Old HESI #2

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? A. Cardiac rhythm and heart rate. B. Daily intake of foods rich in potassium. C. Hourly urinary output D. Thirst ad skin turgor.

A. Cardiac rhythm and heart rate.

A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? A. Maintain both lower extremities elevated on pillows. B. Remove the contracting antiembolic stocking C. Administer diuretics in the morning hours D. Restrict PO fluid intake to 500 ml per shift

A. Maintain both lower extremities elevated on pillows.

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? A. Protect joint function B. Improve circulation C. Control tremors D. Increase weight bearing

A. Protect joint function

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? A. Reduced level of pain B. Full volume of pedal pulses C. Granulating tissue in foot ulcer D. Improved visual acuity.

A. Reduced level of pain

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? A. Sudden dysphagia B. Blurred visual field C. Gradual weakness D. Profuse diarrhea

A. Sudden dysphagia

A client is scheduled to receive an IV dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? A. Ask a chemotherapy-certified nurse to administer the Zofran B. Administer the Zofran after flushing the saline lock with saline C. Hold the scheduled dose of Zofran until the client awakens D. Awaken the client to assess the need for administration of the Zofran.

B. Administer the Zofran after flushing the saline lock with saline

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? A. Instruct the client‟s family member to stay in the visitor waiting area until further notice B. Tell the staff to keep all clients and visitors in the client rooms with the doors closed. C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. D. Call the hospital operator to determine if the is indeed a real emergency or a fire drill

B. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? A. Decrease in serum T4 levels B. Increase in blood pressure C. Decrease in pulse rate D. Goiter no longer palpable

C. Decrease in pulse rate

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? A. Administer prescribed pain medication B. Assess surgical site C. Determine the client‟s vital sign. D. Apply warmed blankets

C. Determine the client‟s vital sign.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn‟s survival? A. Hypoglycemia B. Fluid balance C. Heat loss D. Bleeding tendencies

C. Heat loss

A client at 30-week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? A. Maternal blood pressure of 90/60 B. Fetal heart rate of 170 beats per minute for 15 mints C. Maternal pulse rate of 162 beats per min D. Serum potassium of 2.3 mg/dL

C. Maternal pulse rate of 162 beats per min

An unlicensed assistive personnel (UAP) reports that a client‟s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client‟s serum calcium level D. Administer PRN antianxiety medication

C. Review the client‟s serum calcium level

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client‟s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? A. When the client‟s stroke symptoms started B. If the client is oriented to time C. The client‟s previous GCS score. D. The client‟s blood pressure and respiration rate

C. The client‟s previous GCS score.

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? A. Assess the client‟s vital signs B. Observe the client‟s pupils for dilation C. Document the client‟s drug tolerance D. Administer the analgesic as requested

D. Administer the analgesic as requested

The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? A. Prior to exercising B. Immediately after meals C. Before going to bed D. During acute illness.

D. During acute illness.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying B. Straining on stool C. Vomiting D. Sitting upright.

D. Sitting upright.

The nurse is auscultating a client‟s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) A. Murmur B. s1 s2 C. pericardial friction rub D. s1 s2 s3

D. s1 s2 s3

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client‟s history is a possible contraindication for the use of HRT?

Her mother and sister have a history of breast cancer

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? A. Provide a bedtime snack to be eaten before taking the medication. B. Administer the medication as prescribed with a glass of water C. Contact the prescriber about changing the time of administration. D. Check the client‟s blood pressure prior to administering the med.

B. Administer the medication as prescribed with a glass of water

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? A. Move to welcome and accommodate a new person B. Ask the new person to move belonging to accommodate others C. Tell the new person to move belongings because of limited space D. Bring in additional chairs so that all staff members can be seated

B. Ask the new person to move belonging to accommodate others

What intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client‟s arm? A. Explain the temporary burning of the IV site may occur. B. Assess IV site frequently for signs of extravasation C. Apply a topical anesthetic of the infusion site for burning D. Monitor capillary refill distal to the infusion site.

B. Assess IV site frequently for signs of extravasation

An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client‟s medical records indicates that 100% of the diet provided has been consumed. However, the client‟s weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? A. Examine the client‟s room for hidden food. B. Assign staff to monitor what the client eats. C. Ask the client if the food provided is being eaten or discarded. D. Provide the client with a high calorie diet.

B. Assign staff to monitor what the client eats.

While receiving a male postoperative client‟s staples de nurse observe that the client‟s eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client‟s anxiety, what action should the nurse implement? A. Encourage the client to continue verbalize his anxiety B. Attempt to distract the client with general conversation C. Explain the procedure in detail while removing the staples D. Reassure the client that this is a simple nursing procedure.

