HESI EXAM 4

Methylprednisone 100 mg IV is prescribed for a client. The medication comes in a vial labeled "125 mg per ml." How many ml should the nurse administer?

0.8

A child with Cellulitis receives a prescription for nafcillin 250 mg IM STAT. The available vial is labeled "add 3.4 ml of dilution to provide a solution of 1 gram/4 ml." How many milliliters should the nurse administer?

1

A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning accident. While providing care to the child, the nurse begins talking with his pre-adolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Tell the older brother that he seems depressed C. Ask the older brother how he felt during the incident D. Commend the older brother for his heroic actions

C. Ask the older brother how he felt during the incident

A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the streptococcus bacteria? A. High, protracted fever B. Flaky, peeling skin C. White coating on the tongue D. Red bumps across chest

C. White coating on the tongue

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. What action should the nurse implement? A. Notify the radiation department to withhold the treatments for now B. Determine if the client wishes to cancel further radiation treatments C. Ask the client about his expected goals for this hospitalization D. Explain that palliative care measures can be provided at home

C. Ask the client about his expected goals for this hospitalization

Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl. The nurse prepares to administer a unit of blood for an emergency transfusion. That client has an AB negative blood type and the blood bank sends a unit of Type A RH negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A. Recheck the clients hemoglobin, blood type, and RH factor B. Administer normal saline until Type AB negative is available C. Obtain additional consent for administration of Type A negative blood D. Transfuse Type A negative blood until Type AB negative is available

D. Transfuse Type A negative blood until Type AB negative is available

After reviewing the Braden scale findings of residents in a long term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? a. An older man who sheets are damp each time he is turned b. A woman with osteoporosis who is unable to bear weight c. An older adult who is unstable to communicate elimination needs d. A poorly nourished client who requires liquid supplements

a. An older man who sheets are damp each time he is turned

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? a. Apply sequential compression stockings b. Monitor for urinary incontinence c. Observe for signs of depression d. Provide a wide variety of meal choices

a. Apply sequential compression stockings

A male client who arrives at the emergency department after a motor vehicle collision (MVC) tells the nurse "The car started to slide, and I just decided to let it go. Everyone would be better off if I was no longer was around." How should the nurse respond? a. Ask the client if the MVC was a suicide attempt b. Assess the client for other symptoms of depression c. Report to the health care provider that the client may need an antidepressant d. Determine what is going on in the clients life to make him feel depressed

a. Ask the client if the MVC was a suicide attempt

A client with chronic kidney disease is admitted in heart failure and is complaining of shortness of breath and a headache. Assessment findings include blood pressure 180/90 mmHg, heart rate 130 beats/minute, oxygen saturation 89%, and a temperature of 100 degrees Fahrenheit. A temporary dialysis catheter is inserted for immediate hemodialysis and the client is scheduled for replacement of an arterial venous fistula in the left arm. Which action should the nurse implement? a. Avoid using the left arm for IV access b. Initiate oxygen at 110% per face mask c. Give the PRN dose of enalapril d. Administer PRN antipyretic prescription

a. Avoid using the left arm for IV access

The nurse is interacting with a client who is diagnosed with postpartum depression. Which finding should the nurse document as objective signs of depression? Select all that apply. a. Avoids eye contact b. Interacts with a flat affect c. Expresses suicidal thoughts d. Has a disheveled appearance e. Reports feeling sad

a. Avoids eye contact b. Interacts with a flat affect d. Has a disheveled appearance

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include heart rate of 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? a. Bilateral diffuse wheezing b. Temperature of 100.5 c. Yellow expectorated sputum d. Shortness of breath on exertion

a. Bilateral diffuse wheezing

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Blood transfusion b. Bone marrow transplantation c. Immunosuppressive therapy d. Chemotherapy

a. Blood transfusions

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first? a. Change the surgical dressing to observe the appearance of the incision b. Assess the level of consciousness and vital signs for both clients c. Review the plan of care and the medications that are due for both clients d. Complete a head-to-toe assessment of the client with pneumonia

a. Change the surgical dressing to observe the appearance of the incision

The nurse is assisting the health care provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure isn't effective? a. Chest tube insertion tray b. Intubation tray c. Crash cart d. Ventilator

a. Chest tube insertion tray

Which needles should the nurse administer intravenous fluids via our clients implanted port?

