shelbys HESI Exit Exam

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?

Picking up the second glove

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

Place the side rails in an up position

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

-White blood cell (WBC) count -Sputum culture and sensitivity

The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth.

0.4 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml

A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?

1. Discuss the importance of continuing the usual at-home activities Rationale: Week-end pass are schedules to help the client ease back into the family's routine, so the client can back to normal activities.

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour Rationale:20000/500=40x25=1000

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

1000, 1600, 2200, 0400

A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only)

18 Rationale: 500 mL x 900 units = 450,000/25000 = 18 mL/hour

The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2500

A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only)

3 ml/hour Rationale : 0.01 x 500 x 60 / 100 = 3

Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

A business and professional women's group Rationale: The population at highest risk is A so this is the group that would benefit the most for a screening program of hypothyroidism and occurs between 35 and 60 years of age and is most common in females.

The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

A client with congestive heart failure who reports a 3 pound weight gain in the last two days

The nurse suspect a patient may be hemorrhaging internally. Which findings of an orthostatic test may indicate signs to the nurse of a major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply).

A full pitcher of water is on the bedside table The client is lying in a supine position in bed

The nurse who working in the ED is obtaining evidence for a rape kit from a woman who reports that she was raped. Which intervention is most important for the nurse to implement?

A) Do not allow client to shower until all evidence is obtained. Rationale: It is most important to gather evidence and a shower distorts such evidence. The client should not be allowed to shower until all the evidence is collected.

The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention...

A. Determine the availability of two units of packed cells in the blood bank for client B

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage

A. Natural whole almonds E. Plain, air-popped popcorn

During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?

Prepare for the endotracheal tube to be repositioned

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)?

Prepare the skin for procedure.

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.)

A.) Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B.) T3 and T4 hormone levels are increased C.) Large protruding eyeballs are a sign of hyperthyroid function

The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis.

A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes including hyperosmolar formula.

To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take?

Adhere consistently to standards of care.

A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?

Administer Naxolone IV Rationale: naloxone, the antidote for morphine, is indicated for respiratory depression below 10 breath/minute A is indicative for oxygen saturation is low. B is not indicated at this time. Another dose of morphine within the prescribed time interval © can cause a further decline in the respiratory rate, which could be life-threatening.

A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement?

Administer PRN dose of albuterol

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take?

Advise the UAP to resume positioning the client on schedule

While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?

Promptly remove the arterial catheter from the radial artery. Rationale: The client is manifesting evidence of sensory dysfunction and ischemia distal to the arterial catheter insertion site, so the arterial catheter should promptly be removed to minimize tissue necrosis.

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medication administration

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

An 11-year-old with a headache, nausea, and projectile vomiting

Which client is at the greatest risk for developing delirium?

An adult client who cannot sleep due to constant pain. Rationale: Client who are in constant pain ad have difficulty sleeping or resting are at high risk for delirium. Supplemental oxygen may cause confusion. B is taking medication so is not at high risk of delirium.

After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?

An older man whose sheets are damped each time he is turned. Rational: a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture places the client at a high risk for skin breakdown, and interventions should be implemented to pull moisture away from the client's skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture.

A 16-year-old adolescent with meningococcal meningitis (83) is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 83 Rationale: 1000 ml-----12hr. 1000/12 = 83.33

The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)

Answer: 12,160 Rationale: 4ml x 76kg x 40 (bsa) =12,160 ml

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

Appearance of wound

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take

Ask the client what he is thinking about at his time.

A male client with rheumatoid arthritis is schedule for a procedure in the morning. The... unable to complete the procedure because of early morning stiffness. Which intervention... implement?

Assign a UAP to assist the client with a warm shower early in the morning

While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement?

Attempt to distract the client with general conversation

Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Aural migraine headaches

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider?

Avoid administration of oxygen at high levels for extended periods.

Which class of drugs is the only source of a cure for septic shock?

B. Antiinfectives. Rationale: Anti-infective agents (B), such as antibiotics, are the only drugs that eliminate bacteria. The only way to halt the destruction to organ systems in septic shock is to eliminate the production of endotoxins by bacterial invaders. (A) is contraindicated due to the low cardiac output which results in low blood pressure and occurs in late septic shock. While (C) may reduce some of the destructive effects of massed cell release occurring with the inflammatory response that may occur, endotoxin release would not be stopped. (D) has no therapeutic effect relevant to septic shock.

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother?

B. Withhold this dose. Rationale: This dose should be withheld (B) because the amount absorbed by the infant is unknown. (A and C) pose safety concerns due to the unknown absorption. (D) is not recommended because all of the mixture (food and medicine) may not be eaten.

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Bagel with jelly and skim milk Rationale: D includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium and reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber.

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents Rationale: Cross-sensitivity with cephalosporin can occur in those who are allergic to penicillin, so the nurse should provide this warning.

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?

Begin to show signs of improvement in affect

After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

Bilateral Wheezing.

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

Bone marrow transplantation

An adolescent, whose mother recently died, comes to the school nurse complaining of a headache. Which statement made by the students should warrant further explanation by the nurse?

C. "I miss Mom and would like to go see her'".

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next?

C. Assess client's knowledge of an allergy response

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

C. Fresh horseradish. Rationale: A cardiac diet restrict sodium intake. Horseradish (C) should be recommended because it is low in sodium. (A, B, and D) are high in salt content and should not be offered.

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply)

C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports...which action should the nurse implement to reduce the client's risk for falls? Select all that apply. (SATA)

C.) Schedule frequent rest periods D.) Provide assistance to bedside commode E.) Teach to patch one eye when ambulating

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

Check for a distended bladder

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

Cleanse the foot with soap and water and apply an antibiotic ointment Rationale: The nurse should cleanse the wound first and implement B next.

The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Clear fluid leaking from the nose Rationale: Clear fluid from nose or ear may be cerebrospinal fluid related to a basilar skull fracture and require immediate intervention.

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

Cold sensitivity

A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

Collect a clean-catch specimen

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Complain of headaches and stiff neck

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?

Completely stop cigarette/ cigar smoking Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.

The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is _____. Which action should the nurse take to ensure adequate filling of the drip chamber?

Compress the drip chamber

While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Contact the medical records department supervisor Rationale: Notify the department supervisor of a Privacy officer alerts the appropriate people to a possible internal procedural problem and provides an opportunity of education a prevention of recurrence.

A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the client's blood pressure hourly Rationale: The laboratory results, urinary output, FHR, and vital signs are within expected ranges for a client who is receiving magnesium sulfate for preeclampsia. The client remains hypertensive, son continued hourly monitoring A is indicated Client magnesium center therapeutic range (5 to 7 mEq/L)

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent Rationale: The second stage of labor occurs when the client is fully dilated, and the fetus is crowning, so completing preparations and informing the client that birth is imminent, so A is the first action. B is usually administered immediately prior to delivery. C is usually performed prior of after delivery D is not the priority action at this time.

A client is complaining of intermittent, left, lower abdominal pain that began two days ago...in what order would the nurse implement the following interventions?

Correct order: (DPIA) 1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants

Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom) Correct order: PADD 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

Correct order: (PADD)

A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness but can bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Crutches with 4-point gait. Rationale: Crutches using a 4-point gait provide stability and require weight bearing on both legs, which this client should be able to provide. A is used when is partial or complete leg paralysis or some hemiplegia. B requires at least partial weight bearing on each foot but does not provide the stability of D. C is useful when the client must bear all the weight on one foot and this is not the problem experienced by this client.

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond?

D. "We need to stay focused on the topic." Rationale: (D) is the best response since the nurse should keep the students focused and avoid entering into an argument with them. (A) is defensive; there is no need for the nurse to defend her/his position. (B) is irrelevant; it does not matter how old the student thinks the nurse is. (C) is sarcastic; the nurse should avoid this kind of exchange and remain professional.

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

D.) Use a water soluble lubricant on affected oral and nasal mucosa

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?

Decreases the amount of HCL secretion by the parietal cells in the stomach Rationale: B correctly describe the action of histamine 2 receptor antagonist in helping to prevent peptic ulcer disease.

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?

Delirium Rationale: The client's clinical findings-polypharmia, urinary tract infection, and possible fluid imbalance are the most common causes of cognition and memory impairment, which is characteristic of delirium.

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?

Deltoid

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet?

Demonstrates willingness to adhere to the diet consistently

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider Rationale: A single dose of tasteless, colorless radioactive iodine is administered by mouth and the client is observed for signs of thyroid storm. 85% of clients are cure by one dose. The dose of radioactivity is not enough to warrant (A). B is indicated for a client receiving iodine or iodine compound medications in the treatment of hyperthyroidism. It takes 3 to 4 weeks for sings of hyperthyroidism to subside.

A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client's vital sign. Rationale: The First priority must be to obtain baseline vital signs. A and B should also be accomplished soon, but not until the initial vital signs are determined. C is a nice thing to do.

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin. Rationale: This infant is demonstrating early signs of heart failure due to an increase right ventricular workload caused by a left to right shunt through the VSD, son an inotropic, such as digoxin should be administered first to improve the efficiency of myocardial contractility. Next a high ceiling diuretic to reduce fluid volume and workload of the heart. If hypokalemia occurs as result of potassium-wasting diuretic, should be given to reduce the risk of digoxin toxicity.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Distal pulse intensity

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement?

Elevate the head of the bed 60 to 90 degrees

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Encourage the client to eat finger foods Rationale: Eyes-hand coordination is often affected with dementia. Providing a way to eat without using utensils is likely to help the client maintain independence while obtaining adequate nutrition. A: increase frustration.

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Encourage use of analgesics before position change

After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elev ated blood pressure. Which intervention should the nurse implement first?

Ensure client takes a diuretic q AM

In assessing a client twelve hours 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?

Ensure that no dependent loops are present in the tubing. Rationale: The nurse should ensure that the tubing is not kinked, and adequate flow is maintained to prevent bladder distention. Clear pale pink urine is desirable following TURP and indicates the absence of clots or excessive hemorrhage. A is implemented if the flow is dark red to prevent clot formation, and B if clots is present, to prevent obstruction. C is not a useful action in this situation and causes bladder distention while the bladder irrigation is still infusing

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?

Ensure that the knot can be quickly released.

Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

Eosinophils Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms

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?

Epinephrine Injection, USP IV Rationale: Epinephrine should be administered immediately to open the airway and raise the blood pressure by vasoconstricting the blood vessels. All other medications should be administered after the epinephrine is given.

A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

Evaluate daily blood clotting factors.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

Evaluate the oxygen saturation

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?

Fall prevention measures Rationale: Client instruction should include measures to prevent falls, because elderly clients with decrease bone density are at high risk for bone fractures and impaired bone healing in fracture should occur.

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?

Give a dose of regular insulin per sliding scale Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingerstick glucose level and self-administer a dose of regular insulin per sliding scale.

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias

When implementing a disaster intervention plan, which intervention should the nurse implement first?

Identify a command center where activities are coordinated

An older male client with a 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?

Identify pills in the bag

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?

Identify the source and amount of bleeding.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Ineffective coping related to denial

The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?

Inflammation of the mucous membrane & bronchospasm

At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider Rationale: Surgical preoperative instruction includes NPO after midnight the day of surgery to decrease the risk of aspiration should vomiting occur during anesthesia. While it is possible the C-section will be done on schedule or rescheduled for later in the day, the anesthesia provider should be notified first.

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? pH 7.50; PaCo2 42; HCO3 33; pO2 92

Infuse 0.9 % sodium chloride 500 ml bolus

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

Initiate seizure precaution Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?

Initiate the dosage lockout mechanism on the PCA pump Rationale: Morphine depress respiration, so ensuring that the client cannot overdose on the medications

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

Institute coughing and deep breathing protocols

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? (SATA)

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

Instruct the nurse to use a transparent dressing over the site

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

Last menstrual period was 7 weeks ago Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options are not the most important concerns.

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care?

Monitor for secondary infections.

A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?

Negative pressure environment

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

Neurologically stable without indications of an increased IC

An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take?

Notify the healthcare provider of the client's refusal

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Observe aspiration site.

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Observe the antecubital fossa for inflammation.

A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first.

Observe the perineum

Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

One with the clamp

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

Outline the area with ink and check it every 15 minutes to see if the area has increased

The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Participation of community leaders in planning the program

A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Pulse increase of 10 beats/minute Rationale: Blood volume increases 25 to 40 % in pregnancy which increases cardiac output and increases heart rate by approx. 10 to 20 beats/ mints. Proteinuria is for preeclampsia, Glucosuria is for gestational diabetes. A fundal height for 28 weeks should be at 28 cm not 22

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 per minute, and blood pressure 90/60. Which intervention should the nurse implement first?

Raise the client's legs and feet Rationale: To raise the client's blood pressure is the most immediate and easiest intervention for the nurse to implement. B and C should be done asap to add volume to the vascular space by ceasing to pull fluid from the client. If the blood pressure does not increase, then the procedure may be needing to be stopped. (D)

The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin?

Reddened skin areas disappear within 15 minutes of being turned and positioned.

Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Reduce risks factors for infection Rationale: Interventions aimed at reducing the risk factors of infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection of infections are necessary.

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?

Send stool sample to the lab for a guaiac test Rationale: Thrombolytic drugs increase the tendency for bleeding. So, guaiac (occult blood test) test of the stool should be evaluated to detect bleeding in the intestinal tract.

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child

Sitting up and leaning forward

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?

Take on an empty stomach with a full glass of water

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?