B. Attempt to distract the client with general conversation

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be including in the discharge teaching? A. Do not read without direct lighting for 6 weeks. B. Avoid straining at stool, bending, or lifting heavy objects. C. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. D. Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

B. Avoid straining at stool, bending, or lifting heavy objects.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? A. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. B. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. C. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. D. Beef stir fry, fried rice, egg drop soup, diet coke and pumpkin pie

B. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day and has also experiences a loss of appetite. What instruction should the nurse provide? A. Perform CPT after meals to increase appetite and improve food intake. B. CPT should be performed more frequently, but at least an hour before meals. C. Stop using CPT during the daytime until the child has regained an appetite. D. Perform CPT only in the morning, but increase frequency when appetite improves

B. CPT should be performed more frequently, but at least an hour before meals.

When assessing a multigravida, the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A. Massage the uterus to decrease atony B. Check for a distended bladder C. Increase intravenous infusion D. Review the hemoglobin to determined hemorrhage

B. Check for a distended bladder

A client with Alzheimer‟s disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client‟s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? A. Explain that it may take several weeks for the medication to be effective B. Confirm the desired effect of the medication has been achieved. C. Notify the health care provider than a change may be needed. D. Evaluate when and how the medication is being administered to the client

B. Confirm the desired effect of the medication has been achieved.

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client‟s serum laboratory values requires intervention by the nurse? A. Total calcium 9 mg/dl (2.25 mmol/L SI) B. Creatinine 4 mg/dl (354 micromol/L SI) C. Phosphate 4 mg/dl (1.293 mmol/L SI) D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)

B. Creatinine 4 mg/dl (354 micromol/L SI)

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note because of this increases in glaucoma surgeries? A. Decrease morbidity in the elderly population B. Decrease prevalence of glaucoma in the population. C. Increase mortality in the elderly population D. Increased incidence of glaucoma in the population.

B. Decrease prevalence of glaucoma in the population.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? A. Neutralize hydrochloric (HCI) acid in the stomach B. Decreases the amount of HCL secretion by the parietal cells in the stomach C. Inhibit action of acetylcholine by blocking parasympathetic nerve endings. D. Destroys microorganisms causing stomach inflammation.

B. Decreases the amount of HCL secretion by the parietal cells in the stomach

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of Motion B. Distal pulse intensity C. Extremity sensation D. Presence of exudate

B. Distal pulse intensity

A woman just learned that she was infected with Helicobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? A. Schedule a colonoscopy within the next month. B. Encourage screening for a peptic ulcer. C. Screen all family member for hepatitis A D. Eat small, frequent meals thought the day.

B. Encourage screening for a peptic ulcer.

In assessing a client at 34-weeks‟ gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? A. Elevated thyroid hormone level. B. Hematocrit of 28%. C. Heart rate of 92 beats per minute. D. Systolic murmur.

B. Hematocrit of 28%.

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I‟m trying to start a new business and "I‟m too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? A. Hygiene-self-care deficit B. Imbalance nutrition C. Disturbed sleep pattern D. Self-neglect

B. Imbalance nutrition

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client‟s constipation, which suggestions should the nurse provide? (Select all that apply) A. Decrease laxative use to every other day and use oil retention enemas as needed. B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. E. Report constipation to healthcare provider related to cardiac medication side effects.

B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation.

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client‟s ABG finding, which action is required? A. Report the results to the healthcare provider. B. Increase ventilator rate. C. Administer a dose of sodium carbonate. D. Decrease the flow rate of oxygen.

B. Increase ventilator rate.

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? A. Administer naloxone (Narcan) per PNR protocol B. Initiate seizure precautions C. Obtain a serum drug screen D. Instruct the family about withdrawal symptoms.

B. Initiate seizure precautions

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Assess the client‟s ability to use a numeric pain scale B. Initiate the dosage lockout mechanism on the PCA pump C. Instruct the client to use the medication before the pain become severe D. Assess the abdomen for bowel sounds

B. Initiate the dosage lockout mechanism on the PCA pump

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? A. High protein B. Low fat C. Low sodium D. High carbohydrate

B. Low fat

Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client‟s plan of care? A. Allow the family to visit whenever they wish B. Medicate as needed for pain and anxiety. C. Allow client to participate in care provided D. Maintain quiet, low lighting environment

B. Medicate as needed for pain and anxiety.

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? A. Jaundice skin tone B. Muffled heart sounds C. Pitting peripheral edema D. Bilateral scleral edema

B. Muffled heart sounds

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? A. Observe neck for jugular vein distention B. Notify healthcare provider to prepare for pericardiocentesis C. Asses for paradoxical blood pressure D. Monitor oxygen saturation (Sp02) via continuous pulse oximetry

B. Notify healthcare provider to prepare for pericardiocentesis

After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take? A. Explain the procedure again in detail and clarify any misconceptions. B. Notify the healthcare provider of the client‟s lack of understanding. C. Call the client‟s next of kin and have them provide verbal consent. D. Postpone the procedure until the client understands the risk and benefits.