The one with the little lock on the end

Four hours after the nurse administers interferon alpha subcutaneously into a client, the client develops a headache, muscle aches and a fever of 101.8 degrees Fahrenheit. What action should the nurse implement? a. Administer prescribed PRN dose of acetaminophen for these side effects b. Explain that an antihistamine may be needed in response to this allergic reaction c. Document these findings as an idiosyncratic response to this medication d. Observed the site where the medication was injected for signs of local reaction

a. Administer prescribed PRN dose of acetaminophen for these side effects

The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consultS first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? a. Affirm the nurses plan to review the prescription with the provider b. Advise the nurse to administer the medication as prescribed c. Assume responsibility for discussing the concern with the provider d. Offer to administer the prescription since the nurse has concerns

a. Affirm the nurses plan to review the prescription with the provider

An adult client is admitted to the psychiatric unit with a diagnosis of major depression. After two weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving personal belongings away to visitors, and is in a better mood. Which intervention is best for the nurse to implement? a. Tell the client to keep one's belongings because they will be needed at discharge b. Support the client by validating the progress that has been made c. Reassure the client that the antidepressant drugs are apparently effective d. Ask the client if there are any recent thoughts of harming self

d. Ask the client if there are any recent thoughts of harming self

A client is admitted to the labor and delivery unit in early labor and the nurses assesses the status of her contractions. The frequency of contractions is most accurately valued by counting the minutes and seconds in which manner? a. From the peak of one contraction to the peak of the next contraction b. From the beginning of one contraction to the beginning of the next contraction c. From the beginning of one contraction to the end of that contraction d. From the end of one contraction to the beginning of the next contraction

b. From the beginning of one contraction to the beginning of the next contraction

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? a. Maintain head of bed at 45 degrees b. Infuse 0.9% sodium chloride 500 ml bolus c. Insert nasogastric tube to intermittent suction d. Document strict and intake and output

b. Infuse 0.9% sodium chloride 500 ml bolus

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first? a. Insert a nasogastric tube for feeding b. Initiated a prescribed IV for parenteral fluid c. Give the infant 5% dextrose in water orally d. Feed the infant 3 ounces of isomil

b. Initiated a prescribed IV for parenteral fluid

The nurse is caring for a group of clients with the help of a practical nurse. Which nursing action should the nurse assign to the PN? Select all that apply. a. Start the second blood transfusion for the client 12 hours following a below knee amputation b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty e. Initiate patient-controlled analgesia pumps for two clients immediately postoperatively

b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

The nurse is caring for a client with a suspected diagnosis of osteomyelitis. Which diagnostic test should the nurse prepare the client to expect the health care provider to prescribe? a. Radiographs b. Radionuclide bone scan c. C reactive protein tests d. Erythrocytes sedimentation rate

b. Radionuclide bone scan

When providing client care, the nurse identifies a problem and develops a related clinical question. Next the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence based. When gathering evidence, which consideration is most important? a. Relevance to the situation b. Related personal values c. Frequency that the problem occurs d. Past experience with similar problems

b. Related personal values

The nurse on a pediatric unit of a healthcare facility observes a colleague leaving and open client electronic health record unattended while taking a lunch break. Which action should the nurse take? a. Close the computer and complete the day's assignments b. Remind the colleague of information security principles c. Comment about the action on a staff discussion board d. Discuss the incident with the facilities risk manager

b. Remind the colleague of information security principles

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome. Which information is most important to provide parents of newborns and infants? a. Do not pop bottles for an infant during naps and bedtime b. Remove pillows and soft toys from the crib at bedtime c. Position the intent in a supine position while sleeping d. Keep a bulb syringe accessible for use for an infant

b. Remove pillows and soft toys from the crib at bedtime

A male client with hypertension, who is receiving a new antihypertensive prescription at his last visit returns to the clinic 2 weeks later to evaluate his blood pressure. His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad." In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Heart block due to myocardial damage b. Stroke secondary to hemorrhage c. Acute kidney injury due to glomerular damage d. Blindness secondary to cataracts

b. Stroke secondary to hemorrhage

After spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which is admission assessment finding should the nurse reports of the health care provider? Select all that apply a. Red blood cell count (RBC) b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC) e. Location of the initial IV site

b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC)

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. What action should the nurse take? a. Initiate an infusion of 0.9% normal saline solution b. Prepare a saline flush in a 3 ml syringe c. Position the clients head facing away from the site d. Aspirate for the presence of blood return

d. Aspirate for the presence of blood return

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? a. Remind the UAP to wash hands frequently while in the room b. Help the UAP reposition the gown sleeve over the glove edges c. Confirm that the gown is tide securely at the neck and waist d. Assist the UAP with application of a face mask or face shield

d. Assist UAP with application of a face mask or face shield

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give to this nurse? a. Transfer a client to another unit b. Perform the admission of a new client c. Monitor the central telemetry d. Assist cardiac nurses with their assignments

d. Assist cardiac nurses with their assignments

Following breakfast, the nurse is preparing to administer 0900 medications to the clients on the medical floor. Which medication should be held until a later time? a. The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease b. The antifungal nystatin suspension, for a client who has just brushed his teeth c. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour d. The loop diuretic furosemide, for a client with a serum potassium level of 4.2 meq/L

b. The antifungal nystatin suspension, for a client who has just brushed his teeth