Talk directly to the adolescent while providing care

A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response

Temporary vasodilation Rationale: Uhthoff's sign results from temporary vasodilation

When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?

The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable

A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Toasted wheat bread and jelly Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs the client to eat a snack such as toast, which contains no dairy products and may decrease GI symptoms.

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?

Vomiting

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

Weak palpable distal pulses

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it is painless. What action should the nurse take?

a. Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

a. An older client post-stroke who is aphasic with right-sided hemiplegia

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome?

a. Avoid exposure to respiratory infection

The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication?

a. Irregular pulse

When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next?

a. Notify the healthcare provider

To obtain an estimate of a client's systolic B/P. What action should the nurse take first?

a. Palpate the client's brachial pulse

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. Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.

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 d. Reinforce occlusive CT dressing Rationale: The air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.

The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding?

a. Pupils reactive to accommodation

The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?

a. Remind the client to hold his breath after inhaling the medication

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply:

a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate.

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 should be instructed to weight each morning before breakfast with approximately the same clothing. A is not specifically to HF and fluid retention.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

anxiety Rationale: The client is demonstrating only anxiety. There is no indication that the client is presenting signs of A, C or D

Which nursing intervention has the highest priority for a multigravida who delivered?

b. Assess fundal tone and lochia flow Rationale D is the priority intervention because is a multigravida and this pregnancy predisposes the client to uterine atony which could result in hemorrhage.

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media?

b. Hemophilic Influenza Type B (HiB) vaccine

A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

b. Hyperextended with neck supported by a rolled towel.

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?

c. Auscultated bilateral breath sounds Rationale: Restlessness often results from decreased oxygenation, so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.

The nurse note a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

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

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

d. Muscle spasms of the back and neck

A client who is scheduled for an elective inguinal hernia repair today in day surgery is seen eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?

d. Withhold the preoperative medication

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

infection

The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

medication port

A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect

Decrease in pulse rate Rationale: Beta blockers such as propranolol help control the symptoms of hyperthyroidism, such as palpitations or tachycardia, but do not alter thyroid hormone levels, B is not a desired effect in hyperthyroidism. Beta blocker do not impact the presence of a goiter.

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 as a result of this increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population.

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

Does your pain occur when walking short distances?

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Evaluate both client's pain using a standardized pain scale Rationale: Before administering pain medication, each client' s level of pain should be evaluated using a standardizing scale to determine what type and how much pain medication the clients need.

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?

Maintain both lower extremities elevated on pillows Rationale: Hepatocellular failure and hypertension contribute to third spacing of fluids. The clients complain best addresses by maintaining both extremities in an elevated position on pillows, which uses gravity to facilitate venous return and decrease peripheral edema. Stockings should be reapplied evenly to relieve constriction, but no removed.

Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?

Place the client on fall precautions Rationale: Osteoporosis causes bone to become brittle, fragile and less dense with age, which increases an older client's risk for falls and fractures which increases their risk for another pathology.

Who ever threw that paper......

Your moms a hoe

While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?

a. Ask the client when a family member last visited her.

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

a. Contact the regional organ procurement agency

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

a. Hold the thermometer in place

In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?

a. avoid smoking in the house

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?

a. creatinine clearance 25 mL/ minute

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

b. Achieve satisfactory pain control.

Which intervention should the nurse include in the plan of care for a client with leukocytosis?

b. Monitor temperature regularly

The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client...

b. Report fresh blood in the urine

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication?

c. Push the undiluted Dextrose slowly through the currently infusion IV Rationale: To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose infusing IV.

The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

d. Cloudy dialysate output and rebound abdominal pain

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?

headache, photophobia, and nuchal rigidity Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Administer the medication as prescribed with a glass of water Rationale: Simvastatin (Zocor), a HMG co-enzyme A reductase inhibitor, interferes with cholesterol synthesis pathway. Zocor can be taken at any time.

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse?

Antacids will neutralize the acid in your stomach

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist?

Auscultate bilateral breath sounds

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Determine if the sensation feels uncomfortable. Rational: electronic stimulators, such as a transelectrical nerve stimulator (TENS) unit, have been found to be effective in reducing low back pain by "closing the gate" to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching. Decreasing the electrical signal may be indicated if the sensation is too strong. Other options are not necessary because the tingling sensation is expected.

A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain?

History of alcohol use,

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

What action should the school nurse implement to provide secondary prevention to a school-age children?

Initiate a hearing and vision screening program for first-grader

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?

Play a board game with the client and begin taking about stressor

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor. Rationale: D indicate dehydration, a serious complication following prolonged diarrhea that requires further interventions by the nurse.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

The nurse is conducting the initial assessment of an ill client who is from another culture.... What response should the nurse provide?

b. What practices do you believe will help you heal?"

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?

c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping Rationale: The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalance. Diarrhea is a common occurrence for Crohn's disease. Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening. Treatment of pain is most important but has been only 30 mints since the client was medicated and this issue can be assessed in 10 mints or delegated to another nurse.

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?

c. Delegate care of the crying client to an unlicensed assistant

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 Calculate the client's weigh in kg: 220 pounds divides by 2.2 pounds/kg ꞊100 kg Calculate the client's dose, 80 units x 100 kg ꞊ 8,000 units Use the formula, D / H X Q ꞊ 8,000 units / 1,000 units x 1ml ꞊ 8

Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?

Assist the client in developing a goal of managing the pain Rationale: Neuropathic pain is chronic pain and the nurse should first help the client understand the need to learn to manage the pain.

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi-Fowler position with his arms at his sides. What action should the nurse implement?

Raise the head of the bed to a Fowler's position and support his arms with a pillow Rationale: The Ascites is the accumulation of fluid in the peritoneal or abdominal cavity, and this fluid pushes on the diaphragm, limiting the client's lung expansion and causing dyspnea. To relieve pressure, the head of the bed should be elevated with the arms supported for comfort.

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?

"I have a headache that gets worse when I sit up" Rationale: A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bedrest, analgesic, and hydration.

A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond?

"The heart will stop beating & you will stop breathing."

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.

0.33 mL Rationale: 4mg x 0.5 ml=2/6=0.33 ml

An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4 Rationale: Calculate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last) Correct Order:

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

The nurse is collecting a sterile urine specimen using a straight catheter tray for culture.... (Arrange from first action to last). Correct Order: (DODU)

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

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. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia.

1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia Rationale: The American Heart Association guidelines recommend that the basic life support (BLS) algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate below 60 beats/minutes*** and exhibit signs of poor perfusion. This child is manifesting poor perfusion as evidenced by a low blood pressure and poor oxygenation, so chest compression and assisted manual ventilation should be provided first, followed by administration of drug therapy for persistent bradycardia. Preparation with pad placement for transthoracic pacing should be implemented next, followed by treatment indicated for the underlying cause of the child's bradycardia.

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9 Rationale: 38/20x1=1.9 m

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)? 36 (1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18, back = 18, head = 9, pubic = 1 = 100%)

36% Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equal 36% TBSA, other options are incorrect.

During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

4-5th intercostal space midclavicular

The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

7 Rationale: Convert the client's weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

A 30 year old depressed client who admits to suicide ideation RATIONALE: A client who is suicidal requires psychological assessment, therapeutic communication and knowledge beyond the educational level of a practical nurse (RN). Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse.

A nurse working on an endocrine unit should see which client first?

A client taking corticosteroids who has become disoriented in the last two hours. Rational: meeting the client's need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first.

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 young male with schizophrenia who said voices is telling him to kill his psychiatric. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.)

A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy

A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply)

A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC).

The nurse caring for a 3-month-old boy one day after a pylorostomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Administer a prescribed analgesia for pain Rationale: Since this child is exhibiting signs of pain, the prescribed analgesic should be administered. The behavioral signs of pain in an infant are facial grimaces, restlessness or agitation, and guarding the area of pain, in this case by pulling the knees to the chest

A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. Rationale: Administer morphine sulfate can increase oxygen supply are the priority intervention for symptoms of acute MI and should be supplemented with nitroglycerin and aspirin administration. A may result in overload that the impaired myocardium cannot handdle effectively. C and D are helpful but after. B

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?

Administer the Zofran after flushing the saline lock with saline Rationale: Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepter technique for IV administration via saline lock. Zofran is not a chemotherapy drug and does not need to be administered by a chemotherapy- certified nurse.

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?

Administer the medication via the oral route as prescribe Rationale: Bioavailability refers to the percentage of drug available in the systemic circulation. An increase in dosage is necessary to provide a therapeutic effect for oral medications with significantly reduce bioavailability.

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?

Allopurinol (Zyloprim) Rationale: The effectiveness of allopurinol is diminished when aluminum hydroxide is used leading to an increased chance for gout flare ups. The healthcare provider should be alerted about the allopurinol interaction so any changes in medication regimen may be considered.

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

The charge nurse of critical care unit informed at beginning of shift that less than optimal number registered nurses be working that shift. In planning assignments, which client should receive most care hours by a registered nurse a. A 34 yo admitted today after emergency appendendectomy who has peripheral intravenous catheter, Foley catheter. b. A 48 yo marathon runner w/a central venous catheter experiencing nausea, vomiting due to electrolyte disturbance following a race. c. A 63 yo chain smoker w/ chronic bronchitis receiving O2 nasal cannula and a saline-locked peripheral intravenous catheter. d. An 82 yo client with Alzheimer's disease newly-fractures femur w/Foley catheter and soft wrist restrains applied

An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied Rationale: (D) describe the client at the most risk for injury and complications because of the factor listed. (A) has complete the recovery period form anesthesia but requires critical care because of the invasive lines and new abdominal incision. (B) is likely to be in excellent physical condition and has one invasive line needed for rehydration. (C) is essentially stable, despite having a chronic condition.

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?

An immobile client receiving low molecular weight heparin q12 h. Rationale: A describe the most stable client. The other ones are at high risk for bleeding problems and require the assessment skills.

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?

Antibiotics Rationale: Antibiotic use may be altering the normal flora in the GI tract, resulting in the onset of diarrhea, and several classes of antibiotics result in the overgrowth of Clostridium difficile, resulting in severe diarrhea.

The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse?

Anuria for the last 12 hours. Rationale: Anuria is nonpassage of urine, in practice is defined as passage of less than 100 milliliters of urine in a day. Anuria is often caused by failure in the function of kidneys. It may also occur because of some severe obstruction like kidney stones or tumours. It may occur with end stage kidney disease.

A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse?

Anxiety and restlessness.

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?

Anxiety related to fear of suffocation. Rationale: A common problem with clients who have COPD is anxiety. These clients cannot aerate their bodies, so they feel a perpetual state of suffocation which is worse during exacerbation of their COPD. A classic descriptor of COPD id impaired gas exchange (A). Because the client has typically adapted to impaired gas exchange over a long period of time, and the nurse has assessed a change in her appearance (A) is not the primary diagnosis at this time. Based on the data presented (B and D) are not the best diagnoses in this situation.

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?

Apply light pressure over the area. Rationale: To assess for blanching the nurse should apply pressure to the area of hyperemia with one finger and when the finger is removed evaluate for return of erythema (blanching hyperemia)

A male client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement?

Ask the client about his expected goals for the hospitalization Rationale: Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client's goals for symptom control while receiving treatment in the hospital. Although home care is available the client may not be legible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and would be appropriate unless the radiation conflicts with the client goals.

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

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?

Ask the new person to move belonging to accommodate others

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take

Ask the older brother how he felt during the incident Rationale: The brother's change in demeanor may indicate that he is experiencing post-traumatic stress that warrants further investigation, so the nurse should address the older brother's feeling.

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation Rationale: Infiltration of a vesicant can cause severe tissue damage and necrosis, so the IV site should be assessed regularly for extravasation (B) of the chemotherapeutic agent. The client should be instructed to report any discomfort at the site (A). If pain and burning occur, the IV should be stopped and C is not indicated. Peripheral pulses, not D, provide the best assessment of perfusion distal to the infusion should the drug extravasate or infiltrate.

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 ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?

Assess compliance with routine prescriptions. Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)

An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first

Assess the surroundings for noise and distractions.

An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

While receiving a male postoperative client's staples the nurse observes 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?

Attempt to distract the client with general conversation Rational: Distract is an effective strategy hen a client experience anxiety during an uncomfortable procedure. (A & D) increase the client's anxiety.

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?

Auscultate bowel sounds in all four quadrants

The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching?

Avoid all isometric exercises, but walk regularly Rationale: Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Avoid exposure to large crowds

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Avoid straining at stool, bending, or lifting heavy objects Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement?

B. Infuse a rapid IV normal saline bolus. Rationale: When chest pain is treated with a vasodilator, such as nitroglycerin, and the blood pressure falls to a critical level, a right ventricular infarction may have occurred which requires immediate infusion of IV fluid (B). (A and D) may worsen the condition if implemented prior to rapid infusion of fluids. Chest compressions (C) are not indicated when the client has a pulse.

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Blood pressure 90/76 mm Hg

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?

Brain damage with CP is not progressive but does have a variable course Rationale: CP is nonprogressive cerebral insult due to asphyxia, brain malformation, or toxicity, such as kernicterus. It is characterized by impair movement, posturing and may include perceptual, expressive and intellectual deficits, but the motor disabilities can vary as the child grows (A) and as interventions are implemented to prevent disuse complications.

The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take?

Call the healthcare provider who wrote the prescription

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement?

Clarify end of life desires

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)

Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut

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?

Confirm the desired effect of the medication has been achieved. Rationale: Trazodone oR Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.