B. Notify the healthcare provider of the client‟s lack of understanding.

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client‟s plan of care? A. Determine client‟s level current blood alcohol level. B. Observe for changes in level of consciousness. C. Involve the client‟s family in healthcare decisions. D. Provide grief counseling for client and his family

B. Observe for changes in level of consciousness.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? A. Obtain a urine specimen for culture and sensitivity B. Palpate the client's suprapubic area for distention C. Advise the client to maintain a voiding diary for one week D. Instruct in effective technique to cleanse the glans penis

B. Palpate the client's suprapubic area for distention

In early septic shock states, what is the primary cause of hypotension? A. Peripheral vasoconstriction B. Peripheral vasodilation C. Cardiac failure D. A vagal response

B. Peripheral vasodilation

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A. Abnormal responses for cranial nerves I and II B. Persistent coughing while drinking C. Unilateral facial drooping D. Inappropriate or exaggerated mood swings

B. Persistent coughing while drinking

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? A. Chew food slowly and thoroughly before attempting to swallow B. Plan volume-controlled evenly-space meal thorough the day C. Sip fluid slowly with each meal and between meals D. Eliminate or reduce intake fatty and gas forming food

B. Plan volume-controlled evenly-space meal thorough the day

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A. Replace the IV site with a smaller gauge. B. Redress the abdominal incision C. Leave the lights on in the room at night. D. Apply soft bilateral wrist restraints.

B. Redress the abdominal incision

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? A. Confirm that all the staff nurses are being assigned to equal number of clients. B. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. C. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. D. Analyze the amount of overtime needed by the nursing staff to complete assignments

B. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent.

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi‟s sarcoma lesions. The client is accompanied by two family members. Which action should the nurse take? A. Ask family member to wear gloves when touching the patient B. Send family to the waiting area while the client‟s history is taking C. Obtain a blood sample to determine is the client is HIV positive D. Complete the head to toes assessment to identify other sign of HIV

B. Send family to the waiting area while the client‟s history is taking

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client‟s abdomen is distended. Which prescribed PRN medication should the nurse administer? A. Hydrocodone/Acetaminophen (Lortab) B. Simethicone (Mylicon) C. Promethazine (Phenergan) D. Nalbupine (Nubain)

B. Simethicone (Mylicon)

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client‟s plan of care? A. Elevate lower extremities while out of bed B. Teach family proper range of motion exercises. C. Maintain proper body alignment when in bed D. Encourage diaphragmatic breathing exercises.

B. Teach family proper range of motion exercises.

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? A. Explain how to use communication tools. B. Teach tracheal suctioning techniques C. Encourage self-care and independence. D. Demonstrate how to clean tracheostomy site.

B. Teach tracheal suctioning techniques

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse‟s response should be based on which information about assistive devices? A. They can contribute to increased dependency B. They decrease the risk for joint trauma C. They promote muscle strength D. They diminish range of motion ability.

B. They decrease the risk for joint trauma

The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A. Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle B. Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. C. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

B. Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

The nurse is managing the care of a client with Cushing‟s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) A. Evaluate the client for sleep disturbances B. Weigh the client and report any weight gain. C. Report any client complaint of pain or discomfort. D. Assess the client for weakness and fatigue E. Note and report the client‟s food and liquid intake during meals and snacks.

B. Weigh the client and report any weight gain. C. Report any client complaint of pain or discomfort. E. Note and report the client‟s food and liquid intake during meals and snacks.

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client A. Who is bedfast, with increased serum BUN and creatinine levels B. Who is confused and frequently forgets to go to the bathroom C. With hematuria and decreasing hemoglobin and hematocrit levels D. Who has a history of frequent urinary tract infections.

B. Who is confused and frequently forgets to go to the bathroom

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) 1. Apply pads and prepare for transthoracic pacing 2. Start chest compressions with assisted manual ventilations 3. Administer epinephrine 0.01 mg/kg intraosseous (IO) 4. Review the possible underlying causes for bradycardia. A. 1, 2, 3, 4 B. 2, 4, 3, 1 C. 2, 3, 1, 4 D. 3, 2, 1, 4

C. 2, 3, 1, 4

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? A. 9 % B. 18 % C. 36 % D. 45 %

C. 36 %

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? A. An adult female who has been depress for the past several months and denies suicidal ideations. B. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. C. A young male with schizophrenia who said voices is telling him to kill his psychiatric. D. An elderly male who tell the staff and other client that he is superman and he can fly.

C. A young male with schizophrenia who said voices is telling him to kill his psychiatric.

The healthcare provider changes a client‟s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? A. Continue to administer the medication via the IV route B. Give half the prescribed oral dose until the provider is consulted. C. Administer the medication via the oral route as prescribed. D. Consult with the pharmacist regarding the error in prescription.

C. Administer the medication via the oral route as prescribed.

Based on principles of asepsis, the nurse should consider which circumstance to be sterile? A. One inch- border around the edge of the sterile field set up in the operating room B. A wrapped unopened, sterile 4x4 gauze placed on a damp table top. C. An open sterile Foley catheter kit set up on a table at the nurse waist level D. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.

