SPRING 2023 HESI EXIT
The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet? A Fresh fruits and vegetables. B Iron-rich meats. C Water and herbal teas. D Low fat dairy products.
D Low fat dairy products.
NGN: What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? Select all that apply. A Have the client sign a no-suicide contract B Refer the client for cognitive behavioral therapy C Make the client feel too guilty to commit suicide D Place the client in a locked unit E Have the client remove any sharp objects from the home F Help the client enlist the help of friends and family
A Have the client sign a no-suicide contract F Help the client enlist the help of friends and family
Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? A Obtain a capillary glucose level. B Feed 30 mL of 10% dextrose in water. C Wrap tightly In a warm blanket. D Encourage the mother to breastfeed.
A Obtain a capillary glucose level.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understand the prescribed diet? A Roast pork, fresh strawberries. B Baked potato with skin, raw carrots. C Roasted turkey, canned vegetables. D Pancakes, whole-grain cereals.
C Roasted turkey, canned vegetables.
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." Which is the priority nursing problem for this client? A Knowledge deficit. B Pain (acute). C Anticipatory grieving. D Anxiety.
D Anxiety.
A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which Intervention should the nurse provide to address the client's problem? A Contact a hospice nurse for an evaluation. B Arrange an appointment with a pain specialist. C Form an interdisciplinary team for evaluation. D Ask for a consultation with a psychologist.
B Arrange an appointment with a pain specialist.
A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? A Raise head of bed until to a 90 degree angle. B Position bedside table so the client can lean across it. C Place bed in a reverse trendelenburg position. D Encourage rest until the analgesic becomes effective.
B Position bedside table so the client can lean across it.
The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention? A Circumferential skin irritation. B Red streak tracking the vein. C Cool sensation above the site. D A sluggish blood return.
B Red streak tracking the vein.
The healthcare provider prescribes regular insulin 8 units/hr intravenously (IV). The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)
0.08 mL/hr
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL.". How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
0.2 mL
A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)
0.8 mL
An unlicensed assistive personnel (UP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP's behavior? (Place the actions 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 UP for signs of improvement.
The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention? A An 18-year-old client with antisocial behavior who is being yelled at by other clients. B A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C A 16-year-old client diagnosed with major depression who refuses to participate in a group. D A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
A An 18-year-old client with antisocial behavior who is being yelled at by other clients.
After receiving report, the nurse can most safely plan to assess which client last? A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. B An older client with a distended abdomen and no drainage from the nasogastric tube. C An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac D An adult client with a rectal tube draining clear, pale red liquid drainage.
A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed.
The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A Begins to show signs of improvement in effect. B Expresses feelings of sadness and loneliness. C Neglects personal hygiene and has no appetite. D Lacks interest in the activities of family and friends.
A Begins to show signs of improvement in effect.
A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority? A Instruct parents regarding care of the incisional area. B Mark an outline of the "olive-Shaped" mass in the right epigastric area. C Initiate a continuous infusion of IV fluids per prescription. D Monitor amount of intake and infant's response to feedings.
C Initiate a continuous infusion of IV fluids per prescription.
When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A Increase intravenous infusion. B Massage the uterus to decrease atony. C Review the hemoglobin to determine hemorrhage. D Check for a distended bladder.
D Check for a distended bladder.
NGN: The client is 74 yr old female with a hx of HTN and HLD. She takes lisinopril, simvastatin, and melatonin for sleep. She was admitted today for pneumonia. She visited her PCP last week, and she has lost 2.8kg since that visit. Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing. 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress. 1 Pot
Potential Condition: dehydration Actions to take: Measure BP and Ask the client for a nutrition hx Parameters to monitor: Capillary refill and BG
NGN: The client is awake and alert but restless. He states "I am feeling extremely anxious right now." The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is 4 seconds. Heart rate 101 bpm. Oxygen saturation 90%. Blood pressure 145/89 mmHg. Temperature 100.2F. Respiratory rate 28 bpm. The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the
Respiratory A Respiratory rate 28 bpm C Oxygen saturation 90% Cardiovascular A Heart rate 101 bpm C Capillary refill 4 seconds
NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2 yr old son. She and her father were the only survivors of the crash. She is seeking care for depression. Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The client is exhibiting symptoms of _________ relating to ___________ and __________.
