2nd Hesi Study tips
Phenytoin (Dilantin) is prescribed for a client who has a seizure disorder. Which statement by the client indicates to the practical nurse that the instruction about this drug has been effective?
"I know that I should never stop taking this medication abruptly." Rationale: Abruptly discontinuing the medication (B) can precipitate seizures
A 74-year-old female client asks the practical nurse (PN) if she should get a flu shot. Which response should the PN provide?
"Yes. Normal aging decreases your immunity, making you more susceptible to contagious diseases such as the flu."
Which question should the practical nurse (PN) ask an older client before beginning treatment with gentamicin sulfate (Garamycin)?
Are you hard of hearing?" Rationale: Complications of gentamicin sulfate (Garamycin) therapy include ototoxicity, nephrotoxicity, and neurotoxicity. Determining if the client is hard of hearing (A) before initiation of this aminoglycoside will be helpful as the treatment progresses and ototoxicity is identified as a possible complication. Answers to (B, C, and D) are important elements of any medical history, but they do not have the priority of (A) when assessing for complications of aminoglycoside therapy.
An older female client expresses frustration and embarrassment about her stress incontinence issues. Which information regarding bladder retraining should the nurse provide to the client?
Avoid jumping or running. Rationale: Jumping or running may cause more urine to leak from the urethra (C). Restricting fluid intake may produce less urine; however, it may place the client at risk for dehydration (A). Caffeine is a bladder irritant and should be avoided in clients with stress incontinence (B). Increasing time between voidings will add additional pressure to the sphincter and may cause increased episodes of incontinence (D).
The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply.
Be sure all connections remain airtight. Be sure all connections are taped and secure. Monitor closely for tubing that is kinked or obstructed by the weight of the client. Rationale: Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, lung collapse can occur. Options 2, 3, and 5 are appropriate interventions for the plan of care for a client with a chest tube.
Which instruction should the practical nurse (PN) reinforce when teaching a client who is receiving phenytoin (Dilantin) for seizure control
Brush and floss teeth daily. Rationale: Brushing and flossing the teeth daily prevents gingival hyperplasia (gum disease) that is common with long-term phenytoin (Dilantin) therapy (D). (A, B, and C) are not indicated for client instruction regarding phenytoin (Dilantin).
The nurse is collecting data about how well a client with a gastrointestinal (GI) disorder is able to digest food. Which processes are involved in the complete digestive process? Select all that apply.
Chemical Absorption Mechanical Active transport Rationale: Digestion is the mechanical and chemical process involving the breakdown of foods. Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Options 1 and 3 are incorrect.
The practical nurse (PN) is assessing an 8-month-old who has a medical diagnosis of tetralogy of Fallot. The child demonstrates cyanosis with crying and exertion. Which other symptom is this infant most likely to exhibit?
Clubbed fingers Rationale: Tetralogy of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) resulting from tissue hypoxia
Daily doses of calcium citrate malate (Calcium) and vitamin D are prescribed for a 70-year-old female client. Which instruction should the nurse provide to this client regarding taking the prescribed medications?
Divide the medication over the course of the day and take it in small doses 1 hour after meals and at bedtime. Rationale: Studies have shown a significant reduction in fractures when clients take the calcium and vitamin D supplements in small doses during the course of the day
The nurse reviews the client's intake and output (I&O) for the 8-hour shift. The nurse notes that the client has had 50 mL per hour of IV fluids, 500 mL of IV medications, 35 mL of water, and 75 mL of broth. Calculate the client's intake for the 8-hour shift.
First determine the total amount of IV fluids in the shift (50 mL × 8 hours = 400 mL). Then add all the fluids together (400 mL IV fluids + 500 mL IV medications + 35 mL water + 75 mL broth = 1010 mL).
When caring for a client on digoxin (Lanoxin) therapy, the practical nurse (PN) should be alert for digoxin (Lanoxin) toxicity. Which finding is likely to predispose this client to developing digoxin toxicity?
Hypokalemia—low serum potassium level Rationale: Hypokalemia (C) predisposes the client on digoxin to digoxin toxicity and is usually presented as abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and atrioventricular (AV) dissociation. Assessment of serum potassium levels and prompt correction of hypokalemia are important interventions for the client taking digoxin. (A, B, and D) are not relevant.
An antacid (Maalox) is prescribed for a client with peptic ulcer disease. What is the therapeutic action of this medication that is effective in treating the client's ulcer?