C. An open sterile Foley catheter kit set up on a table at the nurse waist level

In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client‟s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? A. Impaired gas exchange related to narrowing of small airways B. Death anxiety related to concern about prognosis C. Anxiety related to fear of suffocation. D. Ineffective coping related to knowledge deficit about COPD

C. Anxiety related to fear of suffocation.

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5-pound weight gain. Which intervention the nurse implement? A. Arrange transport for admission to the hospital. B. Insert saline lock for IV diuretic therapy. C. Assess compliance with routine prescriptions. D. Instruct the client to monitor daily caloric intake

C. Assess compliance with routine prescriptions.

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? A. discontinue the magnesium sulfate immediately B. Decrease the client's iv rate to 50 ml per hour C. Continue with the plan of care for this client D. Change the client's to NPO status

C. Continue with the plan of care for this client

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? A. Report the incident to the local child protective services. B. Find a home health agency that specializes in brain injuries. C. Determine the mother‟s basic skill level in providing care. D. Consult the ethics committee to determine how to proceed.

C. Determine the mother‟s basic skill level in providing care.

The nurse is preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which action should the nurse include? A. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection B. Administer into the deltoid muscle while the parent holds the infant securely C. Divide the medication into two injections with volumes under 1 mL D. Use a quick dart-like motion to inject into the dorsogluteal site.

C. Divide the medication into two injections with volumes under 1 mL

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A. Prepare the client to independently treat their disease process B. Reduce healthcare costs related to diabetic complications C. Enable clients to become active participating in controlling the disease process D. Increase client‟s knowledge of the diabetic disease process and treatment options

C. Enable clients to become active participating in controlling the disease process

A male client‟s laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client‟s plan of care? A. Cluster care to conserve energy B. Initiate contact isolation C. Encourage him to use an electric razor D. Asses him for adventitious lung sounds

C. Encourage him to use an electric razor

A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A. Evaluate postural blood pressure measurements B. Obtain specimen for uranalysis C. Encourage popsicles and fluids of choice D. Assess bowel sounds in all quadrants

C. Encourage popsicles and fluids of choice

A vacuum-assistive closure (VAC) device is being used to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? A. Empty the device every 8 hours and change the dressing daily ensure sterility B. Extended the transparent film dressing only to edge of wound to prevent tension. C. Ensure the transparent dressing has no tears that might create vacuum leaks D. Use an adhesive remover when changing the dressing to promote comfort.

C. Ensure the transparent dressing has no tears that might create vacuum leaks

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? A. Conduct face to face prevention education group session is Spanish B. Offer low literacy material that explain respiratory hygiene and handwashing techniques C. Establish trust with community leaders and respect cultural and family values. D. Provide public services announcements advising those who aril o seek prompt medical attention.

C. Establish trust with community leaders and respect cultural and family values.

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? A. Prepared both client‟s medication and take to them at once B. Determine when each client last received pain medication. C. Evaluate both client‟s pain using a standardized pain scale D. Provide non-pharmacologic pain management interventions.

C. Evaluate both client‟s pain using a standardized pain scale

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? A. Determine the client‟s level of emotional functioning‟ B. Assess functional ability of the primary support system. C. Evaluate the client‟s mood, cognition and orientation. D. Review the client‟s pattern of adaptive coping skill

C. Evaluate the client‟s mood, cognition and orientation.

Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? A. Application of joint splints B. Effective body mechanisms C. Fall prevention measures. D. Low fat, high protein diet

C. Fall prevention measures.

When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? A. Resume normal physical activity B. Drink electrolyte fluid replacement C. Give a dose of regular insulin per sliding scale D. Measure urinary output over 24 hours.

C. Give a dose of regular insulin per sliding scale

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug‟s effectiveness? A. Body max index (BMI) between 20 and 24 B. Blood pressure reading less than 120/80 mm Hg C. Hemoglobin A1C (HbA1C) reading less than 7% D. Self-reported glucose levels of 120-150 mg/dl.

C. Hemoglobin A1C (HbA1C) reading less than 7%

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? A. The intravenous fluid replacement contains a hypertonic solution of sodium chloride B. Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes D. Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

C. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes

Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse? A. Diarrhea and flatulence B. Abdominal cramps C. Muscle pain D. Altered taste

C. Muscle pain

A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? A. Dark yellow-brown colored urine B. Nonspecific muscle and joint pain C. New onset of purple skin lesions. D. Weakness when getting up to walk.

C. New onset of purple skin lesions.

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F.He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Put a cold cloth on his head and administer acetaminophen. B. Listen to lung sounds and place him in a mist tent. C. Notify the healthcare provider and obtain a tracheostomy tray D. Assist the child to lie down and examine his throat.

C. Notify the healthcare provider and obtain a tracheostomy tray

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? A. Headache B. Joint stiffness C. Persistent fever D. Increase hunger and thirst

C. Persistent fever

During a Woman‟s Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) A. Encourage the woman at risk for cancer to obtain colonoscopy. B. Present a class of breast-self examination C. Prepare a woman for a bone density screening D. Explain the follow-up need it for a client with prehypertension.