The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Confirm the necessity for continued use of the CVC Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the review of the need for continued use of the CVC. Effective hand hygiene and standard precautions should be maintained but protective environment precautions are not needed. B is not needed if continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the site to be visualized for any signs of infection but changing the dressing daily increases the risk for infection.

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

Contact the healthcare provider immediately to report the laboratory value regardless of the advice

Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the progress of labor Rationale: Early deceleration are indicative of head compression as the fetus descends in the birth canal, which is a normal patter during active labor, so labor progression should continue to be monitored

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) 1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

Correct : ODCP 1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus Rationale: First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients' meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle.

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?

Creatinine 4 mg/dl (354 micromol/L SI

A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse?

Cyanotic nailbeds

An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up .

Describes life without purpose Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that is known to increase the risk of suicidal thinking in adolescents and young adults with major depressive disorder. B, C and D are side effects

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Destruction of joint cartilage.

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Determine client's pulse, blood pressure, and respirations Rationale: Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum level. Before administering a central nervous system depressing analgesia, the client's vital signs should be assessed to determine the client's current level of CNS depression. In the immediate postoperative period, during administration to PACU (A, C and D) should be evaluated.

A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Determine if she can ask for support from family, friend, or the baby's father Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety about transitioning to parenthood. The nurse should ask the client who is available to support her.

The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first?

Determine if the clamp on the IV tubing is released Rational: When the pump immediately beeps, it is often because the IV tubing clamp is occluding the flow, so the clamp should be checked first to ensure that it is open. If the alarm is not eliminated after the tubing clamp is released, flushing the IV site with saline is a common practice to clean the needle or to identify resistance due to another source. Local signs of infiltration may indicate the need to select another vein, but the pump's beeping-this early in the procedure is likely due to a mechanical problem. If beeping continues after verifying that the clamp is released the placement or threading of the tubing through the pump should be verified.

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?

Determine the mother's basic skill level in providing care Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother's skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions.

A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure. Rational: once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested

The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication

Determine which side of the body is weak.

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide?

Dialysis would need to be resumed if chronic rejection becomes a reality

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung.

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

Direct the UAP to measure the emesis while the nurse irrigates the NGT

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Discontinue the painful IV after a new IV is inserted

During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?

Discuss the concerns expressed by the client about the vaccination Rationale: the nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form.

The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?

Discussed effective use of the stockings with the client on UA Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity

Distal pulse intensity Rationale: Distal pulse intensity assesses the blood flow through the extremity and is the most important assessment because it provides information about adequate circulation to the extremity. Range of motions evaluates the possibility of long term contractures sensation. C evaluates neurological involvement, and exudate. D provides information about wound infection, but this assessment does not have the priority of determining perfusion to the extremity.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Divide the medication into two injection with volumes under 1ml Rationale: IM injection for children under 3 of age should not exceed 1ml. divide the dose into smaller volumes for injection in two different sites.

A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Do not get pregnant for at least 3 months Rationale: The rubella vaccine can be harmful to an unborn child who is conceived within 3 month of the vaccination.

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement

Document the assessment data Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing

To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Dress each wound separately. Rational: each wound should be dressed separately using a new pair of sterile glove to avoid auto contamination (the transfer of microorganisms' form one infected wound to a non-infected wound). The other choices do not prevent auto contamination.

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

Dry roasted almonds. Rational: alcoholism promotes inadequate food intake and gastrointestinal loss of magnesium include green leafy vegetables and nuts and seeds. Other snacks listed provide much lower amounts of magnesium per serving.

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?

During acute illness Rationale: Client should be instructed to always check their blood glucose whenever they feel sick or nauseated. There is great variability in recommendations for frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test as often as four times a day or as little as once each week, depending on the consistency of their diet and exercise.

A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. Rationale: The Coumadin dose is prescribed and adjusted based on the client's normal consumption of foods containing vitamin K (an essential clotting factor that counteracts the effects of Coumadin), so the client should eat a consistent amount of vitamin K food sources (A). (B and C) alter the effectiveness of the already set dosage of Coumadin. (D) provides a consistent amount of vitamin K but does not take into consideration how much is already being consumed by the client.

Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Eat small meal throughout the day to avoid a full stomach. Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be consumed with foods because they further distend the stomach, but fluids not be limited between meals (A) because this puts the client at risk for dehydration. (B) is not recommended during pregnancy unless prescribed by the health provider because they place the client at risk for electrolyte imbalance (sodium), constipation (aluminum, or diarrhea (magnesium) (C) is less effective than (D) preventing heartburn.

The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Elevate the presenting part off the cord Rationale: The nurse should immediately elevate the presenting part off the cord because when the cord prolapses, the presenting part applies pressure to the cord, especially during each contraction, and reduces perfusion to the fetus. A can be delayed until pressure is removed from the cord. B and D are important but do not have priority.

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low-carbohydrate and high-protein diet Rationale: A client with anorexia nervosa with long term starvation or who self-restrict intake can sign.... Reserves. Providing the client with dietary selections such as low-carbohydrate, high protein.... Hypoglycemic episodes, which can become life-threating.

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?

Encourage him to use an electric razor Rationale: This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving, should be encouraged to reduce the risk of bleeding.

An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?

Ensure proper alignment of the leg in traction. Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the application of Buck's skin traction proper alignment ensures the transaction S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize muscle spasms and surrounding tissue injury related to the fracture. A should be implement but improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but the greatest risk is improper alignment of the traction.

A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm Rationale: Sudden infant death syndrome is the unexplained death of infants under the age of one year. Parents should be educated about the methods to reduce the risk of SIDS, which include use of a firm crib mattress, maternal smoking cessation before and after pregnancy, avoidance of pillows in the crib, and placing the infant in the supine position. (Back to Sleep Campaign)

A vacuum-assistive closure (VAC) device is being use 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?

Ensure the transparent dressing has no tears that might create vacuum leak Rationale: The nurse should ensure that the VAC transparent film is intact, without tears or loose edges C) because a break in the seal resulting in drying the wound and decreasing the vacuum. The vacuum-assisted closure (VAC) device uses an open sponge in the wound bed, sealed with a transparent film dressing and tube extrudes to a suction device that exert negative pressure to remove excess wound fluid, reduce the bacterial count and stimulate granulation. The VAC is changed every other day or third day, not (A) depending on the stage of wound healing and emptied when full or weekly. The transparent wound dressing should extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight seal. Adhesive removers leave a reduce that binder transparent film adherence (D)

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?

Evaluate closet proximal pulse. Rationale: A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

Evaluate swallow Rational: Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH. Difficulty swallowing due to brainstem nerve damage should be care but determining the client's risk for aspiration is most important.

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?

Evaluate the client's mood, cognition and orientation. Rational: the mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client's psychosocial assessment.

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Examine the genitalia as the last part of the total exam. Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this assessment is best left as the last part of the examination. B are best done by a parent, not the nurse. The genitals must be completely visualized and sometimes palpates underwear for a brief period of.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Explain that counseling will be provided to give her information about her cancer risk Rational: BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A)to the client along with options for increased screening or preventative measures. (B) Is completed by the genetic counselor before the client undergoes genetic testing. a positive BRACA1test is not an indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling.

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take?

Explain that memory loss and confusion are common with vitamin B12 deficiency Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Explore client's readiness to discuss the situation Rationale: By assessing the client's level of readiness to discuss her situation the nurse can begin to stablish trust so that further action can be taken to protect her. The nurse needs the client's permission to report the abuse to the police department, which may be obtained after trust is established. B might be an option during the discussion it is most important that the client has a safe refuge even if the abusive partner does not commit seeking help.

Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?

Fat embolism

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

Fetal heart rate of 200 beats/minute

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame Rationale: Aspartame should not be consumed by a child with PKU because ut is converted to phenylalanine in the body. Additionally, milk and milk products are contraindicated for children with PKU.

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first?

Furosemide Rationale: Furosemide is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. It works by acting on the kidneys to increase the flow of urine.

A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan

Further evaluation involving surgery may be needed Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse?

Give IV dose of adenosine rapidly over 1-2 seconds.

During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond?

Give me specific examples to support your statements.

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose Rationale: Cushing syndrome, caused by excess corticosteroids causes hyperglycemia and the client's serum glucose level should be monitor for this side effect.

An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which questions best assists the nurse in obtaining relevant historical data?

Have you had any difficulty in starting your urinary stream"

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?

Hematocrit of 28% Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28% is below pregnant norms and could signify iron-deficiency anemia. Other options are normal finding pregnancy

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Hemoglobin Rational: naproxen can cause gastric bleeding, so the nurse should monitor the client's hemoglobin to assess for possible bleeding. Other options are not likely to be affected by the used of naproxen and are not related to the client's current symptoms.

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?

Hemoglobin A1C (HbA1C) reading less than 7% Rationale: Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood glucose to rise slowly after a meal. The best indicator of acarbose effectiveness is a serum hemoglobin A1 no greater than 7%, an indication of glucose level over time. Acarbose has no effect on pain or blood pressure. Self-reported glucose levels of 120-150 reflect the blood sugar at the time taken and are not the best indicator of drug effectiveness.

The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?

High pitched or fine crackles.

After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done. Rationale: After oral intubation, the client is at high risk for swallowing difficulties. A swallowing evaluation should be done to determine what consistency of liquids the client can tolerate without aspirating. A, B and D helps but does not have the priority.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?

Hydrocortisone Rationale: Hydrocortisone tablets work as a hormone replacement for a natural hormone called cortisol. You may take hydrocortisone tablets if your body does not make enough cortisol - for example if you have Addison's disease or if you've had your adrenal glands taken out.

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?

Identify pills in the bag Rationale: Comorbidity places the client at risk for multiple drug interaction and side effects, and the client's gout therapy may need to be modified. A review of the medication in the bag (D) is the most important way to analyze the client's polypharmacy. And therapeutic response for comorbidities. Obtain a medical history (A), pain evaluation (B), and assessing blood glucose level (C) should be done in a timely manner.

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily Rationale: The plan of care should include an increase in fluid intake (A) to liquefy and thin secretions for easier removal of thick pulmonary secretion which facilitates airway clearance. (B) should be implemented for signs of hypoxia (C) implemented to facilitate lung expansion, and (D) implemented for activity intolerance, but these interventions do not have the priority of (A)

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers. The woman is apparently aware that drugs can be transmitted through breast milk, so A is not helpful. C might be helpful, but the client's history suggest that nonpharmacological methods of anxiety management do not produce the best outcome. (D) the mother's history places her at risk for severe anxiety.

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

Initiate intravenous fluid as prescribed Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)

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?

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest because the use of pillows could result in suffocation and would need to be removed at the onset of the seizure. The nurse can delegate paddling the side rails to the UAP

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?

Jaundice Rationale: Macrolides can cause hepatotoxicity, which is manifested by jaundice and should be reported to the healthcare provider before further doses of the medication are administered, B is a common side effect of macrolides. Fever and Fatigue are expected finding when a client has an infection.

The client with which type of wound is most likely to need immediate intervention by the nurse?

Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut

The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Large amounts of fluid and electrolyte replacement. Rationale: This client, whose output is significantly high will need fluids and electrolyte replacement. The diuretic stage of ARF begins when the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur until the client's BUN and electrolytes indicate a significant improvement that will allow for such changes.

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

Leakage around catheter insertion site

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

Leave the catheter in place and obtain a sterile catheter.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

Leave the room and close the door quietly

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)?

Lethargy Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increase ICP is the client's level or responsiveness or consciousness. B and C are very late signs of ICP.

A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

Level of consciousness Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and mental status.

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first

Listen with the bell at the same location Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm and bell before moving systematically to the next sites.

The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?

Literacy level Rationale: Reading ability, or literacy level is the most important population characteristic in choosing strategies for implementing teaching plan. If the population cannot read it would be useless to reinforce teaching with written material.

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?

Maintain contact transmission precautions

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is given subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min Rationale: The nurse checks the maternal pulse prior to administering the beta sympathomimetic drug terbutaline and notify the healthcare provider before administration of the drug if the pulse is over 140 beats in within normal limits because peripheral vasodilation accompanies pregnancy and causes the BP decrease.

The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

Measure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death.

While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

Measure the area of swelling and crackling. Rational: a crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured, and the finding documented. Other options are not indicated for crepitus.

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?

Measure the client's oral temperature Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client's temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation currently. An indwelling catheter should be avoided if possible because it increases the risk of infection.

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Medicare Rationale: Title XVII of the social security Act of 1965 created Medicare Program to provide medical insurance for person more than 65 years or older, disable or with permeant kidney failure, WIC provides supplemental nutrition to meet the needs of pregnant of breastfeeding woman, infants and children up to age of 6. Medicaid provides financial assistance to pay for medical services for poor older adults, blind, disable and families with dependent children. COBRA(D) health benefit provisions is a limited insurance plan for those who has been laid off or become unemployed.

Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room Rationale: Tetanus is an acute, preventable, and often fatal disease caused by an exotoxin produces by the anaerobic spore forming gram positive bacillus clostridium tetani, which affect neuromuscular junction and causes painful muscular rigidity. In planning caring for a child with tetanus, any environmental stimulation should be minimized.

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension

A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?

Monitor the client's cardiac activity via telemetry. Rational: as insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias related to abnormal serum potassium levels. IV access, assessment of glucose level, and monitoring urine output are important interventions, but do not have the priority of monitoring cardiac function.

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?

Muffled heart sounds Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one is sign of end stage liver disease related to alcoholism but are not immediately life- threatening.

