Exit HESI #4 [Pg. 557 - 601]

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A. Failure to collect all urine specimens during the period of the study will invalidate the test. B. Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C. Dialysis is started when the GFR is lower than 5 mL/min. D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A. Hourly urine output B. Bladder distention C. Urinary incontinence D. Intraoperative bladder decompression E. Urine sample for culture

Hourly urine output Bladder distention Intraoperative bladder decompression

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A. Diabetes insipidus B. Hypotension C. Hyperkalemia D. Uremia

Hypotension

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference

Immunization history

After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.

Ensure that the client receives breakfast within 30 minutes.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? A. Examine for clamp closures. B. Irrigate with a larger syringe. C. Assess for signs of infection. D. Flush the line with heparin.

Examine for clamp closures.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A. Keep the residual limb elevated during positioning. B. Instruct the client to grasp the overhead trapeze bar. C. Maintain alignment with an abduction pillow. D. Use pillow support to prevent turning to a prone position

Instruct the client to grasp the overhead trapeze bar.

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium (Metamucil). C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client.

Obtain a stool specimen for culture and sensitivity

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A. Remove the client's nail polish and dentures. B. Assist the client to the restroom to void. C. Obtain the client's height and weight. D. Offer the client emotional support

Offer the client emotional support.

The nurse should encourage a laboring client to begin pushing at which point? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable

When the cervix is completely dilated

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse-manager to the client's room immediately.

Leave the room and discuss the incident privately with the staff member.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A. Monitor maternal vital signs for hemorrhage. B. Instruct the woman to report any contractions. C. Ensure that the woman has a full bladder prior to beginning. D. Monitor fetal heart rate for 1 hour after the procedure. E. Place the client in a side-lying

Monitor maternal vital signs for hemorrhage. Instruct the woman to report any contractions. Monitor fetal heart rate for 1 hour after the procedure.

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A. Reports feelings of sadness B. Mood changes from depressed to happy C. Begins giving away possessions D. Becomes compliant with medication regimen E. Independently joins a support group

Mood changes from depressed to happy Begins giving away possessions

A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A. Move objects out of the child's immediate area. B. Quickly slip soft restraints on the child's wrists. C. Insert a padded tongue blade between the teeth. D. Place in the recovery position before going for help

Move objects out of the child's immediate area.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? A. Request a prescription for a bed board to provide increased back support. B. Reposition the client so that both feet are supported by the bed board. C. Move the trapeze bar to allow the client to pull with the upper extremities. D. Place trochanter rolls on the lateral aspects of the client's thighs.

Place trochanter rolls on the lateral aspects of the client's thighs.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A. Obtain the remainder of the preoperative admission information. B. Check the vomiting client for signs of tube feeding aspiration. C. Position the client who has vomited on his side and obtain vital signs. D. Teach the preoperative client coughing and deep breathing exercises

Position the client who has vomited on his side and obtain vital signs.

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity.

Save the next urine sample.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A. Participating in telephone consultations with clients B. Identifying oneself by name and title to clients in telehealth communications C. Sending medical records to health care providers via the Internet D. Answering a client-initiated health question via electronic mail

Sending medical records to health care providers via the Internet

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A. Serum digoxin level is 1.5 ng/mL B. Blood pressure is 104/68 mm Hg C. Serum potassium level is 2.5 mEq/L D. Apical pulse is 68/min

Serum potassium level is 2.5 mEq/L

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A. Reduced peripheral edema B. Urinary output of at least 70 mL/hr C. Decrease in urine osmolarity D. Serum sodium level of 137 mEq/L

Serum sodium level of 137 mEq/L

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A. Shave the area where the TENS will be placed. B. Obtain small needles for insertion. C. Place the TENS unit directly over or near the site of pain. D. Explain to the client that drowsiness may occur immediately after using TENS. E. Describe the use of TENS for postoperative procedures such as dressing changes.

Shave the area where the TENS will be placed. Place the TENS unit directly over or near the site of pain. Describe the use of TENS for postoperative procedures such as dressing changes.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler's position without a pillow behind the head B. Semi-Fowler's position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table

Sitting upright and forward with both arms supported on an over the bed table

. A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A. "Is your son's short stature a social embarrassment to him or the family?" B. "What types of foods do both your children eat now and what did they eat when they were infants?" C. "Did any significant trauma occur with the birth of your son?" D. "Did your daughter also start her menstrual period at 12 years of age?"