A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30-second periods of apnea, the healthcare provider is notified, and STAT arterial blood gases are drawn. What ABG results should the nurse anticipate? a. Compensated respiratory acidosis b. Uncompensated respiratory acidosis c. Uncompensated metabolic acidosis d. Compensated metabolic acidosis

b. Uncompensated respiratory acidosis

The parents bring their one-year-old child with a ventricular septal defect to the clinic for a well child visit. Which assessment finding should the nurse report to the health care provider immediately? a. Respirations of 26 breaths/minute at rest b. Expected weight and growth care for an infant c. 2+ pitting edema in the extremities d. Heart rate of 105 beats/minute

c. 2+ pitting edema in the extremities

The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated blood pressure in a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Measure ankle circumference b. Monitor daily sodium intake c. Record usual eating patterns d. Auscultate for irregular heart rate

d. Auscultate for irregular heart rate

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? a. In adult one day postoperative laparoscopic cholecystectomy requesting pain medication b. An adult who's in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection d. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery

c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection

When should intimate partner violence screening occur? a. Once the clinician confirms a history of abuse b. Only when a client presents with an unexplained injury c. As a routine part of each healthcare encounter d. As soon as the clinician suspects a problem

c. As a routine part of each healthcare encounter

For the second time in four months, and overweight client is seen in the clinic because of vulvovaginitis resulting from a candida infection. Which intervention should the nurse implement first? a. Determine the client's typical menstrual cycle b. Obtain the client's blood glucose level c. Ask the client about recent sexual activity d. Review the client results for a complete blood count

c. Ask the client about recent sexual activity

What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication? a. Notify the health care provider b. Complete an incident report documenting the facts c. Assess the client for any adverse effects d. Document the events leading to the error in the nurses' notes

c. Assess the client for any adverse effects

A young client involved in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse provide to the practical nurse who is caring for this client? a. Avoid washing the limb when assisting with bathing b. Elevate limb above the heart when lying in bed c. Avoid planter flexion of the affected limb d. Perform range of motion on the affected limb

c. Avoid planter flexion of the affected limb

In assessing a client with diabetes mellitus type 1, the nurse notes that the client's respirations have changed from 16 with normal depth to 32 and deep, and the client has become lethargic. What assessment data should the nurse obtain next? a. Arterial blood gases b. Core body temperature c. Blood glucose d. Oxygen saturation

c. Blood glucose

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? a. Straight catheterization if unable to avoid b. Advance from clear liquids as tolerated c. Cefazolin 1 gram IVPB q6 hours d. Complete blood count cell count (CBC) in AM

c. Cefazolin 1 gram IVPB q6 hours

The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Skin of palms of the hand b. Current height and weight c. Condition of tooth enamel d. Length of last menses

c. Condition of tooth enamel

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. What teaching should the nurse provide? a. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals b. Multivitamins are contraindicated during treatment with weight control medications such as Orlistat c. Following a well-balanced diet is a much healthier approach to a good nutrition than depending on a multivitamin d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness

d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? Select all that apply. a. Flat affect b. Frequent drooling c. Frequent syncope d. Blurred vision e. Occasional nocturia

c. Frequent syncope d. Blurred vision

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? Select all that apply. a. Chicken bouillon soup and toast b. Fresh vegetables with mayonnaise dip c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples e. Soda crackers and peanut butter

c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples

A client with chronic obstructive lung disease was receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take first? a. Have the client breathe into a paper bag b. Increase oxygen to three liters/minute c. Instruct the client to purse lip breathe d. Ask the client to take short, rapid breaths

c. Instruct the client to purse lip breathe

A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client discharge teaching? a. Use of topical applications to manage pruritis b. Strategies to promote independent self-care c. Instructions regarding a restricted protein diet d. Need for maintaining good oral hygiene

c. Instructions regarding a restricted protein diet

The nurse identifies an electrolyte balance, shortness of breath and a weight gain of 4.4 pounds in 24 hours in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? a. Document abdominal girth b. Monitor daily sodium intake c. Measure ankle circumference d. Auscultate for irregular heart rate