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 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?

Multiple organ dysfunction syndrome (MODS) Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. B is associate with Heart Failure.

One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?

Neurovascular and circulation compromise related to compartment syndrome Rationale: Inflammation from the traumatic injury produces swelling and edema inside the closed space under the skin that produces pressure, which decreases blood flow to capillaries and nerves, causing altered perfusion related to compartment syndrome

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?

No wheezing upon auscultation of the chest. Rationale: No wheezing an auscultation indicates that the client is not exchanging air and is highly compromised immediate action is indicated A, B, and C are sign of hypoxia but no as critical as D

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Notify the healthcare provider

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?

Notify the healthcare provider and obtain a tracheostomy tray Rationale: This child exhibiting signs and symptoms of epiglottitis, a bacterial infection causing acute airway obstruction, so is the immediate action to take.

A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

Observe rhythm on telemetry monitor Rationale: If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels.

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history Rationale: The client is presenting with signs of digitalis toxicity. A list of medication, which is likely to include digoxin (Lanoxin) for heart failure, can direct further assessment in validating digitalis toxicity with serum labels greater than 2 mg/ml that is contributing to client's presenting clinical picture.

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?

Obtain a prescription for an anticholinergic medication Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented.

A client who has a suspected brain tumor is scheduled for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement?

Obtain the client's food allergy history

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Obtain vital signs and breath sounds. Rational: the client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminating. Other options would not assure a safe administration of the medication.

Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider

Oliguria signals tubular necrosis related to hypoperfusion Rationale: Prolonged low blood pressure leads to renal ischemia, which is the common etiology of acute tubular necrosis(ATN) Decreasing urine output is an early indicator of ATN.

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

On left thigh with arrow pointing to inner thigh"

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?

Oxygen saturation

A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

Palpate at the radial pulse site with the pads of two or three fingers Rationale: The radial pulse is easily accessible and palpable unless an IV is placed at the client wrist. A may make the pulse more difficult to palpate B places the stethoscope over a vein rather than an artery and is unlikely to provide an accurate pulse rate. The pulse rate can be accurately counted without implementing.

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

Palpitations and shortness of breath Rationale: An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating and diarrhea.

A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?

Participated actively in all treatments regimens Rationale: indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural clash between the two forms of treatment. The client has already identify he's cultural values (A). (B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural values with the prescribed medical treatment (D).

The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Perform bilateral chest auscultation Rationale: With the ROSC and no respiratory effort intubation is indicated, and as soon as the procedure is completed, the position of the intubation tube should be assessed for proper placement. Auscultating for breath sounds is the first and quickest method to use to check for proper placement of the intubation tube and can be confirmed by a chest x ray.

In early septic shock states, what is the primary cause of hypotension?

Peripheral vasodilation Rationale: Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion.

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?

Persistent coughing while drinking Rationale: After a stroke, clients may experience dysphagia and an impaired gag reflex that is evaluated by a speech pathology team. Coughing while drinking results from impaired swallowing and gag reflex, so a referral to a speech therapist is indicated to evaluate the coordination of oral movements associated with speech and deglutination. Cranial nerves I and II are sensory nerves for taste and sight and do not require a referral to speech pathology. Unilateral facial drooping is associated with stroke but is not a focus of rehabilitation. D sre not addressed by speech therapy.

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?

Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?

Place a client's locked wheelchair on the client's strong side next to the bed. RATIONALE: Placing the wheelchair on the client's strong side offers the greatest stability for the transfer. Holding the client arm's length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position.

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

Place a mask on the client's face.

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?

Place a wedge under the client's right hip Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice.

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Place the implant in a lead container using long-handled forceps Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container.

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client needs a bilateral below-the-knee amputation and pedal pulses that are weak and thready. What action should the nurse take?

Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.

The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt. Rationale: To relieve aortocaval compression caused by the gravid uterus, left lateral uterine displacement (LUD) should be maximized using a firm wedge to support the pelvis and thorax at 30- degree tilt to optimize maternal hemodynamic during CPR. Maternal modification should include ventilation with 100% oxygen, not A. Pregnant adults should be resuscitated using a compression-ventilation ration of 30:2 not C without interruption of continuous compressions. Effective chest compression should be forceful rhythmic application of pressure (fast and hard) at 100 compressions/minutes at the depth of 2 inches (5cm) to generate myocardial and cerebral blood flow.

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?

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

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take?

Postpone the feeding until the infant's vital signs and stable

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?

Provide daily care of tong insertion sites using saline and antibiotic ointment Rationale: Crutchfield tongs, a skeletal traction device for cervical immobilization, requires daily care of the surgically inserted tongs to minimize the risk of infection of the insertion site and cranial bone. Daily cleansing with normal saline solution and antibiotic applications minimizes bacterial colonization and helps to prevent infection.

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?

Provide the man and his mother with a copy of the Patient's Bill of Rights Rationale: The Patient's Bill of Rights is a universally used tool that describes the rights of clients in all healthcare settings and is essential in ensuring that clients care is provided in an ethical manner. (B) may be perceived as defensive and does not provide the man with specific information about expected standards of care. Concern about the quality of care should be addressed by the hospital staff rather than C. All the healthcare agencies are required to maintain policy and procedure manual for the purpose of standardizing delivery of care within the agencies, but the policy manual is unlikely to provide useful information for clients or family members.

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take?

Pull up a chair and sit beside the client's bed

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness. Rationale: Epidural hematomas results from arterial bleeds that cause a rapid increase in ICP, which initially manifested by an early and rapid onset of decreased consciousness. Slowly increasing ICP is more likely to occur with a venous subdural hematoma.

A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider?

Reassess readiness for SNF transfer. Rationale: Based on the client's symptoms, reassessing the client's readiness for rehabilitation in the SNF is critical

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Recommend weigh bearing physical activity

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

Recommend weigh bearing physical activity Rationale: Active weight-bearing exercise is a primary preventive measure for osteoporosis. C is indicated for client with cardiac and liver diseases. D may decrease injuries but is not directed toward slowing bone loss and promoting bone formation.

When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond?

Recompress the wound suction device and secure to plug Rationale: The plug of a wound suction device, such as a Hemovac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated.

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?

Reduced level of pain Rationale: Pregabalin is prescribed to decrease the pain associated with diabetic peripheral neuropathy. A, C and D are not expected outcomes of this medication's effectiveness.

An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual papanicolaou (Pap) smears.

To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement? .

Remind the client to keep his appointments to have his cholesterol level checked. Rationale: Ezetimibe lowers cholesterol and LDL levels, so it is important for the nurse to remind the clients to keep his appointments at the laboratory. D may influence his serum levels, but A provide better indicator.

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?

Remove cigarettes for the client's room Rationale: Safety is the priority, and any items that might cause self-harm, such as cigarettes should be removed immediately to create a safe environment.

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:

Remove sequential compression devices. Rationale: Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted.

A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Rented movies and borrowed books to use while passing time at home

During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Reposition the client with the head of the bed elevated. Rationale: Since children is sickle cell crisis often have shallow breathing due to acute chest syndrome, raising the head of the bed (A) will facilitate chest expansion by decreasing pressure of the diaphragm (B and C) are not be commended, nor should he UAP be corrected in front of the child. D is contraindicated because bed rest is warranted to conserve energy and promote oxygenation.

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?

Reposition the infant every 2 hours. Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy.

The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?

Reposition the restraint tie onto the bedframe. Rationale: Restraints should be secured to the bedframe, which is more stable than the side rails. A is difficult to release quickly. The restrain should be removed from the side rail before the position of the side rail is changed.

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?

Research indicates that mirror therapy is effective in reducing phantom limb pain Rationale: pain relief associated with mirror therapy may be due to the activation of neurons in the hemisphere of the brain that is contralateral to the amputated limb when visual input reduces the activity of systems that perceive protopathic pain.

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Respiratory apnea of 30 seconds Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed first.

Following an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?

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

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?

Review the client's serum calcium level Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.

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?

Review the client's use of over the counter (OTC) medications Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.

When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Schedule an appointment for an out-patient psychosocial assessment. Rationale: Emotional stress can precipitate another adrenal crisis and should be monitored with periodic psychosocial assessments. A may be indicated but does not address the problem after discharge. A blood cortisol level is to diagnosis not to monitor the ongoing disease process. Canceling the discharge only delays the resolution of the problem.

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 member. Which action should the nurse take?

Send family to the waiting area while the client's history is taking Rationale: To protect the client privacy, the family member should be asked to wait outside while the client's history is take. Gloves should be worn when touching the client's body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.

A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

Serum calcium Rationale: Numbness and tingling of the fingers and around the mouth, along with muscle cramps are signs of hypocalcemia

A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Serum potassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L). Rationale: The normal potassium level in the blood is 3.5-5.0 mill Equivalents per liter (mEq/L).

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?

Shock Rationale: This client has symptoms of shock. Two signs of shock are decreased BP, and increased (often weak and thread) pulse, this client has both symptoms. A temperature of 98.6 F is average normal. An increase of temperature. D is correct but is vague and is not specifically related to the assessment date describe, so it is not the best answer.

A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority?

Signs a no-self-harm contract.

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?

Sitting upright. Rationale: The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.

A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Skills of staff and client acuity

An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats/minute. What action should the nurse take?

Slow the feeding and monitor the infant's response.

An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Start an intravenous (IV) infusion of normal saline Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance.

A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Stop the normal saline infusion. Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge needle is preferable.

A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?

Stroke

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Stroke secondary to hemorrhage Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension.

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?

Submit a referral for an evaluation by a physical therapist. Rationale: To promote independence and safety in the home, the client's decline in physical mobility and strength should be evaluated first by the physical therapist who is a member if the home health treatment team.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?

Sudden dysphagia Rationale: Osmotic demyelination, also known as pontine myelinolysis, results in destruction of the myelin sheath that covers nerve cell in the brainstem. This condition can be caused by rapid correction of hyponatremia and is often seen in those with syndrome of inappropriate antidiuretic hormone, Symptoms of pontine myelinolysis are sudden and can include dysphagia, para or quadriparesis and dysarthria. Due to the risk of aspiration the healthcare provider should be notified of the client's sudden onset of difficulty swallowing dysphagia (A). Diplopia not blurred vision (B) may be experienced. Weakness occurs suddenly, rather than gradually (C). Constipation, not diarrhea (D), is common due to decreased motility.

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement?

Suggest the use of alternative sources of protein such as dairy products and nuts

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment. Rationale: The admission assessment of a client should be completed by a professional nurse. A graduate nurse should be supervised by the RN to ensure that the graduate nurse understand and performs within the expected scope of practice. The UAP transport a stable client. (B) The PN can complete C and D

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?

Supplemental feedings with formula Rationale: Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk, the nurse should explain that supplemental bottle formula feeding minimizes the infant's time at the breast and decreases milk supply. B promotes milk production and healing after delivery. C support milk production. C is recommended routine for breast feeding that promote adequate milk supply.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply)

Teach client to use incentive spirometer q2 hours while awake. Remove urinary catheter as soon as possible and encourage voiding.

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?

Teach family proper range of motion exercises. Rationale: Performing proper range of motion exercised helps maintain maximum mobility by preventing excessive muscle atrophy and joint contractures. Elevating lower extremities decreases the amount of peripheral edema. Proper body alignment reduces strain on joints, tendons, ligaments and muscles and minimizes contractures in an abnormal position. Diaphragmatic breathing exercises may decrease the risk of pulmonary complications.

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques Rationale: Suctioning helps to clear secretions and maintain an open airway, which is critical.

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?

Tell the staff to keep all clients and visitors in the client rooms with the doors closed Rationale: The charge nurse should treat the alarm as an actual fire emergency and instruct all clients and visitors to stay in the clients' room with doors closed until otherwise notified. A should be anxiety producing. Visitors should remain in the rooms with the clients. C is only necessary if the location and severity of the fire make the unit unsafe for inhabitants and would only be implemented after other measures to control de fire had failed. D should not be done until after measures are taken to protect clients and visitors.

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor

A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

The additive effect of multiple medications has caused the blood pressure to drop too low Rationale: When medication with a similar action are administered, an additive effect occurs that is the sum of the effects of each of the medication. In this case, several medications that all lower the blood pressure, when administer together, resulted in hypotension.

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

The family reports a great reduction in client's maniac behavior

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?

They decrease the risk for joint trauma Rationale: Assistive devices of this kind are very beneficial in reducing joint trauma(B) caused by excessive twisting. These devices promote independence, rather that increasing dependency

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide?

This hernia is a normal variation that resolves without treatment. Rational: an umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously as the child learns to walk. Other choices are ineffective and unnecessary.

A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?

Thready brachial pulse.

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is:

Three days postoperative colon resection receiving transfusion of packed RBCs.

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?

Titrate the dopamine infusion to raise the BP. Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client's capillary blood glucose should be monitored but is not directly indicated at this time.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?

To reduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

Total calcium 5.0 mg/dl

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

Tracheal deviation toward the left lung. Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax.

Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

Transfuse Type A negative blood until type AB negative is available Rationale: those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client's hemoglobin is critically low, and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation.

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately?

Upper airway stridor

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?

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.

A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors

A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.

The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom)

Verify the drug and dose with the label on the vial Inject the volume of air to be aspirated from each vial Aspirate the desired volume from vial A Aspirate the desired volume from vial B

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next?

Wait 1 minute and palpate the systolic pressure before auscultating again

A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include?

Wash hands before cleaning exit site Rationale: meticulous hand hygiene is essential when performing care for a peritoneal dialysis, infections is a common complication of peritoneal dialysis.

A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 30mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?

Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site RATIONALE: The pre-filled contain 30mg /1ml, so 0.5ml should be wasted to obtain the correct dosage of 15mg for administration in the preferred IM ventrogluteal site. The nurse is responsible for calculating and preparing the prescribed dose using the available concentration, so other options are not indicated.

When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include

Wear long sleeves and pants Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Who is confused and frequently forgets to go to the bathroom Rationale: Overflow incontinence occurs when the bladder becomes overly distended, which is common in the confused client (B) who does not remember to empty his/her bladder.

After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition?

Widening QRS complexes and flat waves

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective? Select all that apply

a- A slice of whole grain toast d- A bowl of cream of wheat Rationale: Patient with CKD have elevated serum potassium, sodium and protein levels. A and D are low in potassium, sodium and protein, Beans are rich in proteins. C are high in sodium and potassium and E are rich in potassium.

The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)

a- Apple juice b- Chicken broth.

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

a- Instruct the client to keep the left leg straight c- Observe the insertion site for a hematoma e- Circle first noted drainage on the dressing

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. e- Review client's abdominal ultrasound findings.

The nurse is preparing to discharge an older adult female client who is at risk for hyPOCALCEMIA nurse include with this client's discharge teaching? (SATA)

a- Report any muscle twitching or seizures b- Take vitamin D with calcium daily d- Low fat yogurt is a good source of calcium e- Keep a diet record to monitor calcium intake Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish.

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

a- The child should avoid eating homemade cookies and cupcakes during parties. Rationale: Celiac disease is an intolerance to products containing gluten. Wheat flour,

When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has:

a. A collapsed lung Rationale: Unilateral absence of chest movement (or unequal lung expansion because one lung is not moving at all) may be indicative previous surgical removal of that lung, a bronchial obstruction, or a collapsed lung caused by air or fluid in the pleural space.

A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:

a. Administer Oxygen via face mask Rationale: The nurse should administer oxygen to increase the amount of oxygen available for the fetus, because is presenting characteristics of late decelerations, caused by uteroplacental insufficiency.

The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?

a. Aspirin content. Rationale: Aspirin content medication are contraindicated for client with polycystic kidney disease because the risk for bleeding.

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which action should the nurse implement? Select all that apply

a. Assess the client for self-care ability b. Provide pain medication instructions c. Teach care of ostomy to care provider

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. Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participates in care by identifying goals for the day is the most important intervention for the client's first day at the unit. Other options can be implemented over time, as the depression decreases.

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 c. Place the client on contact transmission precautions e. Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D) based on the client's history is a wound infection.

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?

a. Confusion and tremors Rationale: daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action.

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy... Which action should the nurse instruct the parents to take if the child begins to vomit?

a. Continue giving Oral Rehydration Salts frequently in small amounts

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?

a. Contraction pattern

The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

a. Contractions of the sternocleidomastoid muscle Rationale: Force inspiration needs to use accessories muscle and rib cage.

Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

a. Decreased abdominal girth

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?

a. Determine current sexual practices Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained.

A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. An unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?

a. Determine how the client is cared for when caregiver is not present

The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?

a. Diabetic ketoacidosis and titrated IV insulin infusion

The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit?

a. Dyspnea, cough, and fatigue.

A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

a. Evaluate the urine osmolality and the serum osmolality values. Rationale: With a known head injury, sudden inadequate secretion of antidiuretic hormone (ADH) can cause excessive output of diluted urine. Evaluating laboratory results should de determined to identify findings of neurogenic diabetes insipidus (DI), such as low urine osmolarity and normal serum osmolarity (A) prior to notify the healthcare provider so that these finding can be included in the report. Massive diuresis, dehydration, and thirst manifest hypotension, irregular tachycardia, decrease skin turgor, but B or C are not related to DI.

The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

a. Exercise at least three times weekly

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

a. Explain that the client will start to lose consciousness and his body system will slow down Rationale: Expected signs of approaching death include noticeable changes in the client's level of consciousness and a slowing down of body systems. The nurse should answer the spouse's questions about the signs of imminent death rather than offering reassurance that may or may not be true. Other options listed may be implemented but the nurse should first answer the spouse's question directly.

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?

a. Give the prescribed antiemetic. Rationale: Hemabate side effects are a light-headed feeling, like you might pass out; shortness of breath. severe nausea, vomiting, or diarrhea; or. increased high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain).

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

a. Hypernatremia Rationale: Hypernatremia can lead to neurological symptoms, such as overactivity in the brain and nerve muscles, confusion, seizures, or even coma. Without treatment, central diabetes inspidus can lead to permanent kidney damage.

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis?

a. I couldn't get my son's socks and shoes on this morning"

The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion?

a. Increase the oxygen flow via nasal cannula if dyspnea is present.

A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

a. Infuse sodium chloride 0.9% (normal saline) Rationale DKA an increase in glucose and ketone bodies, result in hyperosmolar dehydration, so is necessary to restore fluid balance.

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

a. Inspect skin for redness b. Use a residual limb shrinker d. Wash the stump with soap and water Rationale: Several actions are recommended for home care following an amputation. The skin should be inspected regularly for abnormalities such as redness, blistering, or abrasions. A residual limb shrinker should be applied over the stump to protect it and reduce edema. The stump should be washed daily with a mild soap and carefully rinse and dried. The client should avoid cleansing with alcohol because it can dry and crack the skin. Range of motion should be done daily.

The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug?

a. It blocks the effects of histamine, causing decreased secretion of acid

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

a. Long distance runner since high school. Rationale: Osteoarthritis is a degenerative joint disease of the cause by traumatic or repetitive stress to weight-bearing joint such as high impact sport like running.

An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client?

a. Magnesium hydroxide (Maalox) Rationale: Some aluminum containing antacids (Maalox, for example) may cause Acute Kidney Failure if used over long periods of time. Antacids can also disrupt the electrolyte balance of people with CKD.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

a. Monitor abdominal girth. c. Report serum albumin and globulin levels. e. Note signs of swelling and edema. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a JacksonPratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

a. Monitor urine output hourly. Rationale: When one kidney is removed the remaining kidney must do all the volume filtering, so A is immediate to the postoperative period.

The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse?

a. Notify nursing supervisor and hospital chaplain of the child's impending death.

Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)

a. Notify the food services department of the allergy. b. Enter the allergy information in the client's record. e. Add egg allergy to the client's allergy arm band. Rationale: The dietary department needs to screen menu selections for foods that are prepared with eggs. The client's chart should be clearly marked but the statement does not need to be documented in the nurse's note or included in the intake record. Allergy identification on the arm band is a universal location where allergies are noted while client is hospitalized.

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

a. Observe the wound for dehiscence

A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

a. Obtain a pulse oximeter reading

A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?

a. Offer to provide the influenza vaccination to the student while she is at the clinic Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma, but the nasal spray may result in increased wheezing after receiving that form of the vaccination.

The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client with infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

a. Peak and trough levels have not been drawn since the tobramycin was started

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. Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias

The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

a. Place client in Trendelenburg position on the left side

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Place personal religious artifacts on the body. d. Attach identifying name tags to the body. e. Follow cultural beliefs in preparing the body.

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 Rationale: Sedation, given during the procedure may need to be reverse if the client does not easily wake up. Oxygen saturation level should be asses, and oxygen applied to support respiratory effort and oxygenation. The client is still breathing so the bag- valve mask ventilation and CPR are not necessary.

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 Rationale: Primary goal in the management of rheumatoid arthritis is to protect and maintain joint function.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?

a. Roasted turkey canned vegetables Rationale: Foods allowed on a low-fiber diet includes roasted or baked turkey and canned vegetables the foods in the other options are not low in fiber

When administering ceftriaxone sodium (Rocephin) intravenously to a client before... most immediate intervention by the nurse?

a. Stridor Rationale: Stridor, a crowing respiration, indicates the client is experiencing bronchospasm, as a reaction to Rocephin, and antibiotic. The finding requires immediate action by the nurse. B and C are side effects that are not life-threatening. Pruritus may be the result as... and need nursing intervention but is of less immediacy than stridor.

When attempting to establish risk reduction strategies in a community, the nurse notes that regional studies indicate a high number of persons with growth stunting and irreversible mental deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement which screening measure?

a. T4 levels in newborns

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

a. The client has asymmetrical chest wall expansion Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)

a. Topical corticosteroid. e. Oral antihistamine Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated.

A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

a. Urine output 20 ml/hour Rationale: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.

A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/ hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

a. Use a secondary port of the Normal Saline solution to administer the antibiotic.

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

b- Avoid eating grapefruit or drinking grapefruit juice. c- Report changes in the use of daily supplements d- Notify your health care provider if your skin looks yellow Rationale: Side effects can increase if the client consumes grapefruit. OTC medications or herbals should be reported for possible drug interactions. Hepatic injury can occur, and the client should report sign of jaundice or itching, or right upper quadrant pain.

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

b- Schedule the client for the chest radiograph c- Obtain sputum for acid fast bacillus (AFB) testing d- Place a mask on the client until he is moved to isolation. Rationale: Client with history of TB a chest x-ray and sputum are indicated. The client sign and symptoms indicate the pt should wear mask to protect others.

In caring for a client receiving the aminoglycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

b- Serum creatinine Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level which can monitor the renal function.

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide?

b. "His smaller size is probably due to the heart disease" Rationale: Poor growth patterns are associated with heart disease.

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

b. Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d. Monitor continuous oxygen saturation. Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac ischemia. Oxygen saturation monitors for adequate oxygenation.

The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain?

b. Affective Rationale: The affective domain involves our feelings, emotions, and attitudes, and includes the manner in which we deal with things emotionally (feelings, values, appreciation, enthusiasm, motivations, and attitudes).

A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

b. Allow the infant to rest before feeding

A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement?

b. Apply counter-pressure to the sacral area Rationale: B provides pain relief during labor.

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

b. Asses for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI

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?

b. Assign staff to monitor what the client eats. Rationale: clients with an eating disorder have an unhealthy obsession with food. The client's continued weight loss, despites indication that the client has consumed 100% of the diet, should raise questions about the client's intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary.

The nurse should teach the client to observe which precaution while taking dronedarone?

b. Avoid grapefruits and its juice Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking dronedarone.

The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply)

b. Avoid use of alcohol as a sleep aide at bedtime d. Start a weight loss program

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?

b. Check the TPN solution for cloudiness

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and... Which nursing intervention has the highest priority?

b. Determine if the client has an executed living will Rationale: Once the client is intubated and ventilated, emergency intervention should continue until patient t be stable check if the client has an executed living will.

A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?

b. Drink chamomile tea at breakfast and in the evening. Rationale: Chamomile tea is used to aid with digestion and is in fact sometimes used for indigestion. C should not be used by breastfeeding woman or at night when trying to go to sleep. D is for improve circulation, stimulate the internal organs, stretch the body, restore....

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care ...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take?

b. Explain that the hand rub can be completed in less than 2 minutes

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?

b. Hypocapnea reduces ICP

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

b. Inability of the SA node to initiate an impulse at the normal rate Rationale: A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first-degree heart block.

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. 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)

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. Rational: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas.

An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority?

b. Instruct the mother to take the teen to the emergency room

During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement?

b. Instruct the scrub nurse to re-drape the client

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)

b. Interacts with a flat affect. c. Avoids eye contact. d. Has a disheveled appearance. Rationale: Observed finding are objective and include the client's appearance, such as flat affect, lack of eyes contact, and disheveled appearance. A and E are subject only the client can express verbally.

The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost... hypothyroidism, what question is most important for the nurse to ask the mother?

b. Is your son sleepy and difficult to feed? Rationale: Like adults with hypothyroidism, excess fatigue is common and a "good" baby is of.... occurs with hypothyroidism and can result in poor sucking.

A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care?

b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also, the client has a terminal disease and is being discharge home, hospice and health care are not indicating currently. Short term counseling is not an option.

A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)

b. Measure blood glucose c. Monitor vital signs d. Assessed level of consciousness Rationale: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS.

An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

b. Notify the healthcare provider of the client's change in mental status. c. Include q2 hour's reorientation in the client's plan of care. Rationale: The client's condition reflects mental changes that could be related to post procedure stress, sundowner's syndrome, or cerebral complications, the nurses should inform the healthcare provider of the client's change in mental status for the client's safety, q2 hour orientation evaluations and reorientation should be included in the plan of care.

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 beating during the procedure. What action should the nurse take?

b. Notify the healthcare provider of the client's lack of understanding. Rational: the nurse is only witnessing the signature and is not responsible for the client's understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated.

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)... which breakfast selection by the client indicates effective learning?

b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

b. Obtain a detailed report from the nurse transferring the client. Rationale: To maintain continuity of care, it is important for the nurse working on the palliative care unit to obtain a detailed "situation, background, assessment, recommendation (SBAR) report, which provide clinical and no clinical information, as well as further information about the client may need. A, C and D are important intervention but not have priority at this time.

A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important?

b. Obtain a prescription to increase the IV rate

A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement?

b. Obtain a wound swab for culture and sensitivity

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?

b. Oral temperature of 100.6 F Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.

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?

b. Plan volume-controlled evenly-space meal thorough the day Rationale: It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding decreasing risk of dumping syndrome and flatulence.

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

b. Rebound tenderness in the upper quadrants Rationale: Rebound tenderness in the upper quadrant may be indicative of peritonitis. A is a clinical finding associated with bowel obstruction and does not need to be reported D may be something characteristic of the client's condition.

A client with hypertension receives a prescription for enalapril, an angiotensin... instruction should the nurse include in the medication teaching plan?

b. Report increased bruising of bleeding Rationale: ACEIs can cause thrombocytopenia and increased risk for bruising and bleeding. A is not necessary because is a potassium-sparing

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).

b. Report mental status change to the healthcare provider c. Assess the client's breath sounds and oxygen saturation e. Review the client's most recent serum electrolyte values Rationale: The healthcare provider should be informed of changes in the client's condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP (D).

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented?

b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity.

A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement?

b. Schedule a weekly home visit to draw hCG values Rationale: To monitor for development of choriocarcinoma, a complication TD, level of hCG should be monitor for negative results.

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?

b. Stabilize the victim's neck and roll over to evaluate his status

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)

b. Take postoperative vital signs for a client who has an epidural following knee arthroplasty d. Collect a sputum specimen for a client with a fever of unknown origin e. Ambulate a client who had a femoral-popliteal bypass graft yesterday Rationale: Measuring vital signs, collecting specimens, and ambulating a mobile client are within the scope of practice for a UAP

A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?

b. Teach the client how to use a dry heating pad over the painful area

Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

b. The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease Rationale: Carafate coats the mucosal lining prior to eating a meal, so this medication should be held until prior to the next meal.

A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?

b. Therapeutic exercise included in daily routine

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?

b. Too much salt can cause the kidneys to retain fluid Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.

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)

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 Rationale: B, C and E are functions within the scope of practice for the UAO include reporting client complaints of pain.

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

b. nausea and projectile vomiting Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.

A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take?

c) Request that the mother leave the room

During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)

c- Assessment d- Recommendation e- Rationales.

A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)

c. A client must be willing to accept palliative care, not curative care. d. The healthcare provider must project that the client has 6 months or less to live. Rationale: The eligibility criteria for Medicare coverage requires that the client is willing to accept palliative care, not curative care (C). The healthcare provider should provide an expected prognosis of 6 months or less to live (D) which can be extended by the healthcare provider. It is not necessary for all family members to agree with the need for hospice.

A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action?

c. Allow several minutes for the client to respond

Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

c. An open sterile Foley catheter kit set up on a table at the nurse waist level Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile object become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?

c. Ask the family to identify a specific spokesperson

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?

c. Ask the nurse to return home and get her prescription eyeglasses for work

A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

c. Assist the client to sharply flex her thighs up again the abdomen.

A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

c. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness

A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

c. Collect a urine specimen for routine urinalysis Rationale: Acute glomerulonephritis is an auto-immune reaction to a precursory streptococcus. Manifestation of AGN include oliguria, edema, hypertension.

An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

c. Compulsion

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs?

c. Cries frequently during the interview

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?

c. Elevated liver function tests Rationale: Valacyclovir is an antiviral agent of acyclovir which is used in therapy of herpes simplex and varicella-zoster virus infections (shingles). Valacyclovir has been associated with rare instances mild, clinically apparent liver injury.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

c. Enable clients to become active participating in controlling the disease process Rationale: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)

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?

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

The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

c. Evacuate each infant with mother via wheelchair Rationale: Rooming-in and newborn babies are counted with their mothers. To exposure safety and accountability during the evacuations newborns should be evacuated with their mother in a wheelchair while maneuver with fire extinguisher are performed (PASS)...

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

c. Human source grafts require monitoring for signs of graft rejection Rationale: Allograft is a graft created from the client's own skin, which is called harvest site. All types of grafts, from human and nonhuman sources should be monitor for signs of rejection. Graft site are painful. (A). Allografts are obtained from the client, which is a human source (B). scaring does occur under the graft (D)

What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure...

c. Manage the airway

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

c. Moderate amount of foul-smelling lochia.

The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?

c. Move the device one to two inches away from the mouth Rationale: Optimal position of a metered dose inhaler includes placing the inhaler one two inches away from the mouth.

After receiving report, the nurse can most safely plan to assess which client last? The client with...

c. No postoperative drainage in the Jackson-Pratt drain with the bulb compressed Rationale: The most stable client is the one with a functioning drainage device and no drainage. This client can most safely be assessing last. Other clients are either actively bleeding, have an obstruction in the nasogastric tube which may result in vomiting, or may be bleeding and / or may have a malfunction in the Hemovac® drain.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

c. Observe both lower extremities for redness and swelling Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis.

In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

c. Orthopnea Rationale: If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?

c. Perform a sterile vaginal exam Rationale: When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.

After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

c. Place one hand on top of the other and interlace the fingers

While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

c. Psoriasis Rationale: Psoriasis is typically located on the elbow and knees

A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

c. The client will be restricted from eating seafood

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?

c. The client's previous GCS score. Rationale: The normal GCS is 15, and it is most important for the nurse determine if this abnormal score is a sign of improvement or deterioration in the client's conditions. A is irrelevant. B is part of the GCS. The classic vital signs in late or sudden increasing ICP are Cushing's triad (widening pulse pressure, bradycardia with full, bounding pulse, and irregular respirations) Additional vital signs and trending of values are needed to evaluate the current finding(D) and C is a more sensitive, consistent evaluation

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?

c. The hemoglobin A1C was 6.5g/100 ml last week Rationale: A hemoglobin A1C level reflects he average blood sugar the client had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the client understand long-term diabetes control. Normal value in a diabetic patient is up to 6.5 g/100 ml.

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip what?

c. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

c. Unresponsive to painful stimuli Rationale: Eptifibatide, is an inhibitor of platelet aggregation, is administer IV for ACS, and bleeding is a significant side effect. A sudden onset of unresponsiveness may indicate intracranial bleeding, which is the life threatening finding related to bleeding. Although hypotension may indicate bleeding, it is not as significant as unresponsiveness to pain. This medication has a short half-life, so B and D are not life threatening findings.

An African-American man comes into the hypertension screening booth at a community fair. The nurse finds that his blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

c. Your blood pressure is a little high. You need to have it rechecked within one week.

The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

clubbing

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

d. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away" Rationale: It is vital for the nurse to emphasize to the client that the mist should be inhaled, not swallowed. This assessment should be done for all COPD clients, not just those who complain about their inhalers.

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?

d. Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe, but should be treated with analgesics as indicated

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?

d. Affirm that the UAP is using an effective strategy to reduce the client's anxiety. Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase... an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.

The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?

d. Apply downward manual pressure at the suprapubic regions. Rationale: The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.

A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

d. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo Rationale: This condition is an inflammation of the eyelids edges that occurs in older adults. Is controlled with eyelid care using warm moist compresses followed by gently scrub eyelids.

An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse?

d. Ask the client to describe the changes that have occurred

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?

d. Assist cardiac nurses with their assignments

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?

d. Begin parenteral antibiotic therapy Rationale: The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After bond and blood aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics as prescribed.

The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat

d. Cinnamon applesauce RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snacks should be avoided by a client who is taking ciprofloxacin.

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?

d. Condition of hair, nails, and skin Rationale: The assessment of hair, nails and skin is most indicative of long-term nutritional status, which is important in the healing process.

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

d. Determine the infant's blood sugar level

The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

d. Flex the client's head with chin to the chest and insert.

When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)

d. Fortified whole wheat cereals, whole-grain pasta, brown rice e. Spinach, kale, dried raisins and apricots Rationale: Nutritional anemia in pregnancy should be supplemented with additional iron in the diet. Foods that are high in iron content are often protein based, whole grains (D), green leafy vegetables and dried fruits (E). (A, B, and C) are not iron rich sources

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?

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

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?

d. Have the client vocalize the instructions provided. Rationale: A client with both hearing and visual sensory deficit should be repeat the instruction provided so the nurse needs to be sure the clients understand the self-care instructions.

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?

d. Hold the newborn in an upright position Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated using special feeding appliances and nipples such as the Haberman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce a volume that is greater than the neonate can coordinate swallowing. The preferred position of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate's intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate's stomach.

The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?

d. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern. Rationale: Beta blockers such as metoprolol (Toprol SR) are contraindicated in clients with second or third-degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

d. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-sided weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?

d. Install a bed exit safety monitoring device

A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

d. Instill beractant 100 mg/kg in endotracheal tube

The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

d. Narrow therapeutic index. Rationale: Narrow therapeutic index (NTI) drugs are defined as those drugs where small differences in dose or blood concentration may lead to dose and blood concentration dependent, serious therapeutic failures or adverse drug reactions.

While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

d. Notify the employee health nurse.

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

d. Reduce the risk for injury Rationale: Paget's is a metabolic bone disorder which place the client at high risk for injury. Once the client is symptom free the next goal is reducing risk for injury

When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?

d. Reflection

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?

d. Remain upright after taking the medication Rationale: Risendronate, causes reflux and esophageal erosion.

During an Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?

d. Serum potassium Rationale: Electrolyte shifts are common during correction of hyperosmolar and hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic and hypotonic saline solutions to adjust the patient's sodium level. Despite major potassium loss during diuresis in early HHS stages, many patients initially present in a hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum potassium level may drop dramatically.

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

d. The body cells develop resistance to the action of insulin

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?

infectious process

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client?

low fat Rationale: A client with cholecystitis is at risk of gall stones that can be move into the biliary tract and cause pain or obstruction. Reducing dietary fat decrease stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine.

A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?

oatmeal cookies

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

right upper chest, left midaxillary

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?

you need to seek immediate medical assistance to evaluate the cause of these symptoms"

A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

0.4 Rationale: Convert pounds to kg 42lbs = 19.09 kg Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545 Then use the desired dose/ dose on hand x volume on hand (9.545/25x1ml =0.3818=0.4 ml) Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml 25x = 9.545 X= 0.3818 = 0.4)

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?

0.9% sodium chloride solution (normal saline) Rationale: Normal range = 135-145

The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom) 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia.

1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia Rationale: Prolonged low blood pressure leads to renal ischemia, which is the common etiology of acute tubular necrosis(ATN) Decreasing urine output is an early indicator of ATN.

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 Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml

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 clients 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. Assess the client's skin and circulation for impairment related to the restrains 2. Evaluate the client's mentation to determine need to continue the restrains 3. Assign unlicensed assistive personnel to remove restrains and remain with client 4. Contact the client's surgeon and primary healthcare provide

An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.)

1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. Rationale: Noting the date and time of the behavior is the first action that is important in providing factual information. The unit manager should discuss the behavior with the UAP and describe the problems the behaviors causes for the staff, when a problem is identified, it is important to plan and implement solutions, such as scheduled break times during the shift. These interventions should be evaluated based on the UAP's signs of improvements.

When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.)

1. Rub hands palm to palm. 2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet.

Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom)

1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital's chief of medical services. 5. File a formal complaint with the state medical board. Rational: nurses have both an ethical and legal responsibility to advocate for clients' physical and emotional safety. Talking with the physician in a non-confrontational manner is the first step in conflict resolution. If this is not effective, the organizational chain of ineffective, a formal complaint with the state medical board should be implemented.

The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If round is required, round to the nearest tenth.) 2.5 ^ 2 difference answers so double check this one

1.5

Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

47

A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving

700 Rationale: 25000/500x14=700

The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour

A female client reports that she drank a liter of a solution to cleanse her intestines... immediately. How many ml of fluid intake should the nurse document? Whole number

760 Rationale: 1L=1000ml Subtract the emesis, 1 cup (8 oz)=240ml 1000-240=760 ml

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?

A family member of a client with dementia who has been missing for five hours Rationale: safety is always the priority concern and the family member of the missing client with dementia needs assistance with contacting authorities as well as psychological support during this time.

A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

A mother with an infected episiotomy Rationale: An infected episiotomy is essentially an infected surgical incision, and an experienced emergency room nurse is likely be able to care for such a client. A, B and D required specialized maternity nursing care.

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply).

A. Fresh turkey slices and berries E. raw unsalted almonds and apples

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply.)

A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. E. Irregular heart beat. Rationale: (A, B, C, and E) are correct. Addison's crisis results from an acute lack of adrenal cortical hormones. Headache and tremors (A), as well as pallor and diaphoresis (C) may indicate significant hypoglycemia. Hypotension (B) with pale, diaphoretic skin (C) are indicative of progressing signs of life-threatening shock that also require immediate nursing intervention. An irregular heart rate (E) may be the result of hyperkalemia and also requires immediate intervention. (D) is consistent with chronic secondary adrenal insufficiency and does not require immediate nursing intervention.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

Administer a nebulizer Treatment Rationale: The client needs an immediate medicated nebulizer treatment. Sitting in an upright position with head and arms resting on the over-bed table is an ideal position to promote breathing because it promotes lung expansion. Other actions me be accurate but not yet indicated.

A 6 -year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?

Administer a prescribed bronchodilator. Rationale: If the PEFR is below 50% in as asthmatic child, there is severe narrowing of the airway, and a bronchodilator should be administered immediately. B should be implemented after A. C will not alleviate the symptoms and D is not a priority.

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

Advise the client that assignments are not based on clients requests Rationale: Those with antisocial personality disorders are manipulative in order to meet their own needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional maturity prevent effective therapeutic communication and (A and B) will be used to the client's advantage. C encourage further manipulative behavior.

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours?

