HESI 225

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? The belief is held that the "evil eye" enters the child if anything cold is ingested. After surgery the child probably has refused all foods except broth. Eating broth strengthens the child's innate energy called "chi." "Hot" remedies restore balance after surgery, which is considered a "cold" condition.

"Hot" remedies restore balance after surgery, which is considered a "cold" condition. Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body.

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase."

"I will limit my intake of beef to 4 ounces per week." Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins need to decrease rather than increase.

A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? "Be sure to have a complete physical examination before beginning your planned exercise program." "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more." "Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation."

"Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." A client with obesity who intends to begin a weight loss and exercise program may be at risk for cardiovascular complications. The most important teaching is to encourage the client to have a complete medical evaluation so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. Vigorous exercise may result in chest pain, a heart attack, or stroke.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." "It is OK if you don't want to talk about your surgery. I will be available when you are ready." "I will ask a woman who has had a mastectomy to come by and share her experiences with you."

"It is OK if you don't want to talk about your surgery. I will be available when you are ready." When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive.

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? "It is important that you continue your medication while learning to meditate." "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." "Obtain your healthcare provider's permission before starting meditation." "Complementary therapy and western medicine can be effective for you."

"It is important that you continue your medication while learning to meditate." The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued while the physiologic response to meditation is monitored. The healthcare provider should be informed, but permission is not required to meditate. Although it is true that this complementary therapy might be effective, it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? "That means you have derived the maximum benefit, and the heat can be removed." "Your blood vessels are becoming dilated and removing the heat from the site." "We will increase the temperature 5 degrees when the pad no longer feels warm." "The body's receptors adapt over time as they are exposed to heat."

"The body's receptors adapt over time as they are exposed to heat." Thermal adaptation occurs 20 to 30 minutes after heat application. This means the client may not feel the same level of heat as at the start of the treatment. The nurse should not increase the heat setting.

A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? "What is your daily calorie consumption?" "What vitamin and mineral supplements do you take?" "Do you feel that you are overweight?" "Will a clear liquid diet be okay after surgery?"

"What vitamin and mineral supplements do you take?" In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 9 a.m., 1 p.m., and 5 p.m. 8 a.m., 4 p.m., and midnight. Before breakfast, before lunch, and before dinner. With breakfast, with lunch, and with dinner.

8 a.m., 4 p.m., and midnight. Theophylline should be administered on a regular, around-the-clock schedule to provide the best bronchodilating effect and to reduce the potential for adverse effects. Food may alter absorption of the medication, so it should not be taken with meals.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation which, if dislodged, could be life-threatening. Superficial veins are often very easy to find in the feet and legs. Handling a leg or foot with an IV is probably not any more difficult than handling an arm or hand. Even if the nurse believes moving a cannulated leg is more difficult, this is not the most important reason for using the upper extremities. Pain is not a consideration.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer.

A lactating woman nursing her 3-day-old infant. A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, type 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.

Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? Expresses concern about the meaning and importance of life. Remains angry at God for the continuation of the illness. Accepts that punishment from God is not related to illness. Refuses to participate in religious rituals that have no meaning.

Accepts that punishment from God is not related to illness. Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of resolution of spiritual distress.

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? Acknowledge that the spouse is supporting the arm correctly. Encourage the spouse to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct the spouse to grip directly over the joint for better motion.

Acknowledge that the spouse is supporting the arm correctly. The client's spouse is correctly holding the arm above and below the elbow to perform passive range-of motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being exercised should be uncovered while the rest of the body should remain covered for warmth and privacy.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention.

Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention. Assessing for distention is more important than applying a catheter or applying skin protectant.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? Assist the ambulating client back to the bed. Encourage the client to ambulate to resolve pneumonia. Obtain a prescription for portable oxygen while ambulating. Move the oximetry probe from the finger to the earlobe.

Assist the ambulating client back to the bed. An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first the client should return to bed to rest.

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. Wearing a mask while cleaning will not help to avoid allergens. Purchase any type of clothing, but be sure it is washed before wearing it. Pollen count is related to hay fever, not to allergens.

