary intake with the nurse, client mentions that he does still enjoy many foods from back home, such as smelt. Smelt is a fish that is very high in purine and can promote the formation of uric acid crystals in persons prone to developing them. Which response by the nurse is most helpful to the client?
Find out how much and how often the client eats smelt. This is a therapeutic communication technique for clarifying client's dietary practices.
In 2 days, client finds a stone in his urine strainer and takes it to the nephrologist's clinic. The HCP sends the sample to the laboratory and the result reveals that the calculus consists of sodium uric acid precipitant. The ED nurse notes that client reports having chronic, intermittent episodes of gout when documenting his health history. What is the pathophysiology of gout?
Formulation of uric acid crystals within the joints. Disturbances in urate metabolism can result in hyperuricemia and deposition of sodium urate crystals in tissue, leading to a painful disorder called gout.
In 5 minutes, the triage nurse takes the client and his wife to a treatment room, where the ED nurse interviews client about his health history. Which reported chronic condition in his health history is most significant to his acute condition and the reason for this visit?
Gouty arthritis. The cause of gouty arthritis is the formation of uric acid crystals within the joints. The same formation of uric acid crystals can also form renal calculi.
Nutritional IntakeA week later, the nurse notes a change in the client's weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports back to the nurse that the client, weighs 110 lbs (50 kg), is 67 in (170.2 cm) tall, and is consuming 700 calories per day.How should the nurse explain the results of the calorie count to the client and her spouse?
Her calorie consumption is insufficient and will result in weight loss. An average adult requires 20 to 35 calories per kilogram per day. The client, who weighs 110 pounds, (50 kg) kilograms, needs a minimum of 1000 calories per day to maintain her current weight.
Client returns from the radiology department and the HCP tells him that several renal calculi were found on the CT scan and lithotripsy is being scheduled on an outpatient basis. Which discharge instructions should the nurse anticipate giving client? (Select all that apply.)
How to use a urine strainer. The nurse should instruct the client about how to use a urine strainer to catch a calculus once it has passed through the urethra so that it can be analyzed in a laboratory. Once the type of calculus is known, dietary and other therapeutic measures can be instituted to prevent the recurrence of renal calculi.Medication instructions. The nurse should teach the client about every medication that has been prescribed.Increase fluid intake. The nurse should instruct the client to drink 2 to 3 L/day of fluid. This reduces urine solute concentration and promotes passage of the renal calculus once it has become dislodged in the kidney.Follow up with a nephrologist. The nurse should teach the client the importance of follow up care with a nephrologist.
After infusing the formula at 30 mL/hour for 6 hours, the nurse checks the client's residual volume and obtains 75 mL. The prescription for the formula states that the rate should be increased by 10 mL/hour as long as the client's residual volume is less than half the previously infused total volume. Question 22 of 26 Which action should the nurse implement?
Increase the rate of the formula to 40 mL/hour. The client has received 180 mL during the previous 6 hours. Half of that volume is 90 mL (180/2). The residual volume obtained was 75 mL, so the rate of formula should be increased by 10 mL/hour to 40 mL/hour.
Three days later, client arrives to the surgery center for a lithotripsy procedure and his spouse accompanies him. As client prepares for the lithotripsy procedure, the nurse reviews the Informed Consent form and notices that it has not been signed. Which action should the nurse take next?
Inform the HCP immediately. Because nurses do not perform lithotripsy on clients, it is important that the HCP performing the procedure gives this information to the client directly and answers all questions satisfactorily before the client receives sedation before the procedure that day.
Considering the need for dysphagia precautions, what action should the nurse implement to intervene?
Instruct the UAP to add a thickening agent to all liquids. Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is added to liquids to change the consistency, making swallowing easier.
Which intervention should be included in the plan of care to provide the nurse with the most accurate information regarding the client's ongoing nutritional status?
Instruct the UAP to weigh the client once a week. Regular measurement of the client's weight provides a useful measurement of the client's general nutritional status. Assessment of the client's pattern of weight gain or loss should be combined with other measures, such as general assessment and dietary evaluation for a thorough picture of the client's nutritional status.
The nurse recognizes that the client's right-sided weakness is also a factor contributing to her risk for altered nutrition.With which member of the interprofessional team should the nurse consult regarding this problem?
Occupational therapist. Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self-care.
About 45 minutes later, the nurse asks client to rate her pain on the 0 to 10 scale and she rates her pain a 5, stating that the medication has only touched it a little. Which response by the nurse would be most helpful intervention?