c. Measure ankle circumference

The nurse is caring for a client after a thoracentesis that drained 50 ml of clear fluid from the left lung. Which assessment finding should the nurse report to the health care provider immediately? a. Serosanguinous drainage from the chest tube b. Dullness bilaterally on progression c. Mediastinal shift to the right d. Diminished breath sounds in the left lower lobe

c. Mediastinal shift to the right

While changing the clients postoperative dressing, the nurse observes are red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the health care provider, the nurse should evaluate which of the client's laboratory values? a. C reactive protein level b. Serum albumin c. Neutrophil count d. Creatinine level

c. Neutrophil count

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Obtain the infants vital signs b. Observe the instant latching on to the breast c. Place the ID bands on the infant and mother d. Administer vitamin K injection

c. Place the ID bands on the infant and mother

The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asked the nurse for information about the scheduled procedure. What action should the nurse implement? a. Reassure the client that whatever the outcome, he will be able to cope with the results b. Encourage the client to take deep breaths in to avoid thinking negative thoughts c. Repeat the client teaching and leave written instructions for the client d. Remind the client of the instructions that were provided an hour ago

c. Repeat the client teaching and leave written instructions for the client

A nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Evaluate the client for sleep disturbances b. Assess the client for weakness and fatigue c. Report any client complaint of pain or discomfort d. Note in report the client's food and liquid intake during meals and snacks e. Weigh the client and report any weight gain

c. Report any client complaint of pain or discomfort d. Note in report the client's food and liquid intake during meals and snacks e. Weigh the client and report any weight gain

The nurse is managing for clients in the intensive care unit who were mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? a. High pressure alarm sounds when the client is coughing b. Diminished breath sounds in the right posterior base c. Restrained and restless with a low volume alarm sounding d. An audible voice when client is trying to communicate

c. Restrained and restless with a low volume alarm sounding

What is the priority nursing problem for a client with hypoparathyroidism? a. Anxiety b. Imbalanced nutrition c. Risk for injury d. Deficient knowledge

c. Risk for injury

A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a. Serum ph of 7.45 b. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c. Serum potassium of 3.0 mg/dl d. Gastric output of 100 ml in the last 8 hours

c. Serum potassium of 3.0 mg/dl

A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? Select all that apply. a. Arrange in service training through the education department b. Obtain informed consent from clients who will receive care c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee

c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee

A middle-aged man in the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide? a. Keep the infected area covered until the infection is resolved b. Use a fine-tooth comb to remove any knits observed on the scalp c. Take your medication with a glass of water two hours after meals d. Wash your bed linens and hot water after starting the medication

c. Take your medication with a glass of water two hours after meals

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol use. What should the nurse administer to prevent the development of Wernicke's syndrome? a. Atenolol b. Lorazepam c. Thiamine d. Famotidine

c. Thiamine

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach

c. Use cold and allergy medications only as directed by a health care provider

The nurse learns in report that a client was unstable during the previous shift. The nurse should plan to carefully monitor which parameter? a. Circadian rhythms b. Basal metabolic rate c. Vital signs d. Stress levels

c. Vital signs

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider? a. Nausea and headache b. Yellow tinged sputum c. Watery diarrhea d. Increased fatigue

c. Watery diarrhea

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cataracts ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Prepare skin for procedure b. Identify clients pulse points c. Check telemetry monitoring d. Witness consent for procedure

a. Prepare skin for procedure

A seriously ill male client is transferred to the health care facility in a different state. Included in his records are advanced directive and a physician orders for life sustaining treatment. However, the state to which he is transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? a. Request that the new health care provider cosine the POLST document b. Implement the clients wishes as described in his advanced directive c. Ask the clients family to make life sustaining treatment decisions d. Attached an advance directive copy to a medical record prescription page

a. Request that the new health care provider cosine the POLST document

A female client with dementia who needs assistance with meals and activities of daily living often screams at the staff and threatens to hit those who come near her period which nursing problems should be included in the treatment plan? a. Risk for other directed violence b. Impaired verbal communication c. Risk for acute confusion d. Caregiver role strain

a. Risk for other directed violence

After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, "God has abandoned me. What did I do to deserve this?" Based on this response, the nurse decides to include which nursing problem in the clients plan of care? a. Spiritual distress b. Ineffective coping c. Acute pain d. Complicated grieving

a. Spiritual distress

The nurse should withhold which medication if the clients serum potassium level is too high? a. Spironolactone b. Hydrochlorothiazide c. Metolazone d. Furosemide