Avoid any types of sprays, powders, and perfumes. The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? Client. Healthcare provider. A family member. Previous medical records.

Client. A primary source of information for a health assessment is the client. Family members, the medical record, and the healthcare provider are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? Assault. Battery. Malpractice. False imprisonment.

Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? Autopsy of the body is prohibited. Blood transfusions are forbidden. Alcohol use in any form is not allowed. A vegetarian diet must be followed.

Blood transfusions are forbidden. Blood transfusions are forbidden in the Jehovah's Witness religion. Judaism prohibits autopsies and Buddhism forbids the use of alcohol and drugs. Many of these sects follow a vegetarian diet, but the direct impact on nursing care concerns beliefs about transfusions.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices.

Chocolate pudding. The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow, require minimal chewing effort, and provide calories and protein.Gelatin does not provide any nutritional value and the other options require energy to chew and are more difficult to swallow than pudding.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses.

Closed-ended questions. Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client.

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? Commend the client for selecting a high biologic value protein. Remind the client that protein in the diet should be avoided. Suggest that the client also select orange juice, to promote absorption. Encourage the client to attend classes on dietary management of CKD.

Commend the client for selecting a high biologic value protein. Foods such as eggs and milk are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and should not be encouraged. The client has made a good diet choice, so classes on dietary management is not necessary.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? Adequate venous blood flow to the lower extremities. Estimated amount of body fat by an underarm skinfold. Degree of flexion and extension of the client's knee joint. Change in the circumference of the joint in centimeters.

Degree of flexion and extension of the client's knee joint. The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of body parts.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? Asking relevant questions regarding the dressing change. Stating the ability to complete the wound care regimen. Demonstrating the wound care procedure correctly. Showing all the necessary supplies for wound care.

Demonstrating the wound care procedure correctly. A return demonstration of a procedure provides an objective assessment of a client's ability to perform a task, while client statements or questions are subjective measures.Showing that the client possesses the necessary supplies is important, but it is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? Determine the etiology of the problem. Prioritize nursing care interventions. Plan appropriate interventions. Collaborate with the client to set goals.

Determine the etiology of the problem. Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care and priorities of interventions.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? Bewilderment is to be expected, and progresses with age. Disorientation often follows relocation to new surroundings. Uncertainty is a result of irreversible brain pathology. Being perplexed can be prevented with adequate sleep.

Disorientation often follows relocation to new surroundings. Relocation often results in confusion among elderly clients, moving is stressful for anyone. Advancing confusion with age is a stereotypical judgment. Stress in the elderly often manifests itself as confusion. Adequate sleep is not a prevention for confusion.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? Immediately after exhalation. During the inhalation. At the end of three inhalations. Immediately after inhalation.

During the inhalation. The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? Provide additional coffee on the client's breakfast tray. Exchange the client's grape juice for cranberry juice. Bring the client additional fruit at mid-morning. Encourage additional oral intake of juices and water.

Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? Obtain the pre-transfusion hemoglobin level. Prime the tubing and prepare a blood pump set-up. Monitor vital signs every 15 minutes for the first hour. Ensure the accuracy of the blood type match.

Ensure the accuracy of the blood type match. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Preparing the tubing, checking the baseline hemoglobin, and monitoring vital signs should also be implemented prior to administering blood, but checking the blood type has the highest priority.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? Aspirating gastric contents to assure a pH value of 4 or less. Hearing air pass in the stomach after injecting air into the tubing. Examining a chest x-ray obtained after the tubing was inserted. Checking the remaining length of tubing to ensure that the correct length was inserted.

Examining a chest x-ray obtained after the tubing was inserted. Assessing the pH of gastric contents and listening for air in the stomach are both methods used to determine proper placement of the nasogatric tube. However, the best indicator that the tube is properly placed is confirming with a chest x-ray.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? Clamp the tube for 20 minutes. Flush the tube with water. Administer the medications as prescribed. Crush the tablets and dissolve in sterile water.