Offer the second acetaminophen/hydrocodone 500 mg/5 mg by mouth (PO) tablet. Offering the second tablet is what the nurse should do in this situation. One tablet was not effective enough in 45 minutes.
When the nurse is giving care to a client with methicillin-resistant staphylococcus aureus (MRSA) cellulitis, which safety precautions should be observed? (Select all that apply. One, some, or all options may be correct.)
Perform frequent hand washing with antimicrobial soap. Cleaning the hands frequently with antimicrobial soap to prevent spreading infection is an important part of giving care to clients with MRSA cellulitis. Wearing gown, gloves, and mask when giving wound care. Wear gown, gloves, and mask to prevent spreading infection when providing wound care is an important part of giving care to clients with MRSA cellulitis Ensure that the client is assigned to a private room. Ensuring that the client with MRSA cellulitis is assigned to a private room is necessary to prevent spreading the infection. Alternatively, if there are no private rooms available, the client should be placed in a room with a client who has the same infection (cohorting).
Client activates the call light and the nurse comes into her room. She says that she has urinated in the bed and that she is embarrassed. This was an unexpected event. As the nurse and two unlicensed assistive personnel (UAPs) are cleaning up the client, she accidentally urinates again on the clean linens. Which intervention would be the most helpful for the nurse to perform?
Plan on instituting bladder training with this client. The client should obtain a bedside commode to reduce ambulation or have a bedpan available and follow a bladder training program. For example, urinating first thing in the morning, before each meal, and before bedtime might be an effective routine for preventing incontinent accidents.
The nurse reports the data about the client's nutritional status to the health care provider, who orders several lab tests. The nurse obtains a copy of the lab results the next day. Question 12 of 26 Which serum lab value reflects altered nutrition?
Protein of 5.0 g/dL (50g/L). The range for normal serum protein level in an adult is 6.4 to 8.3 g/dL (64 to 83 g/L). A level of 5.0 g/dL (50 g/L) is low, and may be an indicator of malnutrition.
The next morning, the nurse enters the client's room to prepare her to go to the procedure room. The nurse states that the procedure is scheduled in 30 minutes. The client, who is lethargic, tells the nurse she has changed her mind and does not want the procedure performed, stating that she would rather just "go ahead and die." Her spouse is in the room, and he is very upset by her comment. Question 18 of 26 Which action should the nurse implement regarding cancellation of the procedure?
Provide the couple with privacy to discuss the decision. The nurse must address the client's expressed desire to cancel the procedure. The nurse's initial actions should include allowing the couple privacy to discuss the decision, addressing any concerns of the client, and encouraging further communication.
What dietary substance should the nurse instruct the client to reduce or eliminate as much as possible?
Purine. Purine is an amino acid that forms uric acid when metabolized.
The triage nurse continues to assess client's pain. Which elements should be included in the assessment when using the PQRST assessment method? (Select all that apply.)
Quality. Q is for Quality of the pain during assessment, such as sharp or dull. R is for Radiation. Does the pain radiate to a different location? Severity. S is for assessing pain Severity using a valid pain rating scale, such as the 0 to 10 pain scale. Timing. T is for assessing the Temporal or time-related aspects of pain, such as intermittent or constant.
The nurse inserts a peripheral intravenous catheter, gives the IV fentanyl and the sodium chloride bolus, and enters the phone HCP radiology order into the computerized order entry system. Which actions should the nurse take next? (Select all that apply.)
Question the client about any shell fish allergies. The nurse should assess the client for an iodine allergy in preparation for the CT scan with contrast. A shellfish allergy would contraindicate contrast dye administration. Have the client rate his pain on a 10-point scale. The nurse should evaluate the client's response to the IV pain medication that was administered.Determine when the last dose of glucophage was taken. Glucophage should be stopped at least 24 hours before contrast dye is used and not be restarted until adequate kidney function has been established.
The nurse visits with the client's spouse and then observes as the unlicensed assistive personnel (UAP) assists the client with her meal. The UAP gives her a glass of iced tea to drink and the client begins to cough. The nurse recognizes that the client's dysphagia may impact her fluid and nutritional status. The nurse plans interventions related to the client's dysphagia. To which member of the interprofessional team should the nurse obtain a referral order?
Speech therapist. Speech therapists have expertise in the evaluation and management of clients with dysphagia.
The healthcare provider (HCP) notifies the staff that the result of a skin culture taken 3 days ago in the clinic has come back as having methicillin-resistant staphylococcus aureus (MRSA) and the client is diagnosed as having MRSA cellulitis. Which assessment finding(s) would the nurse expect to observe? (Select all that apply. One, some, or all options may be correct.)