"Did your daughter also start her menstrual period at 12 years of age?"

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?"

"Does anyone in your family have glaucoma?"

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis? A. "Has your child had an ear infection recently?" B. "Does your child seem resistant to toilet training?" C. "Is your child a picky eater?" D. "Do you have a family history of bone disorders?"

"Has your child had an ear infection recently?"

The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." D. "I observe my skin daily to see if I have an allergic rash to the medication."

"I take aspirin for my pain."

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years."

"Those are Mongolian spots and will gradually fade in 1 or 2 years."

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A. "Let's play some dominoes for a few minutes." B. "I don't think the violence means the world is ending." C. "The news makes you have upsetting thoughts." D. "Listening to the news seems to be frightening you."

"Listening to the news seems to be frightening you."

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A. "I will avoid coughing, sneezing, and forceful nose blowing." B. "Swimming can begin on the tenth postoperative day." C. "Any mild discomfort can be managed with acetaminophen." D. "Drainage from my ears is expected after the surgery."

"Swimming can begin on the tenth postoperative day."

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?"

"Tell me more about how you're feeling."

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction? A. "I should balance my daily exercise with my dietary intake and insulin dosages." B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C. "I should inject my insulin into a different site to reduce the development of scar tissue." D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

"When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel."

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A. A primigravida who is 8 cm dilated after 14 hours of labor B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation C. A client being induced for fetal demise at 20 weeks' gestation D. A multiparous client who is dilated 5 cm and 50% effaced

A multiparous client who is dilated 5 cm and 50% effaced

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had a appendectomy. The IV tubing being using delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) A. 15 B. 32 C. 64 D. 50

32

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A. Assess skeletal pins for infection. B. Assist the client with toileting. C. Establish thrombus prevention care. D. Evaluate pain management plan.

Assist the client with toileting.

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A. 50 mg/dL B. 80 mg/dL C. 110 mg/dL D. 140 mg/dL

50 mg/dL

The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A. 42 B. 83 C. 125 D. 250

83

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A. A client with an admitting diagnosis of menorrhagia who is now 24 hours post-vaginal hysterectomy B. A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C. A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D. A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol)

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy

A client who is 2 days postoperative with a right total knee replacement

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A. This visual acuity result is five times worse that of a normal finding. B. This line should be seen clearly when the client wears corrective lenses. C. A client with normal vision can read at 100 feet what this client reads at 20 feet. D. This client can see at 100 feet what a client with normal vision can see at 20 feet.

A client with normal vision can read at 100 feet what this client reads at 20 feet.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A. A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B. A client who is receiving continuous ambulatory peritoneal dialysis C. A client with continuous bladder irrigation for hematuria D. A client with renal calculi whose urine needs to be strained

A client with renal calculi whose urine needs to be strained

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci

A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA)

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A. An adolescent who was readmitted to the hospital because of a postoperative infection B. A woman with a new colostomy who requires discharge teaching C. A woman who had a hip replacement and may be transferred to the home care unit D. A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction

A woman who had a hip replacement and may be transferred to the home care unit

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A. Flex the hips and knees and align the knees with the client's knees for safety. B. Allow the client to sit on the side of the bed for a few minutes before transferring. C. Place the client's weight-bearing or strong leg forward and the weak foot back. D. Grasp the transfer belt at the client's sides to provide movement of the client

Allow the client to sit on the side of the bed for a few minutes before transferring.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular self-examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones

Ask about scrotal pain or blood in the semen.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes.

Assess the client for pain and administer pain medication as prescribed.

Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A. Assess the client's ability to swallow liquids. B. Obtain applesauce in which to mix the medication. C. Determine the client's food likes and dislikes. D. Auscultate the client's breath sounds.

Assess the client's ability to swallow liquids.

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PNs to assist health care providers on rounds and perform glucometer checks.

Assign the UAPs to take vital signs and obtain daily weights.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." D. "Would you like to make a change in his pharmacologic regimen?"