a. Spironolactone

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavior

a. State it is unacceptable to undress during interview

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this clients plan of care? a. Teach techniques for scanning the environment b. Practice visual exercises that focus on a still object c. Encourage the use of corrective lenses during the day d. Alternate an eye patch from eye to eye every two hours

a. Teach techniques for scanning the environment

The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor is the most likely explanation for this finding? a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago b. The client's hemoglobin is 10.1 gm/dl and hematocrit is 30.4% c. The client has a 20-pack year history of smoking cigarettes d. The client has a history of allergic bronchitis with recurrent bacterial pneumonia

a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the clients discharge teaching plan? Select all that apply. a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting d. Crossed legs at knee but not at ankle e. Maintain the bed flat while sleeping

a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? a. "How do you cope with the voices?" b. "What are the voices saying?" c. "Which medication works best?" d. "When do you hear voices?"

b. "What are the voices saying?"

What is the primary goal when planning nursing care for a client with degenerative joint disease? a. Improve stress management skills b. Achieve satisfactory pain control c. Obtain adequate rest and sleep d. Reduce risk for infection

b. Achieve satisfactory pain control

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. Which intervention has the highest priority for this client? a. Administer prescribed PRN sleep medications b. Administer prescribed stool softener c. Encourage use of prescribed analgesic perennial sprays d. Encourage breastfeeding to promote uterine involution

b. Administer prescribed stool softener

A male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink frothy sputum. The nurse sits the client and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. Which action should the nurse take? a. Withhold the morphine until the client's dyspnea resolves b. Administer the dose of morphine sulfate as prescribed c. Consult with the charge nurse regarding the morphine prescription d. Review the need for the prescription with the health care provider

b. Administer the dose of morphine sulfate as prescribed

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? a. Encourage the UAP to provide comfort care measures only b. Advise the UAP to resume positioning the client on schedule c. Assign a practical nurse to assist the UAP and turning the client d. Assume total care of the client and monitor neurologic function

b. Advise the UAP to resume positioning the client on schedule

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly

b. Affirm that the client should arise slowly from the chair

The nurse is caring for four clients on a medical unit. Which client is at an increased risk for candidiasis? a. An adolescent in the third trimester of pregnancy who has persistent hyperemesis b. An adult with acquired immunodeficiency syndrome who is taking antibiotics c. The client who is admitted for preoperative surgical consult for morbid obesity d. An older client with chronic kidney disease who has uremic frost

b. An adult with acquired immunodeficiency syndrome who is taking antibiotics

In planning care for a client with early-stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury due to impaired judgement. Which intervention is most important for the nurse to include in this clients plan of care? a. Offer the client frequent reassurance that he/she will be safe b. Arrange the client's environment so the client can move about freely c. Engage the client in regularly scheduled activities during the day d. Assign a UAP to provide the client with total personal care

b. Arrange the client's environment so the client can move about freely

Oxygen at 5 L/minute per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? a. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs b. Avoid administration of oxygen at high levels for extended periods c. Oxygen is less toxic when it is humidified with a hydration source d. Increase oxygen rate during sleep to compensate for slower respiratory rate

b. Avoid administration of oxygen at high levels for extended periods

A client with hemorrhoids asked for information about high fiber diet. Which breakfast menu items should the nurse suggest? Select all that apply. a. Scrambled eggs b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries e. Bacon slices

b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? a. Prepare for emergent oral intubation b. Clarify end of life desires c. Offer sips of favorite beverages d. Initiate comfort measures

b. Clarify end of life desires

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? a. Average client scores improved on specific risk factor knowledge tests b. Clients who develop disease complications promptly received rehabilitation c. Only 30% of clients did not attend self-management education sessions d. More than 50% of at risk clients were diagnosed early in their disease process

b. Clients who develop disease complications promptly received rehabilitation

The mother of a child recently diagnosed with asthma ask the nurse how to help protect her child from having asthma attacks. To avoid triggers for asthma attacks, which instruction should the nurse provide the mother? Select all that apply. a. Decrease the raw sugars in the diet b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