The client is exhibiting symptoms of PTSD relating to EXPERIENCING A LIFE-THREATENING EVENT and LOSING A LOVE ONE.
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 oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A Administer a nebulizer treatment. B Call for an Ambu resuscitation bag. C Increase oxygen to 6 liters/minute. D Assist the client t
A Administer a nebulizer treatment.
A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, "10 mg/mL." How many mL should the nurse administer? (Enter numeric value only.)
4 mL
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A "What are the voices saying?" B "Which medication works best?" C "When do you hear voices?" D "How do you cope with the voices?"
A "What are the voices saying?"
The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.) A Sodium intake can be regulated by limiting canned foods in the diet. B Salt substitutes can help with maintaining a healthy diet. C Alcohol consumption will not produce vascular changes. D Uncontrolled hypertension can lead to renal damage. E Blood pressure readings should be taken at noontime. F Weight management is promoted by taking daily walks for t
A Sodium intake can be regulated by limiting canned foods in the diet. B Salt substitutes can help with maintaining a healthy diet. D Uncontrolled hypertension can lead to renal damage. F Weight management is promoted by taking daily walks for thirty minutes.
NGN: After the examination by the physician, the client was diagnosed with depression and PSTD. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and medication. How can the nurse build a therapeutic relationship with the client? Select all that apply. A The nurse can establish a meaningful connection B The nurse can be open, honest, and sincere C The nurse can communicate acceptance of the client as she is
A The nurse can establish a meaningful connection B The nurse can be open, honest, and sincere C The nurse can communicate acceptance of the client as she is
While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A Use a water soluble lubricant on affected oral and nasal mucosa. B Use a topical lidocaine analgesic for cracked lips. C Ask the mother what she usually uses on the child's lips and nose. D Apply a petroleum jelly to the child's nose and lips.
A Use a water soluble lubricant on affected oral and nasal mucosa.
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? A Watery diarrhea. B Increased fatigue. C Yellow-tinged sputum. D Nausea and headache.
A Watery diarrhea.
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? A Withhold this dose. B Mix the next dose with food. C Give another dose. D Administer a half dose now
A Withhold this dose.
The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider? Reference Range Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)] A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram ST segment elevation. C Urine output 30 mL/hour. D Blood pressure 130/80.
B Electrocardiogram ST segment elevation.
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. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)? A 9%. B 36%. C 18%. D 45 %.
B 36%.
When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.) A Ask the client to describe her reaction to milk and eggs. B Add egg allergy to client's identification arm band. C Eliminate the chicken selections from the client's menu. D Notify the
B Add egg allergy to client's identification arm band. D Notify the dietary department of the client's egg intolerance. E Enter new allergy information in the client's electronic medical record.
NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What actions should the nurse take to assure safety during morphine administration? Select all that apply. A Have a manual resuscitation bag at the bedside B Ask the client about other medications she takes C Perform a 12-lead electrocardiogram D Take an initial respiratory rate
B Ask the client about other medications she takes D Take an initial respiratory rate
A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria? A Red bumps across chest. B White coating on tongue. C High, protracted fever. D Flaky, peeling skin.
B White coating on tongue.
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 A 75-year-old client with renal calculi who requires urine straining. B A 64-year-old client who had a total hip replacement the previous day. C A 30-year-old depressed client who admits to suicide ideation. D An adolescent with multiple contusions due to a fall that occurred 2 days ago.
C A 30-year-old depressed client who admits to suicide ideation.
The nurse observes an unlicensed assistive personnel (UP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? A Help the UAP reposition the gown sleeve over the glove edges. B Remind the UP to wash hands frequently while in the room. C Confirm that the gown is tied securely at the neck and waist. D Assist the UAP with application
C Confirm that the gown is tied securely at the neck and waist.