C. Prepare a woman for a bone density screening

The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? A. Give the child syringes or hospital mask to play it at home prior to hospitalization. B. Include the child in pay therapy with children who are hospitalized for similar surgery. C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. D. Provide doll an equipment to re-enact feeling associated with painful procedures

C. Provide a family tour of the preoperative unit one week before the surgery is scheduled.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? A. Arrange to transport the client to the hospital B. Instruct the client to keep a food journal, including portions size. C. Review the client‟s use of over the counter (OTC) medications. D. Reinforce the importance of keeping the feet elevated.

C. Review the client‟s use of over the counter (OTC) medications.

A young adult client is admitted to the emergency room following a motor vehicle collision. The client‟s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as" Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? A. Infection B. Increase intracranial pressure C. Shock D. Head Injury.

C. Shock

The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? A. The fating blood sugar was 120 mg/dl this morning. B. Urine ketones have been negative for the past 6 months C. The hemoglobin A1C was 6.5g/100 ml last week D. No diabetic ketoacidosis has occurred in 6 months.

C. The hemoglobin A1C was 6.5g/100 ml last week

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is A. Two days postoperative bladder surgery with continuous bladder irrigation infusing. B. One day postoperative laparoscopic cholecystectomy requesting pain medication. C. Three days postoperative colon resection receiving transfusion of packed RBCs. D. Preoperative, in buck‟s traction, and scheduled for hip arthroplasty within the next 12 hours

C. Three days postoperative colon resection receiving transfusion of packed RBCs.

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse‟s proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing.

C. Vitamin supplements for high-risk pregnant women.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A. A young man with schizophrenia who wants to stop taking his medication B. The mother of a child who was involved in a physical fight at school today. C. A client diagnosed with depression who is experiencing sexual dysfunction. D. A family member of a client with dementia who has been missing for five hours

D. A family member of a client with dementia who has been missing for five hours

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client‟s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? A. Give the wife a straw to help facilitate the client‟s drinking. B. Assist the wife and carefully give the client small sips of water C. Obtain a thickening powder before providing any more fluids. D. Ask the wife to stop and assess the client‟s swallowing reflex.

D. Ask the wife to stop and assess the client‟s swallowing reflex.

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? A. Discontinue intravenous therapy B. Obtain a prescription for a diet change C. Assess for abdominal distention and tenderness. D. Auscultate bowel sounds in all four quadrants

D. Auscultate bowel sounds in all four quadrants

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? A. Engage in physical exercise immediately after eating to help decrease cholesterol levels. B. Walk briskly in cold weather to increase cardiac output C. Keep nitroglycerin in a light-colored plastic bottle and readily available. D. Avoid all isometric exercises but walk regularly

D. Avoid all isometric exercises but walk regularly

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? A. Limit intake fatty foods for one month after surgery. B. Notify the healthcare provider if edema occurs. C. Increase activity and exercise gradually, as tolerated. D. Avoid crowds for first two months after surgery.

D. Avoid crowds for first two months after surgery.

A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent‟s lower leg. What action should the nurse implement next? A. Administer antiemetic agents B. Bivalve the cast for distal compromise C. Provide high- calorie, high-protein diet D. Begin parenteral antibiotic therapy

D. Begin parenteral antibiotic therapy

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A. Express feelings of sadness and loneliness B. Neglects personal hygiene and has no appetite C. Lacks interest in the activity of the family and friends D. Begin to show signs of improvement in affect

D. Begin to show signs of improvement in affect

The charge nurse in a critical care unit is reviewing clients‟ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? A. Pulmonary embolus with an intravenous heparin infusion and new onset hematuria B. Myocardial infarction with sinus bradycardia and multiple ectopic beats C. Adult respiratory distress syndrome with pulse oximetry of 85% saturation. D. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

D. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

When evaluating a client‟s rectal bleeding, which findings should the nurse document? A. Number of blood clots expelled with each stool. B. Unique odor noted with GI bleeding C. Evidence of internal hemorrhoids. D. Color characteristics of each stool.

D. Color characteristics of each stool.

An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? A. Consistently applies TED hose before getting dressed in the morning. B. Frequently elevated legs thorough the day. C. Inspect the leg frequently for any irritation or skin breakdown D. Completely stop cigarette/ cigar smoking.

D. Completely stop cigarette/ cigar smoking.

The nurse notes a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A. Encourage the client‟s family to visit more often B. Schedule a daily conference with the social worker C. Encourage the client to participate in group activities D. Engage the client in a non-threatening conversation.

D. Engage the client in a non-threatening conversation.

In assessing a client twelve hour following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? A. Increase the rate of the continuous bladder irrigation B. Manually irrigate the catheter with sterile normal saline C. Clam the catheter above the drainage. D. Ensure that no dependent loops are present in the tubing.