B, C, A, D

The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours

Blood pressure of 90/56 mm Hg

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A. 3+ protein in the urine B. Blood urea nitrogen >25 mg/dL C. Blood pH >7.45 D. Urine output, 2500 mL/day

Blood urea nitrogen >25 mg/dL

A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A. Pain scale B. Vital signs C. Breath sounds D. Level of consciousness

Breath sounds

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. A. Gently insert the catheter without suction using sterile technique. B. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). C. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. D. Apply suction intermittently while withdrawing the catheter.

C, B, A, D

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nursemanager respond to this situation? A. Advocate for the rights of the staff to watch television once their assignments are complete. B. Confront the administrator about making a decision that will negatively affect the residents. C. Offer to develop an alternate solution so that the residents can continue to watch television. D. Remind the administrator that watching television helps the night shift staff remain awake

C. Offer to develop an alternate solution so that the residents can continue to watch television.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A. Ask the UAP to check for the advanced directive while the nurse completes the assessment. B. Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C. Check the medical record for the advanced directive and then complete the client assessment. D. Call for the charge nurse to check the advanced directive while

Call for the charge nurse to check the advanced directive while continuing to assess the client.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods D. Assess the fetal heart rate.

Check the client's blood pressure.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A. Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C. Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D. Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients.

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins

Confusion Crackles in the lungs Dyspnea

A nurse is planning patient care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines

Consult the agency's policies and procedures manual and follow the guidelines.

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A. Open the airway with a chin lifthead tilt maneuver. B. Obtain a fingerstick glucose reading. C. Administer flumazenil (Romazicon). D. Continue to monitor the client.

Continue to monitor the client.

The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received.

Continue with current assignments until more instructions are received.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? A. Stand on a line drawn 10 feet from the chart. B. Read each sentence slowly and carefully. C. Cover one eye while reading the chart with the other. D. Begin by identifying the first line that is hard to read.

Cover one eye while reading the chart with the other.

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A. Encourage staff to participate in online in-service education. B. Assign staff to make sure that all equipment is thoroughly cleaned. C. Ask which staff members would like to go home for the remainder of the day. D. Notify the supervisor that the staff needs additional assignments.

Encourage staff to participate in online in-service education.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A. Encourage the client to turn from side to side every 2 hours. B. Elevate the foot of the client's bed at least 6 inches. C. Encourage the client to ambulate every 3 hours. D. Teach the client how to perform leg exercises while in bed.

Encourage the client to ambulate every 3 hours.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A. Allow the client to discuss the seriousness of the illness. B. Ensure that the client is provided with information about medications. C. Encourage as much independence in decision making as possible. D. Include the client in planning the course of treatment.

Encourage as much independence in decision making as possible.

Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A. Direct the client to sign a liability release form. B. Restrict the client's ability to leave the unit. C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed. E. Provide the client with names of local support groups. F. Notify the health care provider of the client's intention.

Explain the benefits of remaining in the hospital. Instruct the client to take medications as prescribed. Notify the health care provider of the client's intention.

An older client who resides in a long-term care facility is hearingimpaired. How should the nurse modify interventions for this client? A. Turn off the client's television and speak very loudly. B. Communicate in writing whenever it is possible. C. Speak very slowly while exaggerating each word. D. Face the client and speak in a normal tone of voice

Face the client and speak in a normal tone of voice

The nurse 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 nurse should hold the prescribed dose? A. Tachypnea B. Guaiac-positive stool C. Multiple small abdominal bruises D. Dependent pitting edema

Guaiac-positive stool

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished

Health care-associated infection (HAI) transmission of infectious diarrhea is prevented.

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A. Help the client dangle his legs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times a day.

Help the client dangle his legs.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A. Hyperexcitability of reflexes B. Hyperextension of the head and back C. Inability to flex the chin to the chest D. Lateral facial paralysis

Inability to flex the chin to the chest

The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A. Increase in T3 and T4 B. Decrease in heart rate C. Increase in TSH D. Decrease in urine output E. Decrease in periorbital edema

Increase in T3 and T4 Decrease in periorbital edema

The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure

Increased oxygen saturation

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A. Parents of children with spina bifida B. High school girls in a health class C. Individuals interested in having children D. Postpartum women attending a baby care class

Individuals interested in having children

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today.

Inform the client that the scheduled Pap test cannot be done today.

A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A. Administer oxygen per nasal cannula at 2 L/min. B. Plan to check his vital signs again in 30 minutes. C. Notify the health care provider of the change in mental status. D. Ask the client why he thinks there are bugs in the bed.

Notify the health care provider of the change in mental status.

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP

Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited.

Oral hygiene should be performed before the medication.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A. Inspection of the skin B. Breath sound auscultation C. Pain scale measurement D. Mobility limitations

Pain scale measurement

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36- month-old child? (Select all that apply.) A. Record wet diapers. B. Assess for sunken fontanels. C. Examine skin turgor. D. Observe mucous membranes.

Record wet diapers. Examine skin turgor. Observe mucous membranes

Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

Reduced renal excretion

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status.

Report lithium level of 2.0 mEq/L to the primary health care provider. Maintain consistent salt levels in the diet when client is taking lithium. Assess the client's nutritional and hydration status.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A. Perform range-of-motion exercises on the lower extremities every 4 hours. B. Place a small firm pillow under the upper back to flex the lumbar spine gently. C. Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D. Position in reverse Trendelenburg with the feet firmly against the foot of the bed

Rest in bed with the head of the bed elevated 20 degrees and flex the knees.

When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A. Speak privately with the nurse. B. Hold a staff meeting to discuss this issue. C. Review the nurse's current salary. D. Nominate the nurse for employee of the month.

Speak privately with the nurse.

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication.

Take the vital signs to determine the client's response for a potential blood loss.

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A. Team 1: RN team leader, PN; team 2, PN team leader, UAP B. Team 1, RN team leader, UAP; team 2, PN team leader, PN C. Team 1, PN team leader, PN; team 2, RN team leader, UAP D. Team 1, PN team leader, UAP; team 2, RN team leader, PN

Team 1: RN team leader, PN; team 2, PN team leader, UAP

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A. The client is noncompliant with his medications. B. The client recently consumed large quantities of pears or nuts. C. The client's renal function has affected his potassium level. D. The client needs to be started on a potassium supplement.

The client's renal function has affected his potassium level.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A. The client's usual sleeping pattern B. Whether the client smokes C. How much liquid the client consumes before bedtime D. The amount of caffeine that the client consumes during the day

The client's usual sleeping pattern

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A. The color of the dialysate outflow is opaque yellow. B. The dialysate outflow is greater than the inflow. C. The inflow dialysate feels warm to the touch. D. The inflow dialysate contains potassium chloride.

The color of the dialysate outflow is opaque yellow

A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol). How should the nurse respond to this client's statement? A. Bleeding precautions should be implemented. B. Tylenol is indicated for minor aches and pains. C. Acetaminophen reduces inflammation. D. The drug is hepatotoxic and contraindicated.

The drug is hepatotoxic and contraindicated.

A male client with Parkinson's disease has been taking the antiparkinsonian agent amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The medicine doesn't seem to be working anymore." Which information should the nurse provide to this client? A. The dosage probably needs to be increased. B. The medication needs to be changed immediately. C. The medication needs to be taken more frequently. D. The effects of this drug tend to decrease after 3 months.

The effects of this drug tend to decrease after 3 months.

Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake.

The oral mucosa is pink and intact.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A. Sexual intercourse with the spouse occurs four times a week. B. The spouse has never seen the client naked. C. The client has had surgery for permanent birth control. D. A history of a 20-lb weight loss occurred in the past year.

The spouse has never seen the client naked.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client initiated respirations

The ventilator setting for respiratory rate and the client initiated respirations

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly

This sensation occurs as breast milk moves to the nipple.

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat milk

Toasted oat cereal and low-fat milk

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A. Use lanolin to moisturize the tops and bottoms of the feet. B. Soak the feet in warm water for at least 1 hour daily. C. Wash feet daily and dry well, particularly between the toes. D. Use over-the-counter products to remove corns and calluses. E. Wear leather shoes that fit properly

Use lanolin to moisturize the tops and bottoms of the feet. Wash feet daily and dry well, particularly between the toes. Wear leather shoes that fit properly.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A. Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B. Apply ice packs to edematous or tender joints to reduce pain and swelling. C. Warm the child with an electric blanket prior to getting the child out of bed. D. Immobilize swollen joints during acute exacerbations until function returns

Warm the child with an electric blanket prior to getting the child out of bed.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size.

With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department

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