Maintenance of a gastric pH of 3.5 or above Rationale: The objective of antacids is to neutralize gastric acids and keep a pH of 3.5 or above (C), which is necessary for pepsinogen inactivity. (A) is the therapeutic effect of receptor antagonists, such as ranitidine (Zantac). (B) is the therapeutic effect of sucralfate (Carafate). (D) is the therapeutic effect of anticholinergic drugs such as propantheline bromide (Pro-Banthine) used as adjunctive therapy with antacids.
An infant is born with a ventricular septal defect (VSD), and surgery is planned to correct the defect. The practical nurse (PN) should understand that the surgical correction is designed to achieve which hemodynamic outcome?
Prevent the return of oxygenated blood to the lungs. Rationale: Closure of the VSD will stop shunting of oxygenated blood from the left ventricle (higher pressure) to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B), because the left-to right shunting of blood then recirculates through the pulmonary circuit. (D) is common with tetralogy of Fallot, which is a cyanotic defect.
A client is receiving benztropine (Cogentin) and olanzapine (Seroquel) to control psychotic behavior. When reinforcing teaching to the client and/or significant others about these medications, what should the practical nurse (PN) explain about the use of benztropine (Cogentin)?
The benztropine (Cogentin) is used to control extrapyramidal symptoms Rationale: Benztropine (Cogentin), an anticholinergic drug, is used to control extrapyramidal symptoms (C) associated with olanazapine (Seroquel) use. Caution is required in the dosage of Cogentin used in conjunction with olanzapine (Seroquel) (A, B, and D) are not accurate statements regarding the use of benztropine (Cogentin) in clients who are treated with olanzapine (Seroquel) for the control of psychosis.
Which outcome would indicate that the drug lactulose (Cephulac) has had a therapeutic effect?
Two or three soft stools per day Rationale: Two to three stools per day indicate that lactulose is performing as intended (B). Lactulose is administered to reduce blood ammonia by excretion of ammonia through the stool. (A) would be expected if the client received a diuretic. (C) would be expected if the client received an antiemetic. Lactulose does not affect (D).
A short arm cast is applied to a child with a fractured right ulna. The practical nurse (PN) is preparing the parents with home instructions and should reinforce that the parents follow which discharge instruction?
"Call the health care provider immediately if the nail beds appear 'blue' or 'empty. Rationale: Cyanosis (A) indicates impaired circulation to the fingers and should be reported immediately. It is not necessary to check the child's ability to move his fingers every hour for 2 days (B). Elevating the arm above the heart helps to decrease swelling, but (C) does not have the priority that impaired circulation does. It is not necessary to take the child's temperature q4h (D) unless indicated by other symptoms
The H2 receptor blocker famotidine (Pepcid) is prescribed for a client who has been taking antacids for chronic gastritis. Which client statement indicates to the practical nurse (PN) that teaching was effective regarding concurrent use of these medications?
"I will take the antacid after meals and the Pepcid at bedtime." Rationale: When taken at the same time, antacids block the absorption of H2 receptor blockers, so (C) indicates effective teaching.
The parents of a 7-month-old male infant with spastic cerebral palsy bring him to the pediatric clinic. Which statement by the parents warrants immediate intervention by the practical nurse (PN)?
"My son often chokes while I am feeding him." Rationale: Aspiration (A) is a priority when caring for an infant with cerebral palsy and dysphagia. (B and C) are characteristic manifestations of spastic cerebral palsy. These children will posture abnormally and will demonstrate difficulty with fine motor skills. (D) is an expected behavior and may need to be addressed but is not a priority over aspiration and choking.
The mother of a 6-month-old asks the practical nurse (PN) when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control and Prevention, which response is accurate?
12 to 15 months Rationale: The first measles, mumps, and rubella (MMR) vaccine should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age (B). Because of the presence of maternal antibodies, the MMR vaccine is not recommended at (A). MMR is not routinely administered at (C), but other immunizations, such as DTaP and hepatitis B, may be given at that time. The second dose of MMR is routinely administered at (D), provided that at least 4 weeks have elapsed since the first dose, and if both doses were administered beginning at or after 12 months.
When reinforcing teaching about childhood safety precautions to parents, the practical nurse (PN) should know that inducing vomiting is recommended for which child who may have ingested a possible poison?