A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet? A Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin. B Increase the intake of dark green leafy vegetables while taking warfarin. C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D Eat two servings of raw dark green leafy vegetables daily and continue for
C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dI (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Reference Range Total Bilirubin [Reference Range: Newborn:0.1 to 10.5 mg/dL (1.7 to 180 Mcmol/L)] A Cover with a receiving blanket. B Perform diaper changes under the light. CFeed the infant every 4 hours. D Reposition the infant every 2 hour
D Reposition the infant every 2 hours.
A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the cent. Which action should the nurse take? A Remind the UP to apply a fitted respirator mask before entering the client's room. B Assign the UP to provide care for another client and assume full care of the client. C Instruct the UP to notify the nurse of any changes in the client's respiratory status. D Review the need for
D Review the need for the UP to wear a face mask while in close contact with the client.
A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take? A Ask the wife to wait outside the room until the nurse can talk with her. B Keep orienting the client to time an
D Explain the postictal state that usually follows seizures.
A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? A Blood glucose level. B Percussion of abdomen. C Serum electrolytes. D Level of consciousness.
D Level of consciousness.
The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize? A Leg elevation. B Pain management. C Ambulation teaching. D Neurovascular checks.
D Neurovascular checks.
Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first? A Bring the emergency crash cart to the bedside. B Prepare a continuous heparin infusion per protocol. C Notify the healthcare provider. D Provide supplemental oxygen.
D Provide supplemental oxygen.
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide? A Inform that follow-up may end after the treatment is finished. B Emphasize that using safe sex practices removes the risk of STIs. C Clarify that all STIs are transmitted through sexual intercourse. D Remain non-judgmental and assure the client of confidentiality.
D Remain non-judgmental and assure the client of confidentiality.
The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A Instruct the UP to return to the client's room to perform hand washing. B Advise the UP to wear gloves when obtaining vital signs for all clients. C Supervise the UP in the next client's room to evaluate hand hygiene. D Remind the UAP to continue rubbing the hands together until they are dry.
D Remind the UAP to continue rubbing the hands together until they are dry.
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions? A Twin siblings admitted with scarlet fever that is complicated with pneumonia. B An older client with scabies who is admitted from an extended care facility. C A female adolescent admitted with multiple genital Herpes simplex I lesions. D A cl
D A client with a positive Mantoux and sputum cultures results positive for AFB.
What nursing intervention is particularly indicated for the second stage of labor? A Assessing the fetal heart rate and pattern for signs of fetal distress. B Monitoring effects gf oxytocin administration to help achieve cervical dilation. C Providing pain medication to increase the client's tolerance of labor pains. D Assisting the client to push effectively so that expulsion of the fetus can be achieved.
D Assisting the client to push effectively so that expulsion of the fetus can be achieved.
The nurse is assigning care of a client with prostatitis to a practical nurse (P). Which instruction should the nurse provide the PN regarding care of this client? A Restrict oral fluid intake. B Strain all urine. C Maintain contact isolation. D Avoid urinary catheterization.
D Avoid urinary catheterization.
A male client with heart failure becomes short of breath, anxious, and has audible wheezing with sputupink frothy m. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. What action should the nurse take? A Consult with the charge nurse regarding the morphine prescription. B Administer the dose of morphine sulfate as prescribed. C Withhold the morphine until the client's dyspne
D Review the need for the prescription with the healthcare provider.
The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action? A Maintain elevated positioning of the dependent joints on affected side. B Keep the bed in the lowest position and initiate seizure and fall precautions. C Place an indwelling urinary catheter and measure strict intake and
D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
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? A The nurse manager should be updated on the client's status. B The client's status should be conveyed to the chaplain. C The impending signs of death should be documented. D The client's need for pain medication should be determined.
D The client's need for pain medication should be determined.
A 46-year-old male client who had a myocardial infarction (MI) 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 client problem should the nurse included in the plan of care? A Anxiety related to treatment plan. B Decisional conflict due to stress. C Deficient knowledge of lifestyle changes. D. Ineffective coping related to denial.