Flush the tube with water. The NGT should be flushed before, after, and in between each medication administered. Once all medications are administered, the NGT should be clamped for 20 minutes.Other options may be implemented only after the tubing has been flushed.

An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? Prone. Fowler's. Sims'. Supine.

Fowler's. A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. The unresponsive client should be positioned in a semi-sitting (Fowler's) position during feeding through a gastrostomy tube to decrease the occurrence of aspiration. In prone or Sims' positions, the client is placed on the abdomen, an unsafe position for feeding. Placing the client in supine position increases the risk of aspiration.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Thalamus. Hypothalamus. Frontal lobe. Parietal lobe.

Frontal lobe. The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. On the other hand, the thalamus is an afferent relay center in the brain that directs impulses to the cerebral cortex. The hypothalamus regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. The parietal lobe is the location of sensory and motor functions.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position.

Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities.

Give an around-the-clock schedule for administration of analgesics. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks. Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized. Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream. The nurse should document the reason for the late dose, but contacting the healthcare provider or the charge nurse are not warranted.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? Healthcare provider notified of failure to collect specimens for prescribed blood studies. Blood specimens not collected because client no longer wants blood tests performed. Healthcare provider notified of client's refusal to have blood specimens collected for testing. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified.

Healthcare provider notified of client's refusal to have blood specimens collected for testing. When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format. The nurse should not editorialize, make judgments, or document assumptions about the client's wishes.

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

Instruct the client that the stoma will become smaller when the initial swelling diminishes. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? Demonstrates loss of remote memory. Exhibits expressive dysphasia. Has a diminished attention span. Is disoriented to place and time.

Is disoriented to place and time. The client is exhibiting disorientation. Loss of remote memory refers to memory of the distant past. The client is able to express himself without difficulty, and does not demonstrate a diminished attention span.

Which action is most important for the nurse to implement when donning sterile gloves? Maintain thumb at a ninety degree angle. Hold hands with fingers down while gloving. Keep gloved hands above the elbows. Put the glove on the dominant hand first.

Keep gloved hands above the elbows. Gloved hands held below waist level are considered unsterile. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? Listen and show interest as the client expresses these feelings. Reinforce that this behavior means they were not true friends. Ask the healthcare provider for a psychiatric consult. Continue with the assessment and tell the client not to worry.

Listen and show interest as the client expresses these feelings. When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not a therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope.

The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance rather than simply naming the condition. Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to purple skin discolorations that do not itch.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Loosen the right wrist restraint. Apply a pulse oximeter to the right hand. Compare hand color bilaterally. Palpate the right radial pulse.

Loosen the right wrist restraint. The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates decreased circulation. Assessing the depth of color change and the radial pulse are also important nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints).

When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices? Complementary healing practices interfere with the efficacy of the medical model of treatment. Conventional medications are likely to interact with folk remedies and cause adverse effects. Many complementary healing practices can be used in conjunction with conventional practices. Conventional medical practices will ultimately replace the use of complementary healing practices.

Many complementary healing practices can be used in conjunction with conventional practices. Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complementary healing practices can be used in conjunction with conventional medical practices, rather than interfering with conventional practices, causing adverse effects, or replacing conventional medical care.

A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? Mix each medication individually. Use sterile gloves for the procedure. Monitor vital signs before giving medications. Mix all medications together to facilitate administration.

Mix each medication individually. When administering medications through a nasogastric feeding tube, the medications should be mixed separately to prevent clumping.

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Move the chair parallel to the right side of the bed, and stand the client on the right foot. When positioning a client for transfer from bed to chair when the client has left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? Establish a new nursing diagnosis. Note which actions were not implemented. Add additional nursing orders to the plan. Collaborate with the healthcare provider to make changes.

Note which actions were not implemented. First, the nurse should review which actions in the original plan were not implemented in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis.

An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? Reaffirm the client's desire for no resuscitative efforts. Transfer the client to a hospice inpatient facility. Prepare the family for the client's impending death. Notify the healthcare provider of the family's request.