16-month-old who drank 2 ounces of acetaminophen (Tylenol) elixir Rationale: Emesis should be induced for the child who drank the large dose of acetaminophen (Tylenol) elixir (C) because this medication is hepatotoxic. Vomiting is contraindicated for: children younger than 1 year of age (A), petroleum distillates (B) such as charcoal lighter fluid, and corrosives (D) such as dishwasher detergents.
Oral metronidazole (Flagyl) is prescribed for a client diagnosed with vaginal trichomoniasis, a protozoan infection. What precautions should the practical nurse (PN) instruct the client to follow while taking this medication?
Avoid ingesting any alcoholic (ethanol) beverage. Rationale: A disulfiram-like (Antabuse) reaction can occur if the client ingests ethanol (alcohol) (B) while taking metronidazole (Flagyl). (A) should be avoided because protozoa often proliferate in an acidic vaginal flora. Sexual intercourse is the route of spread for vaginal trichomoniasis (C), but the sexual partner should be treated simultaneously to prevent reinfection. (D) lists foods high in Lactobacillus acidophilus that are used to treat antibiotic-induced diarrhea, not trichomoniasis.
A client with hyperkalemia has a prescription for taking sodium polystyrene sulfonate (Kayexalate) for several days. The client also needs to consume a diet low in potassium. Which foods high in potassium content should the client avoid? Select all that apply.
Cabbage Mushrooms Strawberries Rationale: Foods high in potassium content include cabbage, mushrooms, and strawberries. Foods low in potassium content are peaches and soybeans
A client who is receiving chemotherapy asks the practical nurse (PN), "Why is so much of my hair falling out each day?" Which response by the PN best explains the reason for alopecia?
Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." Rationale: The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are results of chemotherapy's effect on the rapidly reproducing cells, both normal and malignant (A). (B and D) do not provide correct information about chemotherapy-induced alopecia. Although (D) is a true statement, it does not effectively answer the client's question.
The practical nurse (PN) is obtaining the medical history of a female client starting a new prescription for conjugated estrogens (Premarin) 0.625 mg PO daily. Before taking the first dose of the medication, which information is most important for the PN to obtain from the client?
Cigarette smoking history Rationale: Smoking cigarettes while on Premarin increases the client's risk for cardiovascular complications (D), so obtaining a smoking history is of highest priority
The health care provider prescribes the anticonvulsant carbamazepine (Tegretol) for an adolescent client with a seizure disorder. The nurse should instruct the client to notify the health care provider if which condition occurs?
Develops a sore throat Rationale: Blood dyscrasias (aplastic anemia, leukopenia, anemia, and thrombocytopenia) can be an adverse effect of carbamazepine (Tegretol). Flulike symptoms (C), such as pallor, fatigue, sore throat, and fever, are indications of such dyscrasias. (A and B) are expected reactions. (D) is a side effect of phenytoin (Dilantin), not carbamazepine (Tegretol).
A client is prescribed a peak and trough level test for the antibiotic vancomycin (Vancocin). What time should the specimen be collected to obtain the trough serum drug concentration?
Immediately before the next antibiotic dose is given Rationale: Trough levels are drawn when the blood level is at its lowest, which is typically just before the next dose is given
The nurse reviews the urine culture results for a client who is taking ciprofloxacin (Cipro) for a urinary tract infection. The nurse notes that the infection is sensitive to sulfonamides. What action is most important for the nurse to take?
Notify the provider of the culture results Rationale: The nurse should notify the health care provider because the client should be placed on a sulfonamide antibiotic
A 4-year-old child is returned to the child's hospital room following a tonsillectomy. The child remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions?
Side-lying Rationale: Side-lying (B) is the most effective position to facilitate the drainage of secretions from the mouth and pharynx and thus reduce the possibility of airway obstruction. (A) is the position used for vaginal and rectal examinations. (C and D) would increase the risk for airway obstruction and aspiration. The supine position would not facilitate drainage, and the prone position would not permit the nurse to observe the child for signs of bleeding such as increased swallowing.
When providing the client diagnosed with osteoporosis a list of foods that should be part of the client's diet, which items should the nurse include? (Select all that apply.)
tomato, cheese and chicken Rationale: The client diagnosed with osteoporosis should eat a diet that is high in protein, calcium, vitamins C and D, and iron to prevent further bone loss. Cheese is high in calcium (C), chicken is high in protein (D), and tomatoes are high in vitamin C (E). Peas (A) and apples (B), although nutritious, are not high in protein, calcium, vitamins C or D, or iron.