D. Ensure that no dependent loops are present in the tubing.

An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed dose of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? A. Request that the CT scan be done immediately B. Review the client‟s history for use of illicit drugs C. Assess client‟s pupils for their reaction to light. D. Explain the reason for using only non-narcotics.

D. Explain the reason for using only non-narcotics.

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client‟s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A. Ask the client with her children present if she fully understands the decision she has made. B. Discuss success of clinical trials and ask the client to consider participating for one month. C. Explain to the family that they must accept their mother‟s decision. D. Explore the client‟s decision to refuse treatment and offer support

D. Explore the client‟s decision to refuse treatment and offer support

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? A. Place the dropper on the upper outer ear canal and instill the medication slowly. B. Warm the medication in the microwave for 10 seconds before instilling. C. Keep the medication refrigerated between administrations. D. Have the child lie with the ear up for one to two minutes after installation

D. Have the child lie with the ear up for one to two minutes after installation

An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Obtain a medical history B. Record pain evaluation C. Assess blood glucose D. Identify pills in the bag.

D. Identify pills in the bag.

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? A. Remove the catheter and insert into urethral opening B. Observe for urine flow and then inflate the balloon. C. Insert the catheter further and observe for discomfort. D. Leave the catheter in place and obtain a sterile catheter.

D. Leave the catheter in place and obtain a sterile catheter.

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? A. An apical pulse of 120 beats per minute B. Extreme agitation with staff and family C. Client report being anxious D. No wheezing upon auscultation of the chest.

D. No wheezing upon auscultation of the chest.

At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A. Encourage the client to turn on her left side. B. Place a pillow under the client‟s head and knees. C. Explain to the client that her position is not safe. D. Place a wedge under the client‟s right hip.

D. Place a wedge under the client‟s right hip.

When entering a client‟s room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? A. Prepare to administer atropine 0.4 mg IVP B. Gather emergency tracheostomy equipment C. Prepare to administer lidocaine at 100 mg IVP D. Place cardiac monitor leads on the client‟s chest

D. Place cardiac monitor leads on the client‟s chest

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? A. Family history is more important than calcium intake in determining the occurrence of osteoporosis B. Calcium should be taken once a day, preferable at the same time of day C. Smoking cessation is more important than calcium intake in preventing osteoporosis. D. Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

D. Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? A. Limit the intake of high calorie foods. B. Eat meals at the same time daily. C. Maintain a low protein diet. D. Restrict daily fluid intake.

D. Restrict daily fluid intake.

Following an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? A. Review the immunization records of all children in the elementary school B. Report the measles outbreak to all community health organizations C. Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. D. Restrict unvaccinated children from attending school until measles outbreak is resolved

D. Restrict unvaccinated children from attending school until measles outbreak is resolved

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a citywide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? A. Go to the emergency department and complete assigned tasks B. Shut all doors to client rooms on the unit in case a fire erupts C. Offer to assist the ICY with ventilator-dependent clients D. Tell all their assigned clients to stay in their rooms.

D. Tell all their assigned clients to stay in their rooms.

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client‟s blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client‟s average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? A. Irrigate the indwelling urinary catheter. B. Prepare the client for external pacing. C. Obtain capillary blood glucose measurement. D. Titrate the dopamine infusion to raise the BP.

D. Titrate the dopamine infusion to raise the BP.

The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

12.5 mL

The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8 mL

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other client‟s rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client‟s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom) 1. Contact the client‟s surgeon and primary healthcare provider 2. Assign unlicensed assistive personnel to remove restrains and remain with client 3. Assess the client‟s skin and circulation for impairment related to the restrains 4. Evaluate the client‟s mentation to determine need to continue the restrains A. 3, 4, 2, 1 B. 2, 3, 1, 4 C. 4, 2, 3, 1 D. 1, 2, 3, 4

A. 3, 4, 2, 1

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client‟s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A. Administer a daily dose of lisinopril as scheduled. B. Assess the client for postural hypotension. C. Notify the healthcare provider immediately D. Provide a PRN dose of acetaminophen for headache E. Withhold the next scheduled daily dose of warfarin.

A. Administer a daily dose of lisinopril as scheduled. D. Provide a PRN dose of acetaminophen for headache

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider‟s attention? A. Allopurinol (Zyloprim) B. Aspirin, low dose C. Furosemide (lasix) D. Enalapril (vasote)

A. Allopurinol (Zyloprim)

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? A. Antibiotics B. Anticoagulants C. Antihypertensive D. Anticholinergics

A. Antibiotics

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client‟s plan of care for today? A. Assist client in identifying goals for the day. B. Encourage client to participate for one hour in a team sport. C. Schedule client for a group that focuses on self-esteem. D. Help client to develop a list of daily affirmations.