A client is being discharged with a prescription of for warfarin. What instruction should the nurse provide this client regarding diet? a. Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin b. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent c. Increase the intake of dark green leafy vegetables while taking warfarin d. Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed

b. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent

The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? a. Body mass index of 31 b. Diabetes mellitus in family history c. Birth control pill usage until age 45 d. 20 pack year history of cigarette smoking

d. 20 pack year history of cigarette smoking

A 300 ml unit of packed red blood cells is prescribed for a client with heart failure who has 3+ pitting adima, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood? a. 50 ml/hour b. 150 ml/hour c. 300 ml/hour d. 75 ml/hour

d. 75 ml/hour

Which environmental factors most significant when planning care for a client with ostemalacia? a. Quiet, calm surroundings b. Cool, moist air c. Stimulating sounds and activity d. Adequate sunlight

d. Adequate sunlight

An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she's sick or stressed. How should the nurse respond? a. Describe the use of the vaccination to treat herpes simplex type 2 b. Explain the use of the vaccination to reduce risk for herpes zoster c. Confirm that consent form is signed before administering the vaccination d. Arrange for skin testing to evaluate if the client is a candidate for the vaccine

b. Explain the use of the vaccination to reduce risk for herpes zoster

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. Prevention through nutrition and exercise b. Avoidance of foods containing purine c. Immobilization of affected joints d. Application of heat and cold therapy

d. Application of heat and cold therapy

A female client is scheduled for an intravenous pyelography today. The nurse instructs the client that the X-ray visualizes the kidneys, uterus, and bladder. Which information is most important for the nurse together before the client goes for the X-ray? a. Determine the last time the client had a bowel movement b. Inquire if she is taking her regularly scheduled medications c. Find out if the client can lie prone for the X-ray d. Ask if the client has an allergy to shellfish

d. Ask if the client has an allergy to shellfish

An older client is referred to a rehabilitation facility following a cerebrovascular accident. The client is aphasic with left sided paralysis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? a. Initiate passive range of motion exercises b. Facilitate a consultation for speech therapy c. Use pictures and gestures to communicate d. Arrange for daily home care assistance

b. Facilitate a consultation for speech therapy

A woman at 12 weeks' gestation comes into the clinic for her first prenatal visit. After completing health history, the nurse should discuss which topic about pregnancy at this initial visit? a. Concerns about parenting b. Knowledge about labor and delivery c. Complications associated with childbirth d. Cultural practices related to childbearing

d. Cultural practices related to childbearing

Prior to surgery, written consent must be obtained. Which is the nurses legal responsibility with regard to obtaining written consent? a. Ask the client or a family member to sign the surgical consent form b. Explain the surgical procedure to the client and ask the client to sign a consent form c. Validate the clients understanding of the surgical procedure to be conducted d. Determine that the surgical consent form has been signed and is included in the clients record

d. Determine that the surgical consent form has been signed and is included in the clients record

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the clients age or type of diabetes? a. Prior to exercising b. Before going to bed c. Immediately after meals d. During acute illness

d. During acute illness

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are being taken so often. Which response by the nurse is most accurate? a. Hypertension leading to sudden shock can develop at any time b. Blood pressure fluctuations means that the condition has become chronic c. Sodium intake with meals and snacks affects the blood pressure d. Elevated blood pressure must be anticipated and identified quickly

d. Elevated blood pressure must be anticipated and identified quickly

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? a. Importance of recording daily weights b. Adherence to a high fiber low fat diet c. Need to check temperature daily d. Events requiring steroid dosage adjustments

d. Events requiring steroid dosage adjustments

A male client with cirrhosis and severe ascites, who is scheduled for a paracentesis tells the nurse that he is in pain and feel short of breath, so he wants to reschedule the procedure. How should the nurse respond? a. Advise the client that the procedure will help diagnose the cause of his symptoms b. Encourage the client to verbalize his fears about the outcome of the procedure c. Offer to notify the health care provider of his desire to reschedule the procedure d. Explain to the client that the paracentesis will provide relief from his discomfort

d. Explain to the client that the paracentesis will provide relief from his discomfort

What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with and HIV infection? a. Increase ability to carry out activities of daily living b. Promote a feeling of general well-being c. Prevent spread of infection to others d. Improve function of the immune system

d. Improve function of the immune system

A woman with an anxiety disorder calls her obstetricians office and tells the nurse of increasing anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her anti-anxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Explain that anxiety is a normal response for a mother of a three-week old d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

The mother of a 7-month-old brings the infant to clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Tell the mother to cleanse with soap and water at each diaper change b. Encourage the mother to apply lotion with each diaper change c. Ask the mother to decrease the infants intake of fruits for 24 hours d. Instruct the mother to change the child's diaper more often

d. Instruct the mother to change the child's diaper more often

When teaching a group of school age children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? a. Wash hands frequently b. Avoid drinking lake water c. Do not share personal products d. Wear long sleeves and pants

d. Wear long sleeves and pants

The healthcare provider prescribes an antibiotic cefdinir 300 mg PO Every 12 hours for a client with a postoperative wound infection. Which food should the nurse encourage this client to eat? a. Avocados and cheese b. Green leafy vegetables c. Fresh fruits d. Yogurt or buttermilk

d. Yogurt or buttermilk

Heparin 0.4 units/kg/minute IV is prescribed for a client who weighs 110 pounds. The available solution is labeled heparin sodium 25,000 units in 5% dextrose injection 250 mL. The nurse should program the infusion pump to deliver how many ml/hour?