Notify the healthcare provider of the family's request. When a family requests hospice care, the nurse should first communicate with the healthcare provider. Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine what additional care should be implemented.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? Sexual activity patterns. Nutritional history. Leisure activities. Financial stressors.

Nutritional history. Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin.

Observe the appearance of the skin under the ice pack. The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.

An older client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? In 8 weeks you will be able to bend at the waist to reach items on the floor. Place a pillow between your knees while lying in bed to prevent hip dislocation. It is safe to use a walker to get out of bed, but you need assistance when walking. Take pain medication 30 minutes after your physical therapy sessions.

Place a pillow between your knees while lying in bed to prevent hip dislocation. The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips. Clients should be instructed to avoid bending at the waist, to seek assistance for both standing and walking until they are stable on a walker or cane, and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions.

Rashes in the axillary, groin, and skin fold regions. Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. Re-oxygenate the client before attempting to suction again.

Re-oxygenate the client before attempting to suction again. Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen.

The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? Tell the UAP to use a larger cuff at the next scheduled assessment. Reassess the client's blood pressure using a larger cuff. Have the unit educator review this procedure with the UAPs. Teach the UAP the correct technique for assessing blood pressure.

Reassess the client's blood pressure using a larger cuff. An unlicensed assistive personnel (UAP) is using the wrong sized cuff to check a blood pressure. The most important action is to ensure that an accurate blood pressure reading is obtained. The nurse should reassess the blood pressure with the correct size cuff. Reassessment should not be postponed.

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Remain calm with the client and record abnormal results in the chart. Notify the medication nurse immediately if the pulse or blood pressure is low. Report the results of the vital signs to the nurse. Reassure the client that the vital signs are normal.

Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the unlicensed assistive personnel (UAP) should report vital sign measurements to the nurse. Any instructions requiring the UAP to interpret the vital signs causes the UAP to function beyond the scope of the UAP's authority.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. Reposition in a Sims' position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Reposition in a Sims' position with the client's weight on the anterior ilium. The left-sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium. The reverse Trendelenburg is inaccurate. The other options should be implemented once the client is positioned.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? Irrigate the nasogastric tube with sterile normal saline. Reposition the client on her side. Advance the nasogastric tube an additional five centimeters. Administer an intravenous antiemetic prescribed for PRN use.

Reposition the client on her side. The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client.

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? Explain that anyone who speaks her language can answer her questions. Provide a translator only in an emergency situation. Ask a family member or friend of the client to translate. Request and document the name of the certified translator.

Request and document the name of the certified translator. A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented. Client information that is translated is private and protected under HIPAA rules, so enaging anyone as a translator is not the best action. Family members are not preferred translators as they may skew information and not translate the exact information.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her husband's brother. In those rural areas women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive information. Since all family members speak fluent English, there is no need for a translator. It is culturally insensitive to encourage the woman to go against her wishes to follow her cultural worldview.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? The client voluntarily signed the form. The client fully understands the procedure. The client agrees with the procedure to be done. The client authorizes continued treatment.

The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure that the client fully understands the procedure. The nurse's signature does not indicate that the client agrees to or authorizes treatment.

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred.

The nurse who transferred the client to the chair when the fall occurred. The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." The nurse most at risk for malpractice is the one in which duty was owed (transferring the client safely) and the injury occurred while the nurse was in charge of the client's care.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? Height in inches or centimeters. Weight in kilograms or pounds. Triceps skin fold thickness. Upper arm circumference.

Upper arm circumference. Upper arm circumference is an indirect measure of muscle mass. Height and weight do not distinguish between fat (adipose) and muscularity. Triceps skin fold thickness is a measure of body fat.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? Arms. Upper torso. Head. Feet.

Upper torso. The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso becoming the center of gravity for older persons.

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? Place the stethoscope bell at random points on the posterior chest. Use the stethoscope bell over the valvular areas of the anterior chest. Move the diaphragm of the stethoscope over the left anterior chest. Position the diaphragm of the stethoscope at Erb's point on the chest.

Use the stethoscope bell over the valvular areas of the anterior chest. Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest.