Hesi Eaq's 2/28/20

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? 1 Encourage range of motion to the client's arm on the affected side 2 Administer the prescribed cough suppressant at the prescribed times 3 Empty and measure the drainage in the collection chamber each shift 4 Apply clamps below the insertion site when getting the client out of bed

Range-of-motion exercises to the client's arm on the affected side promote maintenance of function in the arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. Drainage is marked with time taped on the side of the device. The closed system is not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be avoided because of the danger of precipitating a tension pneumothorax. 1

Hydrochlorothiazide, a thiazide diuretic, has been prescribed for a client with hypertension. The client reports hearing that furosemide is more effective and requests a prescription change. How should the nurse respond? 1 "HCTZ has fewer side effects." 2 "HCTZ does not cause dizziness." 3 "HCTZ is only taken when needed." 4 "HCTZ does not cause dehydration."

Side effects from thiazides generally are minor and rarely result in discontinuation of therapy. Dizziness is a side effect of all diuretics. There is a potential for dehydration with all diuretics. All diuretic medications are taken regularly as directed. 1

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation.

The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance. 4

A client states, "The voices are saying I killed my husband." What is the best response by the nurse? 1 "You're having very frightening thoughts right now." 2 "We'll put you in a private room where you'll be safe." 3 "Tell me more about these worries about your husband." 4 "I just saw your husband, and he seems to be doing fine."

The response "You're having very frightening thoughts right now" demonstrates that the nurse is aware of the client's feelings; reflection opens the channel of communication. The response "We'll put you in a private room where you'll be safe" does not reflect the content of the client's statement. The nurse cannot talk the client out of these delusions by pointing out reality. Focusing on delusional content reinforces false beliefs.

According to which stage of Kohlberg's theory would a nurse ask a higher authority to reduce the treatment expenses of a low-income client? 1 Social contract orientation 2 Society-maintaining orientation 3 Instrument relativist orientation 4 Universal ethical principle orientation

The universal ethical principle orientation stage of Kohlberg's theory states that an individual may not follow a law if it does not seem just. At this stage, the nurse may ask a higher authority to reduce the treatment expenses of a poorer client. According to the social contract orientation stage, a person follows a law even if it is not necessarily just. According to the society-maintaining orientation stage, an individual shows concern for and makes decisions in accordance to his or her society. During the instrument relativist orientation, a child recognizes that there is more than one correct view. 4

When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by what? 1 Medulla 2 Cerebellum 3 Hypothalamus 4 Cerebral cortex

1 The medulla oblongata contains the respiratory center, and the neurons that supply the respiratory muscles originate here; they produce the rhythmic pattern of inspiration and expiration. The cerebellum helps control skeletal muscles. The hypothalamus links the nervous system to the endocrine system and functions as a relay station between the cerebral cortex and lower autonomic centers. The cerebral cortex is unrelated to respirations. The cerebral cortex is the thin layer of gray matter on the surface of the cerebrum that integrates higher mental functions.

The mother of an adolescent reports that her child does not eat properly, performs strenuous physical exercise, and is very introverted. What nursing interventions would be appropriate? Select all that apply. 1 Monitoring the adolescent's fluid and electrolyte status 2 Monitoring the adolescent for disturbances in family interactions 3 Counseling the adolescent about good personal hygiene and sanitation 4 Checking for evidence of self-induced vomiting 5 Developing a mutually agreeable targeted daily caloric intake goal 00:00:04 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

Abnormal habits that involve not eating properly, performing strenuous physical exercise, and being introverted may be signs of anorexia. Adolescents with anorexia may have fluid and electrolyte imbalances due to a reduced intake of nutritious food, which may lead to cardiac problems. Disturbances in family interaction may result in an adolescent's introverted behavior. Self-induced vomiting is a characteristic feature of eating disorders. Because the adolescent may have a low nutrient intake, a mutually agreeable targeted daily caloric intake goal should be crafted. Personal hygiene and sanitation counseling is not appropriate in this case. 1245

The nurse is caring for a client following a laparoscopic cholecystectomy. Which nursing action is priority? 1 Monitor the abdominal dressing for bleeding 2 Instruct on using patient-controlled analgesia 3 Teach about six-week activity restriction 4 Assess puncture sites for bleeding

Assess puncture sites for bleeding. The one to four puncture sites used to perform the surgery laparoscopically should be monitored for any possible bleeding. There will not be an abdominal dressing unless a traditional cholecystectomy is performed. Patient-controlled analgesia is not necessary as there is no abdominal incision. Activity restriction is about one week with a laparoscopic cholecystectomy.