Swelling. The nurse would expect to find red swollen skin patches that are warm to the touch in a client with MRSA cellulitis. Fever. The nurse would expect to find an abnormal and elevated body temperature when measuring the vital signs. Redness. The nurse would expect to find red swollen skin patches that are warm to the touch in a client with MRSA cellulitis. Loss of function. The nurse would expect to find some loss of function due to swelling when assessing a client with MRSA cellulitis.
Client arrives on a stretcher to the medical-surgical unit. The unit is busy, and the charge nurse tells the Emergency Department unlicensed assistive personnel (UAP) to place her in room 3. Which action requires the nurse to intervene immediately?
The UAP raises the bed and attempts to pull the client onto it with bed sheet. This client weighs 220 lbs (100 kgs). This transfer method places the client and the UAP at risk for injury. The client is at risk for skin sheering from the bed sheet and falling. The UAP is at risk for a back injury because their weight is transferred away from the UAP's center of gravity.
Client reports to the nurse that he has a codeine allergy. When he had a cold last winter, he was prescribed cough syrup with codeine and it gave him a rash all over his body. The HCP advised his spouse to give him diphenhydramine 50 mg by mouth and it got better in a couple of days. He states that he stopped taking the cough syrup and he eventually got better. The nurse records the stated allergy in client's medical record and prepares to speak with the HCP. Which information is important for the nurse to include in the conversation with the HCP? (Select all that apply.)
The client has no allergies listed in his medical record. This is Background (SBAR) information that the nurse must give the HCP. [SBAR = Situation, Background, Assessment, Recommendation] Hydrocodone/acetaminophen is prescribed for pain. This is the Situation (SBAR) that the nurse must relay to the HCP. [SBAR = Situation, Background, Assessment, Recommendation] The client reports that cough syrup with codeine gave him a rash. The nurse must share this Assessment (SBAR) interview finding with the HCP. [SBAR = Situation, Background, Assessment, Recommendation] The nurse requests a prescription for fentanyl 50 mcg intravenous push (IVP) now. The nurse may give this Recommendation (SBAR) to the HCP. [SBAR = Situation, Background, Assessment, Recommendation]
The HCP arrives to orient client to the lithotripsy procedure and answer all his questions. Client signs the Informed Consent form. The nurse reviews the form and ensures that it contains all the required elements of informed consent. Which elements should the nurse verify as complete? (Select all that apply.)
The client has signed the form voluntarily. Verifying that the client signed the consent form and that this was done voluntarily is required.The witnesses' signatures are on the form. Verifying that the witnesses have also signed the consent form demonstrating that they saw the consent form being signed voluntarily by the client is required.The date and time the form was signed. Verifying that the form has the date and time it was signed is also a required action.
The nurse obtains further data regarding the client's nutritional status. Which information is best to use for assessment of the client's functional ability related to nutrition?
The client's ability to feed herself with her left hand. This assessment provides information about the client's functional ability
Formula CalculationThe next day, the nurse initiates the feeding prescribed by the HCP. The prescription is for the formula to infuse at 30 mL/hour. The formula is available in 8-ounce cans. The nurse is preparing enough formula for 12 hours. Question 21 of 26 Fill in the blankHow many cans of formula will the nurse need? (Enter numeric value only. If rounding is
The nurse needs a total volume of 360 mL (12 hours x 30 mL/hour).An 8-ounce can of formula contains 240 mL (8 ounces x 30 mL/ounce).360 mL / 240 mL = 1.5 cans.
The unlicensed assistive personnel (UAP) is assisting client with a bed bath. Which action by the UAP requires the nurse to intervene?
Wash all infected areas of skin before uninfected areas. This action will spread the MRSA infection to the rest of the client's skin.
The nurse teaches client about dietary practices that can reduce his incidence of gout and sodium uric acid nephrolithiasis. What is most important to establish before initiating the teaching session?
Who plans and cooks the meals in the household. The person in the client's household who plans and prepares meals has the most influence over how well the client adheres to the recommended dietary changes.
Malocclusions.
abnormalities in the bite rarely seen in cats, common in dogs Crooked teeth
Actively acquired.
body produces its own antibodies The client arrived at the hospital with an MRSA infection; therefore, it is community acquired.
Health care acquired.
infections acquired after admission into a health facility The client arrived at the hospital with an MRSA infection; therefore, it is community acquired.
Periodontitis
inflammation of tissues around a tooth Periodontitis is a severe infection of the gums.
hospital acquired infection
nosocomial infection The client arrived at the hospital with an MRSA infection; therefore, it is community acquired. Hospital acquired infections emerge greater than 48 hours after admission.