NURS 302 Hesi

Normal urine specific gravity

1.001-1.035

Elevated troponin in how many hours:

2-3 hours of an MI, CK-MB take up to 6-9 hrs

Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? Use an end-tital CO2 detector. Ascultate for bilateral breath sounds. Obtain pulse oximeter reading. Check symmetrical chest movement.

A This shows the ETT tube is in the trachea, not the esophagus

A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Select all that apply Some correct answers were not selected Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure.

A, D The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.

During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? Promotion of comfort. Prevention of pregnancy. Instruction in condom use. Information about transmission.

A.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins.

A.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy.

A.

When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? Acute pain related to movement of the stone. Impaired urinary elimination related to obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to need for prevention of recurrence of calculi.

A.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? Heart palpitations. Anorexia. Hypersomnia. Stress incontinence.

A. Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis.

What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? Catheterize every 3 to 4 hours. Maintain sterile technique. Use the Cred maneuver before catheterization. Drink 500 ml of fluid within 2 hours of catheterization.

A. Clean technique is fine at home

During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? Notify the surgeon. Document the assesment. Secure a colostomy pouch over the stoma. Place petrolatum gauze dressing over the stoma.

A. Stoma should be reddish pink & moist Stoma should not be dry, firm, flaccid, dark red or purple (ischemia!)

What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? Wheezing becomes louder. Cough remains unproductive. Vesicular breath sounds decrease. Bronchodilators stimulate coughing.

A. In an acute asthma attack, air flow may be so significantly restricted that breath sounds and wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive.

When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? Dry, itchy skin changes may occur. There is a possibility of long bone pain. Permanent pigment changes to the breast may result. A low-residue diet may be ordered to reduce the likelihood of diarrhea

A. Side effects from radiation to the breast most often include temporary skin changes such as: dryness, tenderness, redness, swelling, and pruritis.

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? A. Upper chest subcutaneous emphysema. B. Tidaling (fluctuation) of fluid in the water-seal chamber. C. Constant air bubbling in the suction-control chamber. D. Pain rated "8" (0-10) at the insertion site.

A. Emphysema indicates air is leaking beneath the skin

The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement? Administer antiemetics every 2 to 3 hours. Position on the left side with knees drawn up. Encourage ice chips sparingly. Give IV fluids with electrolytes.

D. When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration.

man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) Select all that apply Only marijuana cigarettes affect sperm count. Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility. Sperm specimens should be collected in 2 subsequent days.

B, C, D. he use of tobacco, alcohol, and marijuana may affect a man's sperm counts.

he nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) Select all that apply Empty surgical drains once a week using procedure gloves. Report inflammation of the incision site or the affected arm. Wear clothing with snug sleeves over the arm on the operative side. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head.

B, D

When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.) Select all that apply Assessing residual amounts once a day. Keeping the head of the bed elevated 30 degrees. Changing the enteral-feeding bag every 24 hours. Checking the placement of the tube by means of gastric aspiration. Flushing the tube with 50 ml of normal saline solution after each feeding.

B, D HOB elevated 30 degrees, change enteral feeding q 24 hrs, check placement of tube with gastric aspiration, flush tube with 50 mL of normal saline Check residual amounts each time

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Select all that apply Some correct answers were not selected Nail polish. Hearing aid. Wedding band. Left leg brace. Contact lenses. Partial dentures.

B, E, F

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleeping six to eight hours. Achieve a sense of control. Utilize problem solving skills. Increased focus of attention.

B.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? Risk for injury. Impaired comfort. Disturbed body image. Ineffective health maintenance.

B.

The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room.

B.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? Acute pain. Risk for infection. Disturbed body image. Risk for deficient fluid volume.

B.

The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? Extend the left arm laterally with the left palm upward. Extend the arm, dorsiflex the wrist, and extend the fingers. Extend the arms and hold this position for 30 seconds. Extend arms with both legs adducted to shoulder width.

B. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.

client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which conclusion regarding this lab data is accurate? Probable prostatitis. Low risk for prostate cancer. The presence of cancer cells. Biopsy of the prostate is indicated.

B. Clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer.

The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? Encourage fluids to 3000 ml/day. Check stools for occult blood. Provide oral hygiene every 2 hours. Check for fever every 4 hours.

B. Platelet counts should not be less than 100,000!

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? Suprapublic pain and distention. Bounding pulse at 100 beats/minute. Fingerstick glucose of 300 mg/dl. Small vesicular perineal lesions.

C

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? Assessment of the client's vital signs. Document the finding as the only action. Determine the time the client last voided. Insert a rectal tube for the passage of flatus.

C

Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Full thickness burns rather than partial thickness. Supinates extremity but unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Inability to distinguish sharp versus dull sensations in the extremity.

C A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.

What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? Tell another staff member to bring extinguishing equipment to the bedside. Close the doors to the client's area when attempting to extinguish the fire. Use a bag-valve-mask resuscitator while removing the client from the area. Implement an emergency protocol to remove the client from the ventilator.

C. A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source.

The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.

C. Increase intraocular pressure

The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Change drainage unit tubing.

C. Obstruction urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? Obtain a prescription for a laxative. Withhold all oral fluid and food. Assist the client to ambulate in the hall. Administer the prescribed morphine sulfate.

C. Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? Perform active range of motion three times daily. Monitor for Battle's sign every four hours. Teach measures to avoid the Valsalva maneuver. Maintain the head of bed in a flat position.

C. The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Presence of carbonaceous particles in sputum.

C. The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.

The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement? A mask should be worn by anyone entering the client's room. Handwashing is required before and after contact with the client. Gloves should be worn during direct contact with the client's skin. No precautions in addition to standard precautions are necessary.

C. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on "contact precautions".

A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? Give the drug and allow the client to read and sign the consent form. Counter-sign the client's initials on the consent form after giving the drug. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Call the healthcare provider to explain the surgical procedure before the client signs the consent.

C. Versed interferes with cognition and level of consciousness, so sign before the drug is administered

A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands? Ongoing antibiotic therapy is needed for one year. The client should not undergo magnetic resonance imaging. Increased frequency of assessment for prostatic cancer is needed. The client should not be catheterized through the stent for at least three months.

D A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement.

A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? Inform the client how to protect sexual and needle-sharing partners. Teach the client about the medications that are available for treatment. Identify the need to test others who have had risky contact with the client. Discuss retesting to verify the results, which will ensure continuing contact.

D.

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? The xray procedure may last for several hours. A nasogastric tube (NGT) is inserted to instill the barium. Enemas are given to empty the bowel after the procedure. Nothing by mouth is allowed for 6 to 8 hours before the study.

D.

What is the primary nursing problem for a client with asymptomatic primary syphilis? Acute pain. Risk for injury. Sexual dysfunction. Deficient knowledge.

D. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology.

The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? Thinning hair and dry scalp. Increase in appetite and taste-bud acuity. Increase in muscle tone but decreased muscle strength. Increase in abdominal fat deposits.

D. Development of metabolic syndrome!

client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance.

D. Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this drug be taken with food to avoid gastrointestinal upset.

Which client should the nurse assess first? A 27-year-old complaining of severe back pain. A 63-year-old complaining of foot and ankle pain. A 49-year-old with pancreatitis complaining of unrelenting abdominal pain. A 55-year-old newly admitted client complaining of jaw pain and indigestion.

D. Rule out MI~

A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? Ventricular irritability is prevented by the constant rate setting of pacemaker. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. An impulse is fired every second to maintain a heart rate of 60 beats per minute. An electrical stimulus is discharged when no ventricular response is sensed.

D. The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed.

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week.

D. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids.

In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone.

D. After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulating.

A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration.

D. Intraperitoneal hemorrhage, causes periumbilical discoloration Indicates splenic rupture

A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? Determine the client's level of discomfort using a pain rating scale. Ask the client about her past experience with chronic pain. Observe the client's facial expressions for pain and discomfort. Evaluate the client's ability to adjust the voltage to control pain.

D. The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Select all that apply Some correct answers were not selected Vagal stimulation. An increased level of stress. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells.

Hypersecretion of gastric juices, increased number of parietal cells, vagal stimulation,

A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? Rub a liberal amount of cream into the skin thoroughly. Cover the skin with a gauze dressing after applying the cream. Leave the cream on the skin for 1 to 2 hours before the procedure. Use the smallest amount of cream necessary to numb the skin surface.

c

Pleurodesis

Infusion of a sterile, irritating substance into the pleural space, causing the pleural linings to fuse to one another by developing scar tissue

Mycobacterium avium complex (MAC)

MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.

Therapy fro priapism

The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider.

ABX treatment after osteomyelitis

Parenteral ABX for 4-8 weeks Oral ABX for 4-8 weeks

Superior vena cava syndrome

SVC compressed by outside structures

herniorrhaphy

surgical repair of a hernia

Proctosigmoidoscopy

visual examination of the anus and rectum