A client with diabetes mellitus takes insulin daily and is prescribed propranolol (Inderal). Which information should the nurse provide to this client?
A sign of hypoglycemia is that propranolol slows a rapid heart rate. Rationale: A client who takes insulin to manage type 1 diabetes should be instructed to recognize other signs of hypoglycemia, because propranolol slows the heart rate (D). Propranolol blocks glycogenolysis, and clients with diabetes who take insulin are at greater risk for hypoglycemia (A). (B) increases the risk of hypoglycemia, which also results from the suppression of hepatic glycogenolysis, an important mechanism for correcting hypoglycemia. (C) is inaccurate because the risk of hypoglycemia is related to the suppression of beta receptors in the liver.
A full-term infant is admitted to the newborn nursery. During the initial PO feeding, the practical nurse (PN) observes the infant for possible tracheal esophageal atresia. Which symptoms are likely to be exhibited during the feeding if this condition is present?
Choking, coughing, and cyanosis Rationale: (A) includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Projectile vomiting (B) is characteristic of pyloric stenosis in the infant. Apneic spells often occur with prematurity or sepsis, and grunting (C) is a sign of respiratory distress. A scaphoid abdomen (D) is characteristic of diaphragmatic hernia.
The health care provider has prescribed the low-molecular-weight heparin enoxaparin (Lovenox), 30 mg IVP bid for a client following hip replacement. Before administering the first dose, which intervention is most important for the practical nurse (PN) to implement?
Clarify the prescription with the RN and health care provider Rationale: Lovenox is a low-molecular-weight heparin that can only be administered subcutaneously, so the PN should contact and ask the registered nurse (RN) to call the health care provider to clarify the route of administration (D). (A and B) are important nursing interventions but not necessary to the administration of this medication. The client should be instructed about medication side effects (C), but this is of less priority than obtaining a correct prescription
Amitriptyline hydrochloride (Elavil) is prescribed for an adult female client who is clinically depressed. Five days after beginning the drug, the client is admitted to the hospital because of suicide ideation. She tells the practical nurse (PN) that the drug is not working because she is not feeling any better. Which explanation should the PN provide?
It takes 2 to 4 weeks for antidepressant medications to become effective."
The nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.
Monitoring daily weight Monitoring intake and output Maintaining a low-sodium diet Monitoring extremities for edema Rationale: The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.
A 12-year-old boy is admitted from the emergency room with status epilepticus. His parents report that his seizure disorder has been managed with phenytoin (Dilantin) 50 mg PO bid for the past year. What drug should the practical nurse (PN) expect to be prescribed for administration in the event of another series of seizures?
Diazepam (Valium) : Diazepam (Valium) (B) is the drug of choice for the treatment of status epilepticus and is given during a seizure. (A, C, and D) are used for long-term management of seizure disorders but are not as useful as diazepam in the emergency management of status epilepticus
A female client who started taking an oral sulfonamide for a urinary tract infection the previous day reports to the nurse that the medication is causing slight anorexia. She also states that she continues to experience urinary frequency, so she takes the medication with a small sip of cranberry juice and limits her fluid intake. What information should the practical nurse provide?
Drink a full glass of water with the medication and drink additional fluids throughout the day. Rationale: The PN should emphasize the need to take sulfonamides with a full glass of water (C) and to increase fluid intake to prevent crystalluria. Antacids (A) should not be taken with sulfonamides, because the antacid will decrease the absorption rate of the sulfonamide. Cranberry juice (B) is sometimes taken to prevent or alleviate symptoms of urinary tract infection, but fluid intake needs to be increased to prevent crystalluria. Sulfonamides are best administered on an empty stomach (D), with fluids rather than with food. Additionally, it is not necessary to avoid drinking cranberry juice.
The practical nurse (PN) is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the PN should hold the prescribed dose?
Guaiac-positive stool Rationale: Fragmin is a low-molecular-weight heparin (LMWH) anticoagulant used to prevent DVT in the at-risk client. If the client develops overt signs of bleeding such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is related to fluid volume rather than anticoagulant therapy. (D) is an expected result.
A client has a positive skin test for tuberculosis. What prophylactic drug should the practical nurse (PN) expect to be prescribed for this client?
Isoniazid (INH) Rationale: Isoniazid (INH) is highly specific for Mycobacterium tuberculosis and is the drug of choice for clients with positive PPD skin tests
The health care provider prescribes carbamazepine (Tegretol) for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood tests every week. The mother asks why so many blood tests are necessary. What complication is assessed through frequent laboratory testing, which the nurse should explain to this mother?
