HESI comprehensive practice exam 1
A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?
"Tell me about your undergarments so we can discuss how you can have your examination comfortably.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?
"To protect you because you can get an infection very easily."
Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio?
A self-evaluation that identifies how the nurse has met professional objectives and goals.
A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?
A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet.
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?
Ask client to describe triggers of anger.
To assess a client's pupillary response to accommodation, a nurse should perform which activity?
Ask the client to look at a distant object and then at an object held 10 cm from the nose.
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?
Ask the spouse to step out for a few minutes.
Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?
Assess the newborn's feeding patterns of formula or breast milk which has "come in."
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time.
Which information should the nurse give a client with chronic kidney disease (CKD)?
Avoid salt substitutes. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD.
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?
Avoid sharing towels and washcloths with siblings.
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?
Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?
Demonstrate the wound care procedure to the PN while the PN assists
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?
Denial related to the loss of a loved one.
Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?
Describes working hard to develop muscles.
Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?
Diagnostic testing may indicate a fetal problem that could be treated prior to delivery.
An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D).
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?
Early adolescence is a developmental stage of normal experimentation.
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client?
Eat 50% of six small meals each day by the end of one week.
Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?
Encourage the use of an incentive spirometer.
The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement?
Immunizations that decrease occurrences of many contagious diseases Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization (A).
Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?
Implements health programs for construction workers.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to a preselected schedule. (B and C) can be scheduled around time-sensitive delivery of care.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?"
Inadequate lifestyle changes in diet and exercise.
In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?
Increased thirst. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome.
The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?
Individual beliefs.
A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.
A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?
Keep the client in bed in the supine position.
A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?
Look for early signs of a lesion that increases in size with a red border, clear center. The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center (B) at the site of the tick bite.
The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?
Mark the drainage on the dressing and take vital signs. Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing (A) assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. (B) is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection (C). (D) is compared with the previous amount of drainage marked on the dressing, so (A) is necessary.
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?
Monitor for increased blood pressure and pulse.
A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?
Multidisciplinary group.
A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?
Nasal cannula.
A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond?
November 21. Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period.
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?
Obsessive
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?
One chronic and one acute illness.
Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?
Palpate above the symphysis for the bladder. Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis (B) should be implemented first.
The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?
Participants can identify at least three coping strategies to use during labor.
Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take?
Perform hand hygiene
The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for?
Preparing for other diagnostic testing. The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated (B).
The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?
Tell the receptionist to have the healthcare provider return the phone call.
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders.
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond?
The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the original record (C).
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight.
A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?"
The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form (D).
Which approach should the nurse use when preparing a toddler for a procedure?
Demonstrate the procedure using a doll.
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?
A nurse with Marfan's syndrome who is postmenopausal.
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?
A pregnant woman.
Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?
A common side effect of antipsychotic medications is constipation, and increasing high-fiber foods in the diet (A) can help to alleviate this problem.
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy?
"I will keep the baby's eyes covered when the baby is under the light." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light (D).
The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
A Buretrol attachment.
Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?
1.5 mL.
A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?
Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D).
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
Activity intolerance related to postoperative pain.
The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?
Administer analgesics prior to encouraging progressive activities and ambulation.
A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?
Administer isoniazid (INH) daily for 6 to 9 months.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
Administer the dose as prescribed. Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose.
A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide?
Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. (D) is not indicated.
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
An African-American client may have slightly yellow sclerae.
After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response?
An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized (D)
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?
Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance.
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?
Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A).
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?
Case manager.
The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?
Change in level of consciousness. Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function.
During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?
Chlamydia. Chlamydia (B) is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year
After eye drops are instilled, which instruction should the nurse provide to the client?
Close your eyelids.
The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?
Confidentiality.
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement?
Confront the client about the consequences of the behavior.
When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care?
Coordinating and educating about multidisciplinary services.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally.
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?
Decrease the risk of bradycardia during surgery.
A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide?
Five to seven days after menses cease. Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses.
The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?
Frequent blood pressure checks, including readings taken by automated machines, are recommended.
Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
Give one hour before or two hours after a meal.
A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?
Headache and hyperirritability are common.
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?
History of inflammatory bowel disorders.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
How long has the client been taking the medication? Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant.
Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?
Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability (C).
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?
Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?
Hypotension, rapid weak pulse, and rapid respiratory rate.
During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?
Identify the problem.
An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?
Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.
The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care?
Progressive leg exercises to obtain 90-degree flexion
A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?
Provide antiinflammatory response.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?
Purplish-red pinpoint lesions of the skin.
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?
Recalls drinking a glass of juice after midnight. The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications.
What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies?
Recognizes the value of a client's input into their own health care. Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires (C).
During the physical assessment, which finding should the nurse recognize as a normal finding?
Regular pulsation at the epigastric area when the client is supine Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment.
A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?
Report the incident to the immediate supervisor.
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
Rhinorrhoea or otorrhoea with Halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.
A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?
Rubber-tipped clamps.
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
S1 murmur auscultated in supine position.
A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?
Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence.
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D).
The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with
Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock.
When engaging in planned change on the unit, what should the nurse-manager establish first?
Staff members are aware of the need for change.
The scope of professional nursing practice is determined by rules promulgated by which organization?
State's Board of Nursing.
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
Stimulate contraction of the uterus.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
Stop the code immediately.
Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?
Supervised and guided visits with infant.
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
Supine with the foot of the bed elevated.
The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis?
Swimming lessons in an indoor pool.
During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?
Taking medication, with community follow-up.
A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide?
The infection has walled off into an area of infected bone creating a barrier to antibiotics. A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area (D). (A and B) do not address the encasement of the necrotic tissue. Although a sinus tract may occur, (C) does not address the purpose of the surgery.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake.
A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?
This anti-estrogen drug inhibits malignancy growth. Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
Tolerance of exertion.
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?
Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
Prior to a cardiac catheterization, which activity should the nurse have the client practice?
Valsalva's maneuver and coughing.
The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?
Wanting the drug is all that matters to an addict.
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
Wear the brace over a T-shirt 23 hours per day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace.
A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?
When did the symptoms begin after the last dose of opiate analgesic? Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic. The onset of withdrawal for opiate analgesics typically coincides with the time of the next habitual drug dose at 4-6 hours and may last as long as 7 to 14 days, so determining the time of the last dose (D) pinpoints the relationship of opiate dependency and withdrawal symptoms.
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
Withhold the medication and contact the healthcare provider. Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity.
Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?
You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?
A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings?
Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive
Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client
reports decrease in pain.