A. Assist client in identifying goals for the day.

The mother of a child with cerebral palsy (CP) ask the nurse if her child‟s impaired movements will worsen as the child grows. Which response provides the best explanation? A. Brain damage with CP is not progressive but does have a variable course B. CP is one of the most common permanent physical disability in children C. Severe motor dysfunction determines the extent of successful habilitation D. Continued development of the brain lesion determines the child‟s outcome.

A. Brain damage with CP is not progressive but does have a variable course

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) A. Collect multiple site screening culture for MRSA B. Call healthcare provider for a prescription for linezolid (Zyrovix) C. Place the client on contact transmission precautions D. Obtain sputum specimen for culture and sensitivity E. Continue to monitor for client sign of infection.

A. Collect multiple site screening culture for MRSA C. Place the client on contact transmission precautions E. Continue to monitor for client sign of infection.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? A. Convey to the client that birth is imminent. B. Prepare the client for spinal anesthesia C. Empty the client‟s bladder using a straight catheter D. Prepare the coach to accompany the client to delivery

A. Convey to the client that birth is imminent.

An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? A. Delirium B. Depression C. Dementia D. Psychotic episode

A. Delirium

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? A. Ensure that the knot can be quickly released. B. Tie the knot with a double turn or square knot. C. Move the ties so the restraints are secured to the side rails. D. Ensure that the restraints are snug against the client's wrist.

A. Ensure that the knot can be quickly released.

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? A. Epinephrine Injection, USP IV B. Diphenhydramine IV C. Albuterol (Ventolin) inhaler D. Methylprednisolone IV

A. Epinephrine Injection, USP IV

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? A. Evaluate closet proximal pulse. B. Asses skin elasticity of the stump. C. Observe for swelling around the stump. D. Note amount color of wound drainage.

A. Evaluate closet proximal pulse.

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin Aspart q6h are prescribed. What action should the nurse include in this client‟s plan of care? A. Fingerstick glucose assessment q6h with meals B. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose C. Review with the client proper foot care and prevention of injury D. Do not contaminate the insulin aspart so that it is available for iv use E. Coordinate carbohydrate controlled meals at consistent times and intervals F. Teach subcutaneous injection technique, site rotation and insulin management

A. Fingerstick glucose assessment q6h with meals C. Review with the client proper foot care and prevention of injury E. Coordinate carbohydrate controlled meals at consistent times and intervals F. Teach subcutaneous injection technique, site rotation and insulin management

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant‟s plan of care? A. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90% B. Administer diuretics via secondary infusion in the morning only C. Evaluate heart rate for effectiveness of cardio tonic medications D. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples E. Ensure Interrupted and frequent rest periods between procedures.

A. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens below 90% C. Evaluate heart rate for effectiveness of cardio tonic medications D. Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples E. Ensure Interrupted and frequent rest periods between procedures.

The nurse is auscultating a client‟s lung sounds. Which description should the nurse use to document this sound? A. High pitched or fine crackles. B. Rhonchi C. High pitched wheeze D. Stridor

A. High pitched or fine crackles.

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization‟s budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? A. How many departments can use this equipment? B. Will the equipment require annual repair? C. Is the cost of the equipment reasonable? D. Can the equipment be updated each year?

A. How many departments can use this equipment?

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffectiveairway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client‟s plan of care? A. Increase fluid intake to 3,000 ml/daily B. Administer O2 at 5L/mint per nasal cannula C. Maintain the client in a semi Fowler‟s position D. Provide frequent rest period.

A. Increase fluid intake to 3,000 ml/daily

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? A. Jaundice B. Nausea C. Fever D. Fatigue

A. Jaundice

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? A. Lethargy B. Decorticate posturing C. Fixed dilated pupil D. Clear drainage from the ear.

A. Lethargy

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) A. Move obstacle away from client B. Monitor physical movements C. Insert an oral padded tongue blade D. Observe for a patent airway E. Record the duration of the seizure F. Restrain extremity to avoid seizures

A. Move obstacle away from client B. Monitor physical movements D. Observe for a patent airway E. Record the duration of the seizure

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 60,000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? A. Multiple organ dysfunction syndrome (MODS) B. Disseminated intravascular coagulation (DIC) C. Chronic obstructive disease. D. Acquired immunodeficiency syndrome (AIDS)

A. Multiple organ dysfunction syndrome (MODS)

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) A. Pasta, noodles, rice. B. Egg, tofu, ground meat. C. Mashed, potatoes, pudding, milk. D. Brussel sprouts, blackberries, seeds. E. Corn bran, whole wheat bread, whole grains.