Myelosuppression Rationale: Myelosuppression (C) is the highest priority complication that can potentially affect clients managed with carbamazepine (Tegretol) therapy
The nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. Which terms apply to an android pelvis? Select all that apply
Narrow wedge shape Unfavorable for a vaginal birth Rationale: The android pelvis is wedge-shaped and narrow and is unfavorable for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable shape for a vaginal birth. An anthropoid pelvis is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvis; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvis is flattened with a wide, short, oval shape and is also an unfavorable shape for a vaginal birth.
The nurse is repositioning a client who has a chest tube. The tubing becomes stuck on the bed rail, and the chest tube is dislodged from the client's chest. Which intervention has the highest priority (Select all that apply.)
Notify the health care provider immediately. Apply an occlusive dressing over the disconnection site. Rationale: The priority nursing actions to take when a chest tube is dislodged is to place an occlusive dressing over the disconnection site (E) and to notify the health care provider immediately (C). Taking the client's vital signs following dislodgment of a chest tube is important but is not the priority action (A). An incident report can be completed after the patient is stabilized (B). The intact chest tube is placed in a bottle of sterile water while the drainage system is being replaced (D).
A health care provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the practical nurse (PN) to consider that a cross allergy is possible with what drug allergy?
Penicillins Rationale: Cross allergies exist between penicillins (A) and cephalosporins such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.
A child with cystic fibrosis is receiving ticarcillin disodium (Ticar) for Pseudomonas pneumonia. What adverse effect should the nurse assess for and report promptly to the health care provider?
Petechiae Rationale: Adverse effects of ticarcillin disodium (Ticar) include hypothrombinemia and decreased platelet adhesion, which can result in the presence of petechiae (A). (B, C, and D) are not adverse effects primarily associated with the administration of ticarcillin
A client is receiving ampicillin sodium (Omnipen) for a sinus infection. The practical nurse (PN) should reinforce that the client notify the health care provider immediately if which symptom occurs?
Rash Rationale: Rash (A) is the most common adverse effect of all penicillins, indicating an allergy to the medication, which could result in anaphylactic shock, a medical emergency. (B, C, and D) are common side effects of penicillins that should subside after the body adjusts to the medication. These would not require immediate medical care unless the symptoms persist beyond the first few days or become extremely severe.
The health care provider prescribes amoxicillin 60 mg PO three times a day for a child who weighs 13 pounds. The pediatric dosage range is 20 to 40 mg/kg/day in three equal doses. What is the maximum dosage in 24 hours that should be given? (Fill in the blank.)
Rationale: First, convert the pounds to kg because the conversion is for kg. 1 kg = 2.2 lb 13 lb/(2.2 lb/kg) = 5.9 kg Second, determine the maximum dose the child can have in 24 hours: 40 mg × 5.9 kg = 236 mg. The maximum dose the child can have is 236 mg.
While examining a 6-year-old visiting the clinic for fever and a rash, the practical nurse (PN) notices several elevated 1- to 3-mm white spots on the buccal mucosa. What other signs should the PN expect this child to exhibit?
Red blotchy macular rash on the face and neck Rationale: Elevated white spots on the oral mucosa of a child are likely Koplik's spots and are indicative of rubeola. They are accompanied by a red blotchy rash that starts on the face (D) and spreads to the neck, the trunk, and the rest of the body. (A, B, and C) are inaccurate
Minocycline (Minocin) 50 mg PO every 8 hours is prescribed for a 18-year old adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (Select all that apply.)
Report vaginal itching or discharge. Protect skin from natural and artificial ultraviolet light. Avoid driving until response to medication is known. Use a nonhormonal method of contraception if sexually active Rationale: Correct selections are (A, C, D, and F). Adverse effects of tetracyclines include superinfections, photosensitivity, and decreased efficacy of oral contraceptives. Therefore, the client should report vaginal itching or discharge (A), protect the skin from ultraviolet light (C), and use a nonhormonal method of contraception (F) while on the medication. Minocycline (Minocin) is known to cause dizziness and ataxia, so until the client's response to the medication is known, driving (D) should be avoided. Tetracyclines should be taken around the clock (B) and exhibit decreased absorption when taken with antacids, so (E) is contraindicated.