D. Ineffective coping related to denial.
NGN: Client was brought in for his 5 yr old well visit and to update vaccines. The mother reports that the child is having some trouble paying attention in school and has had a poor appetite in the past few weeks. Which intervention is appropriate to manage the lead poisoning level of 7ug/dL (0.34umol/L). Each row must have at least one, but may have more than one, response option selected. Monitor h&H for potential anemia. Monitor blood lead levels at 1 month, then every 3-4 months. Chelation
Monitor H&H for potential anemia.- NOT NEEDED Monitor blood lead levels at 1 month, then every 3-4 months.- NEEDED Chelation therapy.- NEEDED Provide family with lea education, regular developmental and behavioral surveillance, and social service referral if necessary.- NEEDED Ask parent about the age of their home and any home remedies that may have been taken.- NEEDED Providing supplemental oxygen.- NEEDED Monitor urine glucose and protein for renal effects of lead.- NOT NEEDED
NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. The nurse is discussing the client's pain management with a student nurse. Choose the most likely options for the information missing from the statement (s) by selecting from the lists of options provided. Morphine is a(n) __________ and it activates __________ receptors and is
Morphine is a(n) AGONIST-ANTAGONIST OPIOD and it activates BETA receptors and is used to relieve PAIN.
NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. Drag from the choices below to fill in each blank in the following sentence. The nurse should place the client in a ANSWER 1 position to promote ANSWER 2. Answer 1: trendelenburg, supine, prone, or
The nurse should place the client in a SEMI-FOWLER'S position to promote LUNG EXPANSION.
NGN: During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing from the statement by selecting the list of options provided. The statement by the client represents _______ and should be followed up with __________.
The statement by the client represents SUICIDAL IDEATION and should be followed up with AN ASSESSMENT OF RISK FACTORS FOR SUICIDE.
An older client with a history of cataracts is recovering from intraocular lens implant (OL) surgery to the left eye. During the post-procedure period, which intervention should the nurse implement? A Encourage deep breathing and coughing exercises. B Obtain vital signs every 2 hours during hospitalization. C Provide an eye shield to be worn while sleeping. D Teach a family member to administer eye drops.
C Provide an eye shield to be worn while sleeping.
A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement? A Explain exercise daily regimen. B Demonstrate specific strengthening exercises. C Provide typed instructions for healthy diet selection D Reinforce need for adequate hydration.
C Provide typed instructions for healthy diet selection
The nurse receives a shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement? A Allow time for the behavior and then redirect the client to other activities. B Teach the client thought stopping techniques and ways to refocus behaviors. C Assist the client to identify stimuli that precipitates the activity. D Encourage t
A Allow time for the behavior and then redirect the client to other activities.
A nurse took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, which action is best fo the charge nurse to take? A Meet with staff to assess their feelings about the impaired nurse's return to the unit. B Allow the impaired nurse to return to work and monitor medic
B Allow the impaired nurse to return to work and monitor medication administration.
) A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action(s) should the nurse take? (Select all that apply.) A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. C Call healthcare provider for a prescrip
A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. E Continue to monitor the client for signs of an infection.
NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply. A Docusate sodium B Methadone C Propofol D Naloxone E Senna F Ibuprofen
A Docusate sodium D Naloxone
112) An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse explore further with the client? (SATA) A History of hypertension. B Homosexual lifestyle. C Vege
A History of hypertension. E Family health history.
An older client admitted for observation following a fall while getting out of the bath tub becomes increasingly confused. The family arrives with the home medication list and the client's healthcare power of attorney. When providing a report to the healthcare provider using BAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A Increasing confusion of the client. B Client's healthcare power of attorney. C Fall at home as reaso
A Increasing confusion of the client.
What action should the school nurse implement to provide secondary prevention for school-aged children? A Initiate a hearing and vision screening program for first graders. B Prepare a presentation on how to prevent the spread of lice. C Observe a person with type 1 diabetes self-administer a dose of insulin. D Collaborate with a science teacher to prepare a health lesson.
A Initiate a hearing and vision screening program for first graders.
A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implements while administering this medication? A Measure urinary output every hour. B Initiate seizure precautions. C Monitor serum potassium frequently. D Assess pupillary response to light hourly
A Measure urinary output every hour.
