Exit Hesi 400-499

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle?

(Mark the location where the second paddle should be placed on the image).

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

A 10-year-old who is receiving chemotherapy and the infusion pump is beeping

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

A slice of whole grain toast A bowl of cream of wheat

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

Ask the client about his expected goals for the hospitalization

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

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

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

Assess the client for self-care ability Provide pain medication instructions Teach care of ostomy to car provider

The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should nurse include in the client's discharge teaching? SATA

Avoid prolonged standing or sitting Use recliner for long period of sitting continue wearing elastic stocking

During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)

Background - Assessment - Recommendation

After a routine physical examination, the healthcare admits a woman with a history of systemic lupus erythematous to the hospital because she has three plus pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention?

Blood pressure 170/98

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented w/ which symptoms requires the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large, spicy meal

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

Compress the drip chamber

The nurse is presenting information about fetal development to a group of parents. when discussing cephalocaudal fetal development, which information should the nurse gives the parents?

Development progress from head to rump

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

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

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

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

A young adult female presents at the emergency center with acute lower abdominal pain. lOMoARcPSD|12755628 Which assessment finding is most important for the nurse to report to the healthcare provider?

Last menstrual period was 7 weeks ago

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important to include for plan?

Maintain effective breathing patterns

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

Marinating pain level below 4 when implementing outpatient pain clinic strategies.

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

Monitor for an elevated temperature

An older female who ambulate with a quad cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)

Move personal items within client's reach Lower bed to the lower possible position Give directions to call for assistance • Assist client to the bathroom in 2 hours.

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating

Normal sinus rhythm and complaining of chest pain

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

Notify the healthcare provider

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

Observe rhythm on telemetry monitor

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

Participated actively in all treatment's regimens

In assessing a pressure ulcer on a client's hip, which action should the nurse include?

Photograph the lesion with a ruler placed next to the lesion

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

Prepare for the endotracheal tube to be repositioned

A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?

Prepare the client for intubation

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemichyperosmolar...in addition to the client's glucose, which laboratory value is most important to monitor?

Serum potassium

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

The child should avoid eating homemade cookies and cupcakes during parties

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

Wear long sleeves and pants

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?

• 0.9% sodium chloride solution (normal saline)

The nurse is conducting health assessments. Which assessment finding increases a 56- year-old woman's risk for developing osteoporosis?

• 20 pack-year history of cigarette smoking

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

• Advise the client to empty her bladder fully when she first voids

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?

• Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

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

• Altered consciousness within the first 24 hours after injury.

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

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

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?

• Ask the family to identify a specific spokesperson

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?

• Ask the nurse to return home and get her prescription eyeglasses for work.

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

• Assess IV site frequently for signs of extravasation

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?

• Assist cardiac nurses with their assignments

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?

• Auscultate all quadrant of the abdomen.

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

• Auscultated bilateral breath sounds

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding bad

• Blood pressure 149/101

Which information is important for the nurse to obtain when determining a client's risk for (OSAS)?

• Body mass index

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

• Check the TPN solution for cloudiness

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications?

• Clopidogrel (Plavix), an antiplatelet agent, given orally • Methylprednisolone (solu-medrol), a corticosteroid, to be given IV • Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous

A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

• Complete pre-infusion checklist

A nurse is conducting a physical assessment of young adult. Information indication of nutrition status?

• Condition of hair, nails, and skin

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

• Contact the regional organ procurement agency

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

• Contact the regional organ procurement agency

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs?

• Cries frequently during the interview

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

• Cyanotic nailbeds

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

• Delegate care of the crying client to an unlicensed assistant

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

• Determine current sexual practice

A male client was transferred yesterday from the emergency department to the telemetry unit b/c he had ST depression and resolved chest pain. EKG shows ventricular tachycardia, what action is best?

• Determine the client's responsiveness and respirations

A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority? • Risk for self-directed violence related to impulsive action The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?

• Diaphoresis

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

• Discuss the importance of continuing the usual at-home activities

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?

• Elevated liver function tests

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

• Encourage use of analgesics before position change

nurse ask the parent to stay during the examination of male toddler's genital area. Best intervention?

• Examine the genitalia as the last part of the total exam.

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

• Hemophilic Influenza Type B (HiB) vaccine

A male client is admitted with burns to his face and neck. Which position will prevent contract?

• Hyperextended with neck supported by a rolled towel.

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

• Hypocapnea reduces ICP

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

• I need to have regular pap smears

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

• Initiate intravenous fluid as prescribed

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

• Intravenous administration of thyroid hormones

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

• It blocks the effects of histamine, causing decreased secretion of acid

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?

• Left forearm hematoma

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

• Monitor temperature regularly

A client with superficial burns to the face, neck, and hands resulting from a house fire... which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?

• Mucous membranes cherry red color

The nurse is interviewing a client with schizophrenia. Which behavior needs urgent intervention?

• Muscle spasms of the back and neck

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

• Observe both lower extremities for redness and swelling

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

• Observe the amount of urine in the client's urinary drainage bag

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

• Observe the wound for dehiscence

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

• Obtain a prescription for DNR

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

• Obtain a prescription to increase the IV rate

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

• Oral temperature of 100.6 F

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?

• Overlook the client's behavior.

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

• Participation of community leaders in planning the program

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

• Picking up the second glove

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

• Place a washcloth in the sink while cleaning the dentures

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

• Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. No one is available to send for help, What action should the nurse take first?

• Stabilize the victim's neck and roll over to evaluate his status

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

• Stroke

A male client returns to mental health clinic for assistance w/ his anxiety, manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over bridges. What action should you implement?

• Teach client to listen to music or audio books while driving

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

• The body cells develop resistance to the action of insulin.

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

• The client has asymmetrical chest wall expansion

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

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

A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that client understands the dietary restrictions?

• Turkey salad sandwich.

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

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

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

• Wash hands before cleaning exit site

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

• creatinine clearance 25 mL/ minute

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

• headache, photophobia, and nuchal rigidity

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?

• infectious process

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

• nausea and projectile vomit

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?

Too much salt can cause the kidneys to retain fluid