A delusional client refuses to eat because of a belief that the food is poisoned. What is the most appropriate initial nursing intervention? 1 Stating that the food is not poisoned 2 Tasting the food in the client's presence 3 Showing the client that other people are eating without being harmed 4 Telling the client that tube feedings will be started if she doesn't start eating

1 Clients cannot be argued out of delusions, so the best approach is a simple statement of reality. Tasting the food in the client's presence is a form of entering into the client's delusions; the client may feel that only a particular part of the meal is free of poison. Showing the client that other people are eating without being harmed is trying to argue the client out of the delusion and will not work. The client can formulate a reason ("They have the antidote") to continue the false belief. Threats are always inappropriate nursing interventions

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the best nursing interventions in this situation? Select all that apply. 1 The nurse should provide a protective environment. 2 The nurse should assist with personal hygiene. 3 The nurse should educate the client about correct body mechanics. 4 The nurse should promote activities that reinforce reality. 5 The nurse should teach the client's caregiver proper feeding techniques.

1,2,4 When caring for an older adult who is in a confused state, the nurse should provide a protective environment, assist with personal hygiene, and promote activities that reinforce reality. If a client is suffering from arthritis, the nurse should educate him or her about correct body mechanics. If the nurse is caring for a dementia client, then he or she should teach the family caregiver proper feeding techniques.

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na+ (sodium) 149 mEq/L (149 mmol/L); K + (potassium) 3.2 mEq/L (3.2 mmol/L); Hb (hemoglobin) 17 g/dL (170 mmol/L); and glucose 90 mg/dL (5 mmol/L). What should the nurse teach the client? Select all that apply. 1 Avoid foods high in salt. 2 Restrict your fluid intake. 3 Eat foods high in potassium. 4 Limit your carbohydrate intake. 5 Continue your regular diet as before.

1,3 Based on the laboratory results and not directly related to the client's chronic medical condition, dietary recommendations are as follows: A sodium level of more than 145 mEq (145 mmol/L) is considered hypernatremia; the client should be taught to avoid foods high in sodium (e.g., processed foods, specific condiments). A potassium level less than 3.5 mEq/L (3.5 mmol/L) is considered hypokalemia. Therefore, the client should be encouraged to eat foods high in potassium. Restricting fluid intake will increase the serum sodium level and therefore is contraindicated. A glucose level of 90 mg/dL (5 mmol/L) is within the expected range of less than 110 mg/dL (6 mmol/L) and is not a concern. The laboratory results for serum sodium and serum potassium are not within the expected values, and the client should be taught how to alter the diet.

During a disaster response, the emergency department (ED) charge nurse is performing functions according to the healthcare facility emergency preparedness and response plan. Which interventions performed by the ED charge nurse are most appropriate? Select all that apply. 1 Recruit general staff nurses to care for mass casualty victims 2 Assign a communications nurse to work with the media personnel 3 Assign an emergency department (ED) nurse to care for the stable ED clients 4 Assign acritical care unit nurse to transfer the clients out to expand the capacity 5 Inform the medical command physician about the need for providers with specialty training

2,4,5 During an actual disaster, the ED charge nurse along with other personnel act in collaboration with the medical command physician and triage officer to organize nursing and ancillary services to meet client needs. The ED charge nurse assigns a communications nurse and a critical care unit nurse to transfer the clients out of the unit to expand the capacity for mass casualty victims and informs about the need for providers with specialty training. General staff nurses are recruited to provide care for stable ED clients. ED nurses are assigned to care for mass casualty victims

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? 1 Stroke volume 2 Venous pressure 3 Coronary artery patency 4 Left ventricular functioning

4 The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart. The patency of the coronary arteries usually is evaluated by cardiac catheterization.

Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled trials are studies in which subjects are assigned randomly to a treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group to determine the development of an outcome. Expert opinion based on scientific principles is not based on actual evidence; it is relied on when there is no evidence from research.

A nurse is reviewing studies to answer a clinical question as part of an evidence-informed practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. 1. Randomized controlled trial 2. Meta-analysis 3. Cohort study 4. Expert opinion based on scientific principles 5. Controlled trial without randomization

A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain? 1 Keep the left foot cool 2 Cross legs with the left one on top 3 Comply with the prescribed exercise program 4 Keep the foot elevated at a 30-degree angle

An exercise/rest program helps develop collateral circulation, which improves well-being and enables clients to increase their ability to walk longer distances. A cool environment favors constriction of peripheral blood vessels and further decreases arterial flow. Crossing the legs increases local pressure, which tends to occlude blood vessels. Elevation slows inflow of arterial blood, leading to further oxygen deprivation and pain. 3

The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Select all that apply. 1 Keep the client's head of bed elevated at least 10 degrees. 2 Connect tube feeding bag to client and feeding pump. 3 Flush with warm water before beginning feeding. 4 Check prescription for correct client formula. 5 Set correct rate and initiate pump. 6 Check for diarrhea.