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.) A Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). C Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively. D Start the second blood transfusion for a clie
A Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement? A Prepare for rapid sequence intuba
A Prepare for rapid sequence intubation.
The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? A Push the undiluted Dextrose slowly through the currently infusing IV. B Dilute the Dextrose in one liter of 0.9% Normal Saline solution. C Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL. D Ask the pharmacist to add the Dextrose to a TPN solution.
A Push the undiluted Dextrose slowly through the currently infusing IV.
A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client's teaching plan? (Select all that apply.) A Report persistent polyuria to the healthcare provider. B Use sliding scale insulin for fingerstick glucose elevations. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia. E Take an additional dose for signs of hyperglycem
A Report persistent polyuria to the healthcare provider. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia.
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention (s) should the nurse implement? (Select all that apply.) A Report serum albumin and globulin levels. B Provide diet low in phosphorus. C Increase oral fluid intake to 1,500 mL daily. D Note signs of swelling and edema. E Monitor abdominal girth.
A Report serum albumin and globulin levels. D Note signs of swelling and edema. E Monitor abdominal girth.
Which intervention Is most important for the nurse to include in the plan of Care for a client who is 12 hours post-thyroidectomy ? A Resume antithyroid drug therapy. B Prepare to administer radioactive iodine treatments. C Anticipate and monitor for hypothermia. D Maintain a semi-Fowler position.
A Resume antithyroid drug therapy.
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A Erythrocytes, hemoglobin, and hematocrit. B Serum potassium, calcium, and phosphorus. C Blood pressure, heart rate, and temperature. D Leukocytes, neutrophils, and thyroxine.
B Serum potassium, calcium, and phosphorus.
An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture
B Culture sputum, urine, burn wound, and all intravenous access sites.
The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s)made by the client should the nurse recognize as needing additional education? (Select all that apply.) A Keep a food diary. B Eat more canned vegetables. C Consume foods with saturated fats. D Walk 30 minutes per day. E Include oatmeal for breakfast. F Use a salt substitute.
B Eat more canned vegetables. C Consume foods with saturated fats.
The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A Prop the infant with a pillow when in a side-lying position. B Ensure that the infant's crib mattress is firm. C Place the infant in a prone position whenever possible. D Swaddle the infant in a blanket for sleeping.
B Ensure that the infant's crib mattress is firm.
A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement? Reference Range: Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)]. A Evaluate patency of the AV graft for resumption of hemodialysis. B Ensure
B Ensure the client receives frequent small meals containing complete proteins.
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. Which action should the nurse take first? A Report the finding to the police department. B Explore client's readiness to discuss the situation. C Determine the frequency and type of client's abuse. D Discuss treatment options for abusive partners.
B Explore client's readiness to discuss the situation.
NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. To start the client on oxygen as ordered, what should the nurse collect from the supply room? Select all that apply. A Sterile water B Flowmeter C Lamb's wool D Suction canister E Humidifier bottle
B Flowmeter G Nasal cannula
The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding? A Using salt, herbs, and spices will improve the flavor of foods. B Get an eye examination with an ophthalmologist annually. C Arrange diet schedule around three regular meals a day. D Inspect feet every month for ingrown nails, cuts, and calluses.
B Get an eye examination with an ophthalmologist annually.
The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.) A Encourage increased intake of high protein foods. B Instruct the daughter to check her mother's temperature. C Determine if the mother has recently experienced a fall. D Ask if the mother is experiencing any pain with urination. E Review the client's current food and medication allergies.
B Instruct the daughter to check her mother's temperature. C Determine if the mother has recently experienced a fall. D Ask if the mother is experiencing any pain with urination.
Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? A Confront the client's denial of substance abuse. B Maintain a quiet, non-stimulating environment. C Force oral fluids and provide frequent small meals. D Encourage attendance and group participation.
B Maintain a quiet, non-stimulating environment.
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? A Assess perineal area. B Observe insertion site. C Palpate flank area. D Measure abdominal girth
B Observe insertion site.
A client is admitted to the hospital after experiencing a stroke or cerebrovascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A Inappropriate or exaggerated mood swings. B Persistent coughing while drinking. C Abnormal responses for cranial nerves I and Il. D Unilateral facial drooping.