Agitation and threats to harms staff

The healthcare provider prescribes heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)

Answer 12 Rationale: 144/2.2= 65kg 18units/kg/hr 65 kg x 18units/kg/hr= 1170 units/hr 25000 units heparin/250 ml of D5W = 100 units heparin per ml of solution

A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)

Answer: 1.6 Rational: using the formula D/H x Q 200mg/250 mg x 2ml = 200/250 = 1.6 ml

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next?

Ask for a full explanation from the interpreter of the witnessed discussion

A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

Assist the client's to a bedside commode every two hours

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Auscultate for irregular heart rate. Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.

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?

Avoid crowds for first two months after surgery.

A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID). Rationale: Dabigatran, a directed reversible thrombin inhibitor, is prescribe to reduce the risk of stroke in client with atrial fibrillation. The risk of bleeding and GI event can be significant and the concomitant use of NSAID and other anticoagulants should be avoided.

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

B. Begin manual ventilation immediately. Rationale: The first action that must be taken is to begin manual ventilation. Remember the ABC's — airway, breathing and circulation! The nurse's highest priority is to ensure that the client is receiving oxygen. Also, remember Maslow — safety is a primary human need and breathing is fundamental to safety. (A, C, and D) do not have the priority of initiating manual ventilation.

The nurse observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What action should the nurse perform first?

B. observe the amount of urine in the clients urinary drainage bag. Rationale: If blood clots are present, the nurse should first determine if urinary output has become obstructed by observing the amount of urine in the urinary drainage bag (B) Continuous bladder irrigation is performed to prevent blood clots that may form and obstruct the outflow of urine

A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Baked apples topped with dried raisins Rationale: A patient with chemotherapy-induced severe neutropenia is at high risk for infection. A low bacteria diet is required D is a healthy snack for a client receiving chemotherapy. A, B and C have a high bacterial count and should be avoided.

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?

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie Rationale: B is limited in sodium, is high in fiber, and no additional fat is added through cooking, so it is the best choice for an antihypertensive meal. A high in sodium and cholesterol, which should be avoid. C is high in fat and caffeine which can elevate the BP D is high in sodium and cholesterol and includes caffeine.

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first?

C. Initiate a prescribed IV for parental fluid

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan?

C. Keep room temperature 80 Rationale: Keeping the environment warm (C) may minimize vasoconstriction which decreases blood flow and causes the pain associated with Raynaud's disease. The client is not helpless and does not require a caregiver (A). Exercise (B) may increase pain. TED stockings (D) have no therapeutic value for those with Raynaud's disease.

When checking a third grader's height and weight, the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

C. Refer child to the family healthcare provider. Rationale: ADHD is most commonly managed with methylphenidate, which causes insomnia due to CNS stimulation and growth suppression secondary to appetite suppression. The child should be referred to the healthcare provider (C) because a change in the administration schedule of methylphenidate or discontinuing the drug is indicated until the child's growth increases. (A and B) may not ensure referral for a valuation of the medication's impact on the child's growth pattern. (D) is ineffective.

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?

CPT should be performed more frequently, but at least an hour before meals. Rationale: CPT with inhalation therapy should be performed several times a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals.

After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

Capillary refill of 8 seconds Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds indicates poor perfusion and requires immediate attention

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?

Cardiac rhythm and heart rate Rationale: Hypokalemia is a side effect of potassium-wasting diuretics, such as Lasix, and manifest as muscle weakness, hypotension, tachycardia, and cardiac dysrhythmias, so changes in the child's heart rate and cardiac rhythm should be reported to the healthcare provider. Although BCD can affect the serum potassium level, the most important finding is the effect of hypokalemia on the child's cardiac rate and rhythm.

During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Check the client for lacerations or fractures Rationale: After the client falls, the nurse should immediately assess for the possibility of injuries and provide first aid as needed

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large, spicy meal Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

Chest pain and dysrhythmia

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

Chest physiotherapy should be performed twice a day before a meal.

When evaluating a client's rectal bleeding, which findings should the nurse document?

Color characteristics of each stool Rationale: Color characteristics indicate if blood is coming from high in the GI tract, which would be black and tarry, or from lower area near rectum, which would be bright red blood.

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?

Come to the clinic to be seen by a healthcare provider

A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Culture for sensitive organisms. RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client's laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Current diagnosis of hepatitis B Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment.

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

D. Tell the client that the nurse will be back to talk to her after medications are given. Rationale: The nurse should first acknowledge the client's grief and arrange with the client a time to provide support, then complete the administration of medications (D). During that time, the nurse should assess the client to determine what intervention is best to offer the grieving client (A). The nurse, not the UAP (B), should talk with the client to determine if the client needs her spiritual advisor's counsel and support. The client's grief is not an emergency situation, so after acknowledging it and informing her that the nurse will return to talk with her, the nurse should finish administering the medications (C) and then spend time supporting the grieving client.

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy?

D. Three year history of taking oral contraceptives

Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Direct the nurse to continue the surgical hand scrub for a 5 minute duration Rationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of 5 mints. It is not necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the day require the same process for the same amount of time, (B and C)

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication?

Divalproex. Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate non-compliance with the medication regimen

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

Document the extent of the bruising in the medical record

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Elevated blood pressure must be anticipated and identified quickly

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?

Encourage popsicles and fluids of choice Rationale: specific gravity of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated.

A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?

Encourage the client to continue expressing her fears and concerns. Rational: the nurse should show support for the client by encouraging her to continue expressing her concerns. A diagnosis has not yet been made, so it is too early to discuss treatment options. Other options dismiss the client's feelings or are premature given that the diagnosis is not yet made.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Explain that the client may be placed in five positions Rationale: Frequently, the client is placed in five positions (head down, prone, right and left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be performed before meals to prevent nausea, vomiting and aspiration(A). The client should breath slow and exhale through pursed lips to help keep airway open so that secretions can be drained while assuming the various positions. C is not required

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 does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics. Rationale: The client needs to understand that any pain medication that can mask declining neurological symptoms, such as narcotics should be avoid. There is no indication that the CT scan needs to be done immediately. In the absent of additional information B is presumptive. Regular neurological assessment is necessary, but they do not address the client's pain.

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Explore the client's reasons for wanting to be discharged.

The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?

Fever and dysuria.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation Rationale: Elderly clients are at risk of developing hypermagnesemia as a result of chronic laxative abuse.

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?

Heat loss Rationale: Adequate thermoregulation is the nurse next priority. The newborn is at risk for significant heat loss due to a large surface area exposed to the environment, a thin layer of subcutaneous fat, and distribution of brow fat. Heat loss increases the neonate's metabolic pathway's utilization of oxygen and glucose.

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?

How many departments can use this equipment?

A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?

Hypotension

An adult client is exhibit the manic 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?

Imbalance nutrition Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority

A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile Rationale: Because the motor function controlling eye closure, brow movement and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell's palsy has occurred.

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?

Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate

The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client?

Inform him that the nurse is busy admitting a new client and will talk to him later. Rational: the psychiatric nurse must set limits with antisocial behavior so that appropriate behavior is demonstrated. Interrupting a conversation is rude and inappropriate, so telling the client that they can talk later is the best course of action. Other options may cause the client to become angry and they do not address the client's behavior. The nurse should not involve this client with newly admitted client's admission procedure.

An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first?

Insertion of a left- sided chest tube.

Which action should the school nurse take first when conducting a screening for scoliosis?

Inspect for symmetrical shoulder height. Rationale: Children between 9 and 15 years old should be screening for scoliosis, which is exhibited.... Vertebral column. Screening for scoliosis should begin with inspection of shoulder height

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child's diaper more often. Rationale: Changing the diaper more often helps to decrease the amount of time the skin comes in contact with wet soiled diapers and helps heal the irritation.

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Instructions about how much fluid the child should drink daily Rationale: It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that has a specific plan for hydration is developed so that a crisis can be delayed. Other choices listed are not the most important topics to include in the discharge teaching.

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to flow slowly with little excessive peristalsis does not cause immediate release of stool.

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?

Left forearm hematoma Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent concern.

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

Lower the left arm below the level of the heart

A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

Maintain contact transmission precaution Rationale: The client may have residual postoperative MRSA infection, a resistant and highly contagious healthcare-associated infection (HAI), that requires strict contact precautions (A), as recommend by the Center for Disease Control (CDC).

A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest?

Malignancy

An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest?

Malignancy

A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement?

Measure vital signs Rationale: Abrupt withdrawal of an exogenous corticosteroids can precipitate adrenal insufficiency and hypoglycemia, hypokalemia, and circulatory collapse can occur. Is most important for the nurse to assess vital sign to impending shock.

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?

Medicate as needed for pain and anxiety. Rationale: Neuropathic pain in MS is related to damage to peripheral nerves or structures in the CNS can be sudden, intense or lingering, and shooting, electric shock-like sensations that results for paroxysmal firing of injured nerves. Once the client enters palliative care, the primary goal is comfort.

A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding?

Multiple convictions for misdemeanors and class B felonies.

Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse?

Muscle pain Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP.

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolve immediately Rational: a major teaching goal for an elderly client with osteoporosis is maintenance of safety to prevent falls. Injury due to a fall, usually resulting in a hip fracture, can result in reduced mobility and associated complications. Other goals are also important when teaching clients who have osteoporosis, but they do not have the priority of preventing falls, which relates to safety.

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?

New onset of purple skin lesions. Rationale: During the convalescence period of hepatitis A, the client major complain is malaise and fatigability. Purple skin lesions may be indicative of the liver's impaired ability to produce clothing elements and should be reported to the healthcare provider (C) for further analysis. Urine may become dark when excess bilirubin is excreted by the kidney, which is expected even when the client is not jaundice during the acute phase hepatitis (A). Myalgia and arthralgia (B) are intermittent complains with ongoing malaise, fatigue and weakness (D) during convalescence of hepatitis A.

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?

Notify healthcare provider to prepare for pericardiocentesis Rationale: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?

Notify the healthcare provider of the vomiting. Rational: transdermal scopolamine is used to prevent nausea and vomiting from anesthesia and surgery. The nurse should notify the healthcare provider if the medication is ineffective. The patch should be applied behind the ear and should remain in place to reduce the nausea and vomiting. Nausea and vomiting are no side effects of the medication.

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Observe for unilateral swelling

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement

Obtain a clean catch mid-stream specimen Rationale: This elderly is experiencing symptoms of urinary tract infection. The nurse should obtain a clean catch mid-stream specimen to determine the causative agent so an anti-infective agent can be prescribed.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

Offer the client oral fluids Rationale: Increasing oral fluid intake reduces the risk of problems associated with immobility, so the UAP should be instructed to offer the client oral fluids every two hours, or whenever turning he client. It is not necessary to empty the urinary bag or feed the client every two hours. Assessment is a nursing function, and UAPs do not have the expertise to perform assessment of breath sounds.

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?

Overlook the client's behavior.

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?

Palpate the client's suprapubic area for distention Rationale: the client is exhibiting classic signs of an enlarge prostate gland, which restricts urine flow and cause bothersome lower urinary tract symptoms (LUTS) and urinary retention, which is characterized by the client's voiding patterns and perception of incomplete bladder emptying.

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Place a portable toilet next to the bed

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system?

Plastic tubing located at the chest insertion site

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

Prepare a woman for a bone density screening Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client's fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.

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?

Provide a family tour of the preoperative unit one week before the surgery is scheduled Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.

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?

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

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Report any signs of cloudy urine output. Rationale Infection can be life-threatening and cloudy urine output is a sign of urinary tract infection, which should be reported immediately.

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?

Restrict daily fluid intake. Rationale: the client is exhibiting signs of Cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relieve the edema and decrease workload on the right-side of the heart.

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

Review the staff nurse job description to ensure that it is clear, accurate, and current

Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided.

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse?

Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) Rationale: The typical range for serum creatinine is: For adult men, 0.74 to 1.35 mg/dL. For adult women, 0.59 to 1.04 mg/dL.

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?

Simethicone (Mylicon) Rationale: Simethicone is an antiflatulent that is used to increase the client's ability to expel flatus (B), which relieves the clients discomfort (A and D) are analgesic used to manage pain but do not alleviate the causes of the pain (C) is an antiemetic used to treat nauseas and does not relive excess flatus.

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply).

Space activities to allow for rest periods Take warm baths before starting exercise

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement?

Stop the transfusion start a saline

The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide?

Stop using the ointment and encourage complete drying of the feet and wearing clean socks. Rationale: Athlete's foot (tinea pedi) is a fungal infection that afflicts the feet and causes scaliness and cracking of the skin between the toes and on the soles of the feet. The feet should be ventilated, dried well after bathing, and clean socks should be placed on the feet after bathing. Antifungal ointments may be prescribed, but antibiotic ointments are not useful.

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care

Teach need for dietary and supplementary vitamin D3 Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normal-appearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he is underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide 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?

Tell all their assigned clients to stay in their rooms. Rationale: A power failure leaves a unit in total darkness except for battery operated lighting. The top priority should be ensuring client safety by having clients stay in their rooms, and UAP can implement this. A is a higher priority in external disaster. B would further compound the lighting problems and is not indicated unless file or smoke is visible. C contraindicated until client safety is ensured on the assigned unit.

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

The client's need for pain medication should be determined. Rationale: Palliative care includes nursing interventions that provide relief for the dying client's suffering by assessment and treatment of pain and other problems that are physical, psychosocial and spiritual. After the family is notified for the client's impending death, the client's need for pain medication should be assessed.

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

The technique is intended to maintain straight spinal alignment. Rationale: The main rationale for use of the long-rolling technique is to maintain the client's spine straight alignment.

A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?

Thiamine (Vitamin B1) Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.