Connect the feeding bag to the client and pump and check for any residual feeding before initiating the feeding. Always check the most recent tube feeding prescription before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should be assessed. The client's head of bed needs to be elevated at least 30 degrees. 23456

victim of a car crash tells the nurse, "I don't believe in God anymore now that I'm paralyzed." The nurse asks the client to discuss how the condition has affected his or her ability to express what is important to him or her. Which aspect of spiritual assessment does this question address? 1 Faith 2 Vocation 3 Connectedness 4 Life and self-responsibility

In discussing how the client's condition has affected his or her ability to express what is important to him or her, the nurse is addressing the vocation aspect of the client's spirituality. Questions about prayer, religious practices, and the meaning of life address the faith aspect of spirituality. Questions about community and feeling associated with spiritual practices address the connectedness aspect of spirituality. Questions about how the paralysis affects the client's next steps and changes in the client's life address the life and self-responsibility aspect of spirituality.

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine isethionate intravenously (IV) once daily. The nurse should monitor the client for what adverse effect? 1 Hypertension 2 Hypokalemia 3 Hypoglycemia 4 Hypercalcemia 00:00:03 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

Pentamidine isethionate can cause either hypoglycemia or hyperglycemia even after therapy is discontinued, and therefore blood glucose levels should be monitored. Hypotension, not hypertension, occurs with pentamidine isethionate. Hyperkalemia, not hypokalemia, occurs with pentamidine isethionate. Hypocalcemia, not hypercalcemia, occurs with pentamidine isethionate. 3

A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? 1 "Your skin will look like a blistering sunburn." 2 "A localized skin reaction usually occurs." 3 "A daily application of an emollient will prevent a burn." 4 "Your family must have had experience with radiation therapy."

Radiodermatitis occurs 3 to 6 weeks after the start of treatment. The word "burn" should be avoided because it may increase anxiety. Emollients are contraindicated; they may alter the calculated x ray route and injure healthy tissue. The response about the client's family does not address the client's concern. 2

Which teaching point regarding safety should the nurse include in the instructions for the parents of a school-age client who is a latchkey child? 1 "Consider getting a pet for your child." 2 "Plan play dates for your child to attend on afternoons you are not home." 3 "Teach your child not to display the keys used to enter the home after school." 4 "Provide structured activities for your child to complete while they are home alone."

Teaching the child not to display the house keys used to enter the home after school is a safety teaching point the nurse should include in the teaching session. Planning for play dates on afternoons the parent will not be home is an important point to emphasize in regards to after-school activities. Getting a pet is a teaching point directed towards decreasing the child's loneliness while home alone. Providing structured activities for the child is an important point to emphasize regarding after-school activities, not safety.

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client? 1 Temporary episodes of neurologic dysfunction 2 Intermittent attacks caused by multiple small clots 3 Ischemic attacks that result in progressive neurologic deterioration 4 Exacerbations of neurologic dysfunction alternating with remissions

The nurse manager has increased demands when leading a case-management system. Analyzing the status of clients' movement through clinical pathways is a way to determine if the case managers are adequately managing a caseload of clients. The nursing case manager engages with all departments in a healthcare organization; therefore, it is important for the nurse manager to coordinate communication among these groups. Quality improvement is constantly assessed to ensure that the clinical pathway is appropriate for the diagnosis-related group (DRG). Studying staffing ratios would be appropriate for team nursing. Revising position descriptions for cross-trained staff would be appropriate for client-focused care.

The nurse is questioning a client who reports pain. Which questions asked by the nurse are appropriate? Select all that apply. 1 "Where does it hurt?" 2 "What makes the pain worse?" 3 "How long have you noticed it?" 4 "Have you been treated for pain previously?" 5 "How severe is your pain on a scale of 0 to 10?"

The nurse should follow an orderly and systematic approach when collecting information. The nurse should ask specific questions of the client such as "Where does it hurt?", "What makes the pain worse?", "How long you have noticed it?" and "How severe is your pain on a scale of 0 to 10?" Questions such as "Have you been treated for pain previously?" should be asked after understanding the characteristics of the pain.

A 4-month-old infant is admitted to the pediatric unit for cleft lip repair. The nursing assistant asks the nurse why the repair is being done at this age. What is the best response the nurse can give as to why cleft lip repair is performed so soon? 1 Tends to obstruct breathing 2 Can cause severe feeding problems 3 May cause respiratory tract infections 4 Has an emotional effect on the parents

The visual effect of the cleft lip on the parents may significantly affect the parent-child attachment process and is often considered a reason for early surgical intervention. The best age to have cleft lip surgery varies, but preferably between 4 months and 12 months of age. The infant also uses the nose to breathe; a cleft lip does not obstruct breathing. Feeding may be accomplished with breastfeeding or the use of specially designed bottles and nipples; this is not, by itself, an indication for early surgery. Infants with cleft palate have severe feeding problems. Precautions other than surgery can be taken to prevent ear and upper respiratory tract infections. 4

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include? 1 Administering water after the feeding is completed 2 Maintaining the supine position during the feeding 3 Heating the feeding to slightly above body temperature 4 Determining tube placement by instilling water before the feeding

Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.