12

A 154-pound client with diabetic ketoacidosis is receiving an IV abnormal saline 100 ml with regular insulin 100 units. The health care provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to infuse how many ml/hour?

7

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays in normal sinus rhythm, but he has no spontaneous respirations, and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Observed for swelling at the fracture site B. Begin chest compressions at 100/minute C. Analyze the cardiac rhythm in another lead D. Obtain a 12-lead electrocardiogram

B. Begin chest compressions at 100/minute

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature of 96 degrees Fahrenheit, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure 64 mmHg, and central venous pressure 7 mmHg. Serum laboratory findings include hemoglobin 6.6 grams/dl, platelets 60,000/mm^3, and white blood cell count 30,000mm^3. Based on these findings the client is that greatest risk for which pathophysiological condition? A. Chronic obstructive pulmonary disease (COPD) B. Multiple organ dysfunction syndrome (MODS) C. Disseminated intravascular coagulation (DIC) D. Acquired immune deficiency syndrome (AIDS)

B. Multiple organ dysfunction syndrome (MODS)

A young adult female client with recurrent pelvic pain for 3 years returns to the clinic for relief of severe dysmenorrhea. The nurse views her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A. An option to diagnose disease extent and provide therapeutic treatment is laparoscopy B. Infertility is successfully treated with removal of intra-abdominal endometrial lesions C. The symptoms of endometriosis can increase with menopause D. Oral contraceptives increase the symptoms of endometriosis

D. Oral contraceptives increase the symptoms of endometriosis

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. Plumb line test indicates fetal position curvature c. Babinski tests that reveals fanning out of toes d. Moro test precipitating a startle response

a. Ortolani maneuver causing a click at the hip joint

A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first? a. Determine the clients vital signs b. Administer prescribed pain medication c. Apply warm blankets d. Assess the surgical site

a. Determine the clients vital signs

The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? a. Difficulty breathing b. Increased blood pressure c. Chills and tremors d. Nausea and vomiting

a. Difficulty breathing

The healthcare provider prescribes a placebo instead of pain medication. What intervention should the nurse implement? a. Discuss ethical concerns about placebo use with the health care provider b. Administer the placebo as prescribed when the client complaints of pain c. Tell the charge nurse about the prescribed placebo and refuse to administer it d. Inform the client that the provider prescribed a placebo instead of pain medication

a. Discuss ethical concerns about placebo use with the health care provider

An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 milliliters of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of bed b. Complete focus assessment c. Offer PRN pain medication d. Send emesis sample to the lab

a. Elevate the head of bed c. Offer PRN pain medication b. Complete focus assessment d. Send emesis sample to the lab

The nurse notes that a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a. Engage the client in non-threatening conversations b. Encourage the client to participate in group activities c. Encourage the clients family to visit more often d. Schedule a daily conference with the social worker

a. Engage the client in non-threatening conversations

An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus is admitted to the telemetry unit for sudden onset of dizziness with palpitations and a burning sensation in her chest. Which intervention should the nurse implement first? a. Evaluate telemetry cardiac rhythm b. Administer an oral antacid c. Assess blood glucose level d. Review clients last meal choices

a. Evaluate telemetry cardiac rhythm

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? a. Identify the source and amount of bleeding b. Apply direct pressure to the client's IV site c. Clean up the spilled blood to reduce infection transmission d. Notify the health care provider that the client appears to be bleeding

a. Identify the source and amount of bleeding

A client with chronic kidney disease (CKD) is discharged with a prescription for epoetin alpha subcutaneously. In teaching the client about the medication, the nurse should emphasize the benefit of increasing which food product in the diet? a. Iron rich foods b. High fiber foods c. Citrus fruits and vegetables d. Dairy products

a. Iron rich foods

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type one diabetes mellitus, the client tells the nurse in a loud voice to leave the room. What action should the nurse take? a. Leave the clients room and return later in the day b. Explain that insulin is a life saving drug for the client c. Encourage client to implement relaxation techniques d. Refer the client to the social worker for support therapy