B Persistent coughing while drinking.
NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. What 2 orders should the nurse complete first? A Sputum culture B Place the client on a cardiorespiratory monitor C Start a PIV D NPO E Acetaminophen 350mg PO q6h for temperature greater than 101F F
B Place the client on a cardiorespiratory monitor F Start O2 3L via NC
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. Which intervention should the nurse implement? A Leave the lights on in the room at night. B Redress the abdominal incision C Apply soft bilateral wrist restraints. D Replace the IV site with a smaller gauge.
B Redress the abdominal incision
An adult 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? Reference Range: Blood alcohol level [Reference Range: 0 to 10.9 mmol/L (0% to 0.05%)] Lithium (Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L] A Blood alcohol level of 0.09% (90 mmol/L) B Serum lithium level of 1.6 mEq/L (1.6 mmol/L) C Six ho
B Serum lithium level of 1.6 mEq/L (1.6 mmol/L)
An older adult with terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should he nurse include in this client's plan of care? (Select all that apply). A Record the client's desire to live. B Teach client how to use guided imagery. C Instruct client and family to reconsider end of life choices. D Encourage family to bring the client old photographs. E Encourage family to visit frequently.
B Teach client how to use guided imagery. D Encourage family to bring the client old photographs. E Encourage family to visit frequently.
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 explanation should the nurse provide? A Restrictive clothing will be adequate to help the hernia go away. B This hernia is a normal variation that resolves without treatment. C The quarter should be secured with an elastic bandage wrap. D An abdominal binder can be worn daily to reduce the protrusion.
B This hernia is a normal variation that resolves without treatment.
A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take? A Secure chest tube to the stretcher for transport. B Administer PRN pain medication prior to transport. C Keep chest tube container below the site of insertion. D Mark the amount of chest drainage on the container.
C Keep chest tube container below the site of insertion.
A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome? A Instruct the client to take analgesics on a regular schedule. B Encourage the client to verbalize anxiety and grief. C Maintain intravenous therapy. D Identify potential sources of infection.
C Maintain intravenous therapy.
An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in client's plan of care? A Measure and record the client's urinary output every day. B Provide the client with teaching regarding a cardiac diet. C Obtain a blood pressure reading
C Obtain a blood pressure reading before client gets out of bed.
NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. The charge nurse places a fall precautions sign on the client's door. What side effects of Morphine could contribute to this client's fall risk? Select all that apply. A Urinary retention B Seizures C Orthostatic hypotension D Sedation E Nausea F Itching G Euphoria
C Orthostatic hypotension D Sedation G Euphoria
The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? A Center attention on positive upbeat music. B Find outlets for more social interaction. C Practice using muscle relaxation techniques. D Think about reasons the episodes occur.
C Practice using muscle relaxation techniques.
A male client reports to the on-call clinic nurse that he took tadalafil 10mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? A Tell the client to have someone bring him to an emergency department immediately. B Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. C Reassure the client that skin flushing is a common
C Reassure the client that skin flushing is a common side effect of the medication.
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take? A Explain to the client that the dosage has been changed. B Tell him to take the medication then verify the dosage at the next healthcare team meeting. C Withhold the medication until the dosage can be confirmed. D Inform him that he may refuse the medication and document whether or not
C Withhold the medication until the dosage can be confirmed.
Which environmental factor is most significant when planning care for a client with osteomalacia? A Cool, moist air. B Stimulating sounds and activity. C Quiet, calm surroundings. D Adequate sunlight.
D Adequate sunlight.
A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next? A Remove the catheter and palpate the client's bladder for residual distention. B Clamp the catheter for thirty minutes and then resume draining. C Remove the catheter and replace it with an indwelling cath
D Allow the bladder to empty completely or up to 1,000 mL of urine.
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A Suggest that the child be encouraged to participate in a team sport to encourage socialization. B Explain that their child is too young to understand the risks associated with swimming. C Provide a list of alternative activities that are less likely to cause the child to experience fatigue. D Encourage
D Encourage the parents to allow the child to continue attending swimming lessons with supervision.