A client in the postanesthesia care unit (PACU) has an eight (8) (Normal) on the Aldrete postanesthesia scoring system. What intervention should nurse implement

Transfer the client to the surgical floor. Rationale: A score of 7 to 8 is normal and indicates that the client can be discharge from PACU. The PACU assessment form includes 5 mints areas of assessment: muscle activity, circulation, consciousness level, and oxygen saturation. Each of these 5 areas receives two points for normal. A, B, C are interventions that are not indicated for a score of 8.

Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client

Use two forms of contraception while taking this drug. Rationale: Antibiotic, especially broad-spectrum drugs, like azithromycin, decrease the effectiveness of oral contraceptives and some spermicides, so the adolescent should be encouraging to use at least two forms of contraception to prevent pregnancy

The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Watery diarrhea

The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which foods should the nurse encourage this client to eat?

Yogurt and/or buttermilk. Rationale: A should be encouraging to help maintain intestinal flora and decrease diarrhea, which is a common side effect of antibiotic therapy, particularly cephradine. B and C are contraindicated because they can increase bowel elimination, thereby exacerbating diarrhea as a side effect.

An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

a- History of hypertension. e- Family heath history. Rationale: Based on the client's family history and medication for management of hypertension, the nurse should further explore these risk for ischemic heart disease.

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthcare provider d- The healthcare team will formulate a plan of care to keep the client comfortable Rationale: An adult client who is mentally competent has the autonomy and the client's right to make her own decision regarding her treatment.

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. d. Provide a PRN dose of acetaminophen for headache Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client's blood pressure. A PRN dose of acetaminophen should be given for the client's headache. The other options are not indicated for this situation.

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?

a. Auscultate all quadrants of the abdomen.

The home care nurse provide self-care instruction for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply

a. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client?

a. Blood pressure 149/101

Which information is more important for the nurse to obtain when determining a client's risk for Obstructive Sleep Apnea Syndrome (OSAS)?

a. Body mass index

Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?

a. Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately 150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take?

a. Clamp the tubing and instruct the client to breathe deeply before continuing. Rationale: Clamping the tube momentarily allows the muscle to relax and prevents expulsion of the solution prematurely. B may be eventually necessary but A should be tried first.

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribed medications?

a. Clopidogrel (Plavix), an antiplatelet agent, given orally Rationale: Because of the emesis is coffee brown appearance, which is an indicator of bleeding in GI tract, the nurse should consult the health care provider because increase the risk of bleeding.

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?

a. Determine the client's responsiveness and respirations Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)

a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure

A male client with cancer, who is receiving antineoplastic drugs, is admitted to the... what findings is most often manifest this condition?

a. Ecchymosis and hematemesis

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

a. Expresses an understanding of the procedure

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 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% 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 uninterrupted and frequent rest periods between procedures. Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

a. Monitor for an elevated temperature Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.

During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client?

b. Lie on the left or right side when sleeping or resting

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 d. Observe for a patent airway e. Record the duration of the seizure Rationale: Moving this away from the client helps prevent to unnecessary injurie. Observing for the pt airway alert the nurse to provide airway assistance as soon as the seizure stop D and E provide the healthcare provider with an accurate description of the seizure activities. C inserting something on the mouth can obstruct may cause further airway obstruction and is contraindicated even if the client is biting the tongue. F may cause further injury and is contraindicated.

An older female who ambulates with a quad-cane prefers to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)

a. Move personal items within client's reach b. Lower bed to the lower possible position d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours. Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication?

a. Nausea and indigestion.

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

a. Negative pressure environment

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? Select all that Apply

a. Poor feeding and vomiting b. Leakage of CSF from the incisional site d. Abdominal distention Rationale: A, B and D are sign of postoperative complications. Shunt malfunction is most often caused by mechanical obstruction, which can result from ventricular exudate, distal end thrombosis or displacement, and/or infection. CNS infection is usually manifested by poor feeding, vomiting, elevated temperature, decreased responsiveness and seizure activity. Incisional leakage should be tested for glucose, an indication of CSF, which place the infant at risk for infection. Abdominal distention is a manifestation of peritonitis or a postoperative ileus from distal catheter placement. C is not a result of a shunt obstruction and E is a normal finding for one-week-old neonate.

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

Which interventions should the nurse include in a long-term plan of care for a client with COPD?

a. Reduce risk factors for infection Rationale: Interventions aimed at reducing the risk factors of infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection of infections are necessary

A client whose wrists are sutured from a recent suicide attempt has been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

a. Risk for self-directed violence related to impulsive actions

After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply)

a. The client voluntarily grants permission for the procedure to be done c. The client is competent to sign the consent without impairment of judgment d. The client understands the risks and benefits associated with the procedure Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to the client's signature on surgical consent indicates that the client voluntary gives consent for the scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of the procedure.

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

a. Transfuse packed red blood cells Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical.

A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?

a. Turkey salad sandwich.

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse?

a. Uncontrollable drooling

A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

a. Urinary output of 25mL per hour

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement?

b- Ask the client if she has had any recent thoughts of harming herself.

After removing a left femoral arterial sheath, which assessment findings warrant immediate interventions by the nurse? (Select all that applied.)

b- Unrelieved back and flank pain. c- Cool and pale left leg and foot. d- Left groin egg-size hematoma.

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

b- What food does your baby usually eat in a normal day? Rationale: The normal weight gain in the first year of life is approx. twice the birth weight

When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?

b- Yogurt. e- Processed cheese. Rationale: In hypoparathyroidism, the client's diet should be supplemented with calcium rich foods which include dairy products.

The nurse is conducting health assessments. Which assessment finding increases a 56 year-old woman's risk for developing osteoporosis?

b. 20 pack-year history of cigarette smoking Rationale: Cigarette smoking (2 packs/day x 10 years = 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens and are also protective against development of osteoporosis. D is not related to the development of osteoporosis.

A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?

b. Acknowledge the client's stress and suggest that she consider respite care. Rationale: When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care.

After checking the fingerstick glucose at 1630, what action should the nurse implement?

b. Administer 8 units of insulin aspart SubQ

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

b. Advise the client to empty her bladder fully when she first voids

A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering?

b. Bronchodilators

A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?

b. Catheterize for residual urine after next voiding

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

b. Contains a list with definitions of unfamiliar terms c. Uses common words with few Syllables e. Uses pictures to help illustrate complex ideas Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner's attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font.

A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest?

b. Encourage screening for a peptic ulcer. Rationale: Helicobacter pylori is a gram- negative organism than can colonize in the stomach and is associated with peptic ulcers formation.

The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate?

b. Ensure that the scale is calibrated before a weight is obtained

A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours?

b. Evaluate daily serial renal laboratory studies for progressive elevations.

A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment?

b. Explain that a protruding abdomen is typical for toddler

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

b. Fluid shifts from intravascular to interstitial area due to decreased serum protein c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen d. Increased circulating aldosterone levels that increase sodium and water retention Rationale: When liver fail production of albumin is reduced. Since albumin is the primary serum protein creating intravascular osmotic pressure, decreased serum protein allows a fluids shift into the interstitial space. Pressure increases in the portal circulation © when venous return from the upper GI tract cannot flow freely into sclerosed liver, which cause a pressure gradient to further Increase fluid shifts into the abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone resulting in sodium and water retention.

The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?

b. Long-term care facility e. Home health agency Long term care facilities and home health agencies performs ADLs. Hospice provides empathetic, attentive care for dying. C provide physical therapy to strengthen a part of the body.

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restraints are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care?

b. Maintain effective breathing patterns Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C)

A client with superficial burns to the face, neck, and hands resulting from a house fire... which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?

b. Mucous membranes cherry red color

A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?

b. Muscle cramping Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating?

b. Normal sinus rhythm and complaining of chest pain

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?

b. Observe for changes in level of consciousness. Rationale: Based on the client's history of drinking, he may be exhibiting sign of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

b. Obtain a prescription for DNR

In assessing a pressure ulcer on a client's hip, which action should the nurse include?

b. Photograph the lesion with a ruler placed next to the lesion Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

b. Place a washcloth in the sink while cleaning the dentures

A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result...dealing with the healthcare provider. What action should the nurse manager implement?

b. Plan an interdisciplinary staff meeting to develop strategies to enhance client care

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

b. Recognize signs and symptoms of hypoglycemia. c. Report persistent polyuria to the healthcare provider. e. Take Glucophage with the morning and evening meal. Rationale: Glucophage, an antidiabetic agent, acts by inhibiting hepatic glucose production and increases peripheral tissue sensitivity to insulin. The client and family should be taught to recognize signs and symptoms of hypoglycemia. If the dose of Glucophage is inadequate, signs of hypoglycemia, such as polydipsia and polyuria, should be reported to the healthcare provider. Glucophage should be taken with meals to reduce GI upset and increase absorption (E).

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?

b. Redress the abdominal incision Rationale: The abdominal incision should be redressed using aseptic-techniques. The IV site should be assessed to ensure that it has not been dislodged and a dressing reapplied, if need it. Leaving the light on at night may interfere with the client's sleep and increase confusion. Restraints are not indicated and should only be used as a last resort to keep client from self-harm.

The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer's diseases. The client's wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

b. Suggest enrolling the client in adult daycare instead of rotating among family Rationale: Suggesting a viable alternative, such as adult daycare provides an option to allow the spouse respite the least disruption to routines and environment.

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

b. Surgeon needs to see client immediately to evaluate the situation

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement?

b. Teach client to listen to music or audio books while driving

A toddler presents to the clinic with a barking cough, stridor, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

c. Administered Nebulized Epinephrine

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

c. Allow time for the behavior and then redirect the client to other activities

When should intimate partner violence (IPV) screening occur?

c. As a routine part of each healthcare encounter

A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care?

c. Avoid foods that caused gas before the colostomy

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?

c. Continue with the plan of care for this client Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys

The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents?

c. Development progress from head to rump

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?

c. Diaphoresis

The nurse is caring for a client with an NG tube. Which task can the nurse delegate to the UAP?

c. Disconnect the NG suction so the client can ambulate in the hallway

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

c. Document the finding in the infant's record

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger?

c. Full bladder Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.

When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

c. Get a blood pressure cuff.

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

c. Have the adolescent list the procedural steps for safe insulin administration.

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

c. I need to have regular pap smears

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?

c. Increase intravenous infusion Rationale: a fundus that is dextroverted (up to the right) and elevated above the umbilicus is indicative of bladder distension/urine retention.

A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

c. Maintain strict aseptic technique.

A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?

c. Prepare the client for intubation

A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?

c. Provide immediate defibrillation

A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?

c. Provide only necessary information in short, simple explanations with written instructions to take home Rationale: Simple, short explanations should be provided. Information is not retained when the recipient is anxious, and too much information can increase worry. Ethically, discharge instructions may not be postponed.

A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

c. Report the client's jaw pain to the healthcare provider. Rationale: Bisphosponates, including alendronate, can cause osteonecrosis of jaw, which should be reported to the healthcare provider © for evaluation. Incorrect administration (A) such as failing to remain upright after taking the medication, can contribute to esophageal reactions, but does not causes haw pain. Jaw pain is not a symptom of osteoporosis and is not relieved with saline throat gargles.

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

c. Viral meningitis whose temperature changed from 101 F to 102 F. Rationale: The most stable patient should be assigned to the PN, changes in the Glasgow coma Scale indicated the client's neurological status is worsening. The client decreasing BP is physiologically unstable. An increasing systolic blood pressure and widening pulse pressure is indicative of increasing intracranial pressure.

The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

corner of the mouth to the tip of the ear

In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next?

d. Observe the amount and dose of morphine in the PCA pump syringe

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?

d. Ask the wife to stop and assess the client's swallowing reflex. Rationale: Until a swallowing reflex has been established, giving oral fluids can be dangerous, even life-threatening. The nurse should immediately stop the dangerous situation and assess the client. It is most important to determine if the client can swallow before giving him anything by mouth.

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?

d. Blood pressure 170/98 Rationale: SLE can result in renal complication such as glomerulonephritis, which can cause a critically high blood pressure that necessitates immediate intervention. A, B and C are symptoms of glomerulonephritis and should be treated once the blood pressure is under control

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?

d. Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation Rationale: A slight bilirubin elevation and anemia are expected finding in a stable client with chronic liver failure who should be transferred to a less-acute medical unit.

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?

d. Encourage the client to describe the pain. Rationale: Neuropathic pain is caused by damage within the nervous system. Description of the pain such as burning or numbness helps identify the pain as neuropathic, allowing appropriate treatment to be initiated. Elevation is to unlikely to impact the pain. Persons with diabetes mellitus may develop peripheral neuropathy, nut there is no immediate need to measure this client's capillary glucose. (C) is not a useful intervention in assessing or managing neuropathic pain.

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse?

d. Evidence of hypoventilation Rationale: Hypoventilation indicates respiratory muscle weakness, and if the client is unable to breath... respiratory distress and life-threatening.

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?

d. Explore the client's decision to refuse treatment and offer support Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client's decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

d. Have a meconium aspirator available at delivery

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

d. Monitor mental status. Rationale: Administer lactulose to a patient with hepatic encephalopathy to lower serum ammonia level, so mental status should be improving.

Which intervention should the nurse implement for a client with a superficial (first degree) burn?

d. Place wet cloths on the burned areas for short periods of time. Rationale: D provides comfort and helps to relive the pain of a first degree burn, which involves only the epidermal layer of the skin.

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

place the id bands on the infant and mother