The nurse prepares a client for removal of a nasogastric (NG) tube. Which request made by the nurse to the client will make the procedure more comfortable for the client?
Take a deep breath and hold it until the tube is removed. Rationale: The client should be instructed to take a deep breath and hold it because this will close the epiglottis and allow for easy removal of the tube through the esophagus and nose (B). It is not correct to ask the client to perform the Valsalva maneuver (A). Asking the client to take a sip of water could place the client at risk for aspiration during the removal of the NG tube (C). Asking the client to take a deep breath and exhale during the removal of the NG tube is incorrect (D).
Phenazopyridine (Pyridium) is commonly prescribed for clients with urinary tract infections. What statement should the nurse include when teaching clients about the administration of phenazopyridine (Pyridium)?
Take this medication with food to decrease gastric irritation Rationale: Phenazopyridine (Pyridium), a urinary analgesic used to relieve pain associated with chronic urinary tract infections, can be taken with food to decrease gastric irritation (C). It will typically cause the urine to turn a red-orange color, so it should not be discontinued if this occurs (A). (B) is incorrect. Pyridium should only be used for 2 days (D) when taken together with an antibacterial agent, which is typically prescribed for approximately 2 weeks
A 12-year-old with type 1 diabetes mellitus complains of abdominal pain and has experienced increased thirst during the previous 24 hours. What action should the practical nurse implement first?
Test urine for ketones and glucose. Rationale: This child is exhibiting signs of impending diabetic ketoacidosis (DKA), so the child's urine should be tested for ketones and glucose (C) to assess for DKA. (A) should also be performed, but first the urine should be tested, which is a quick and easy test to assess for DKA. If DKA is present, (B) should not be administered. (D) does not have the priority of assessing for DKA in a child with type 1 diabetes who is exhibiting these symptoms.
The nurse admits a client to the nursing home. Which observation by the nurse may indicate the client suffers from presbycusis
The client frequently asks the nurse to repeat statements Rationale: Presbycusis is a sensorial hearing loss associated with aging. Clients with presbycusis have difficulty understanding normal voice tones
A client comes to the community-based clinic complaining of a persistent cough. The nurse understands that the client is at high risk for tuberculosis based on which risk factors for the disease? (Select all that apply.)
The client has AIDS. The client is a smoker. The client has been living in a homeless shelter. Rationale: Risk factors for tuberculosis include an immunodeficiency disease (A), increased age (B), and living in crowded conditions, such as in a homeless shelter (D). Smoking is not a risk factor for tuberculosis (C). Being admitted to the hospital does not create a risk factor for tuberculosis (E).
The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply.
The client's mental status The client's respiratory function Rationale: The early signs of fat embolism include changes in the client's mental status or signs of impaired respiratory function caused by impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment are likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs of fat embolism
A healthy 58-year-old client asks the practical nurse (PN) about taking the pneumococcal vaccine (Pneumovax). Which statement should the PN offer to the client that provides the most accurate information about this vaccine?
The immunization is administered once to older adults or persons with a history of chronic illness. Rationale: It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in a lifetime (B). (Some recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but revaccination is sometimes required with immunosuppressed clients or clients with a history of pneumonia
The nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, which instruction should the nurse provide the mother?
Thicken the feedings by adding rice cereal to the formula. Rationale: Small, more frequent feedings with frequent burping are often tried as the first line of treatment in gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. However, thickened feedings do not affect reflux time.
A child with nephrotic syndrome is receiving prednisone (Deltasone). The practical nurse (PN) reviews breakfast foods at a fast food restaurant with the child's mother. Which selections indicate that the mother understands the dietary guidelines necessary for her child?
Toasted oat cereal and low-fat milk Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is
What is the most important information for the practical nurse (PN) to review with a 12-year-old who is receiving long-term and rescue medications for routine management of asthma?
Use albuterol (Proventil) for prevention of exercise-induced bronchospasm. Rationale: When used before exercise, the beta-adrenergic agonist albuterol can prevent an asthma attack (C). Cold fluids can precipitate bronchospasms (A). (B) is a good exercise for children with asthma because of the moist environment (swimming pool area) and because while swimming the child takes deep breaths and exhales slowly
A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which manifestation requires health care provider (HCP) notification by the parents?
Vomiting Rationale: The parents of a child with a hernia need to be instructed about the signs of strangulation. These signs include vomiting, pain, and an irreducible mass. The parents should be instructed to contact the HCP immediately if strangulation is suspected