A. Pasta, noodles, rice. B. Egg, tofu, ground meat. C. Mashed, potatoes, pudding, milk.

The nurse is caring for a one-week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? A. Poor feeding and vomiting B. Leakage of CSF from the incisional site C. Hyperactive bowel sound D. Abdominal distention E. WBC count of 10000/mm3

A. Poor feeding and vomiting B. Leakage of CSF from the incisional site D. Abdominal distention

Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply. A. Prepare medication reversal agent B. Check oxygen saturation level C. Apply oxygen via nasal cannula D. Initiate bag- valve mask ventilation. E. Begin cardiopulmonary resuscitation

A. Prepare medication reversal agent B. Check oxygen saturation level C. Apply oxygen via nasal cannula

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Prepare the skin for procedure. B. Identify client's pulse points C. Witness consent for procedure D. Check telemetry monitoring

A. Prepare the skin for procedure.

A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse? A. Provide an opportunity for him to clarify his values related to the decision B. Encourage him to share memories about his life with his wife and family C. Advise him to seek several opinions before making decision D. Offer to contact the hospital chaplain or social worker to offer support.

A. Provide an opportunity for him to clarify his values related to the decision

A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client‟s a plan of care? A. Provide daily care of tong insertion sites using saline and antibiotic ointment B. Modify the client‟s diet to prevent constipation C. Encourage active range of motion q2 to 4 hours. D. Instruct the client to report any symptoms of upper extremity paresthesia

A. Provide daily care of tong insertion sites using saline and antibiotic ointment

While assessing a client‟s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client‟s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? A. Provide supplemental oxygen B. Auscultate bilateral lung fields C. Administer a nebulizer treatment D. Reinforce occlusive CT dressing E. Give PRN dose of pain medication

A. Provide supplemental oxygen B. Auscultate bilateral lung fields D. Reinforce occlusive CT dressing

A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? A. Provide the man and his mother with a copy of the Patient‟s Bill of Rights B. Explain that the hospital adheres to all national accreditation standards C. Advise the man to discuss his concerns with his mother‟s healthcare provider D. Determine if he would like to review the hospital‟s manual of approved polices.

A. Provide the man and his mother with a copy of the Patient‟s Bill of Rights

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? A. Raise the client‟s legs and feet B. Administer 250 ml saline bolus C. Decrease blood flow from dialyzer D. Stop the hemodialysis procedure

A. Raise the client‟s legs and feet

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? A. Recommend weigh bearing physical activity B. Reduce intake of foods high in vitamin D C. Decrease intake of foods high in fat D. Minimize heavy lifting and bending.

A. Recommend weigh bearing physical activity

To evaluate the effectiveness of male client‟s new prescription for ezetimibe, which action should the clinic nurse implement? A. Remind the client to keep his appointments to have his cholesterol level checked. B. Teach the client to weigh himself weekly and keep a log of the measurements C. Assess the elasticity of the client‟s skin at the next scheduled clinic appointment D. Encourage the client to keep a diary of his food intake until his next visit to the clinic.

A. Remind the client to keep his appointments to have his cholesterol level checked.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client‟s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: A. Remove sequential compression devices. B. Apply PRN oxygen per nasal cannula. C. Administer a PRN dose of an antipyretic. D. Reinforce the surgical wound dressing.

A. Remove sequential compression devices.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? A. Remove the heating pads and place a soft blanket over the client‟s leg and feet. B. Advise the UAP to observe the client‟s skin while the heating pads are in place. C. Elevate the client‟s feet on a pillow and monitor the client‟s pedal pulses frequently. D. Instruct the UAP to reposition the heating pads to the sides of the legs and feet

A. Remove the heating pads and place a soft blanket over the client‟s leg and feet.

The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? A. Reposition the infant every 2 hours. B. Perform diaper changes under the light. C. Feed the infant every 4 hours. D. Cover with a receiving blanket.

A. Reposition the infant every 2 hours.

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? A. Research indicates that mirror therapy is effective in reducing phantom limb pain B. You can try mirror therapy, but do not expect to complete elimination of the pain C. Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective D. Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

A. Research indicates that mirror therapy is effective in reducing phantom limb pain

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first? A. Respiratory apnea of 30 seconds B. Oxygen saturation rate of 88% C. Eight premature ventricular beats every minute D. Disconnected monitor signal for the last 6 minutes.

A. Respiratory apnea of 30 seconds

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A. Send stool sample to the lab for a guaiac test B. Observe stool for a day-colored appearance. C. Obtain specimen for culture and sensitivity analysis D. Asses for fatty yellow streaks in the client‟s stool.

A. Send stool sample to the lab for a guaiac test

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? A. Supplemental feedings with formula B. Maternal diet high in protein C. Maternal intake of increased oral fluid D. Breastfeeding every 2 or 3 hours

A. Supplemental feedings with formula

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client‟s discharge teaching plan? A. Weigh every morning B. Eat a high protein diet C. Perform range of motion exercises D. Limit fluid intake to 1,500 ml daily

A. Weigh every morning

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? A. Withhold food and fluid intake. B. Initiate IV fluid replacement. C. Administer antiemetic as needed. D. Evaluate intake and output ratio

A. Withhold food and fluid intake.

The healthcare provider prescribes the antibiotic Cephradine (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? A. Yogurt and/or buttermilk. B. Avocados and cheese C. Green leafy vegetables D. Fresh fruits

A. Yogurt and/or buttermilk.