a. Leave the clients room and return later in the day

A client with acute renal failure is admitted for uncontrolled type one diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in the clients plan of care? a. Monitor the client's cardiac activity via telemetry b. Assess glucose via finger stick every four to six hours c. Maintain venous access with an infusion of normal saline d. Evaluate hourly urine output for return of normal renal function

a. Monitor the client's cardiac activity via telemetry

An adult male is brought into the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Nausea with projectile vomiting b. Rebound abdominal tenderness c. Diminished bilateral breath sounds d. Rib pain with deep inspiration

a. Nausea with projectile vomiting

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate that the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Observe aspiration site b. Monitor skin elasticity c. Measure urinary output d. Assess body temperature

a. Observe aspiration site

A client was admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? a. Observe breathing patterns b. Assess blood pressure c. Measure body temperature d. Palpate for pedal edema

a. Observe breathing patterns b. Assess blood pressure c. Measure body temperature d. Palpate for pedal edema

A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? a. Obtain a urine specimen for a prescribed culture and sensitivity test b. Teach the client about the side effects of the prescribed anti-infective drug c. Administer the initial dose of the anti-infective drug as prescribed d. Assess the last 24 hour oral and intravenous fluid intake and urine output

a. Obtain a urine specimen for a prescribed culture and sensitivity test

A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the health care provider has prescribed all these medications. Which information should the nurse include when responding to this client? Select all that apply. a. Pupillary dilation is necessary to access the eye chamber for lens removal b. A medication is used to induce sleep during the procedure c. One of the medications is used to anesthetize the corneal surface d. The iris must be paralyzed during surgery to prevent it from reacting to light e. These medications assistant instructing the client's vision during the surgery

a. Pupillary dilation is necessary to access the eye chamber for lens removal d. The iris must be paralyzed during surgery to prevent it from reacting to light

When assessing the surgical dressing of a client who had an abdominal surgery the previous day, the nurse observes that a small amount of drainage present on the dressing and the wounds Hemovac suction device is empty with the plug open. How should the nurse respond? a. Recompress the wound suction device and secure the plug b. Notify the health care provider that the drain is not working c. Replace the dressing and remove the drainage device d. Repositioned the drainage device to keep the plug open

a. Recompress the wound suction device and secure the plug

A client with diabetic peripheral neuropathy has been taking pregabalin for four days. Which finding indicates to the nurse that the medication is effective? a. Reduced level of pain b. Full volume of pedal pulses c. Granulating tissue in foot ulcer d. Improved visual acuity

a. Reduced level of pain

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative. Which nursing care intervention should the nurse include in the client's plan of care? Select all apply. a. Remove urinary catheter as soon as possible and encourage voiding b. Assess pain level and medicate PRN as prescribed c. Maintain sequential compression devices while in bed d. Teach client to use incentives spirometer every two hours while awake e. Administer low molecular weight heparin as prescribed

a. Remove urinary catheter as soon as possible and encourage voiding d. Teach client to use incentives spirometer every two hours while awake

A male client who is experiencing musculoskeletal pain is discharged with instructions to take ibuprofen, on non-steroidal anti-inflammatory drug by mouth BID. After receiving discharge teaching, the client states he plans to take the medication twice daily, with breakfast and dinner. How should the nurse respond? a. Review the need to limit intake of leafy, green vegetables such as spinach b. Confirm that the client has an effective plan for when to take the medication c. Explain the need to take the medication before meals to increase absorption d. Remind the client to increase fluid intake while taking the medication

b. Confirm that the client has an effective plan for when to take the medication

A client at 28 weeks' gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? a. Recount the heart rate manually to confirm a monitor malfunction b. Contact the health care provider after initiating oxygen per face mask c. Explain that there is no indication the fetal heart rate is due to trauma d. Evaluate the presence of preterm labor by performing a vaginal examination

b. Contact the health care provider after initiating oxygen per face mask

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effects is the nurse likely to note as a result of this increase in glaucoma surgeries? a. Decrease morbidity in the elderly population b. Decrease prevalence of glaucoma in the population c. Increase mortality in the elderly population d. Increased incidence of glaucoma in the population

b. Decrease prevalence of glaucoma in the population

Which assessment is most important for the nurse to include in the daily plan of care for a client with a burnt extremity? a. Extremity sensation b. Distal pulse intensity c. Presence of exudate d. Range of motion

b. Distal pulse intensity

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life threatening and should be reported to the health care provider immediately? a. Difficulty with balance b. Intensifying headache c. Right ear hearing loss d. Facial numbness

b. Intensifying headache

A client with cirrhosis of the liver having numerous, liquid, incontinent stools, and continues to be confused. After reviewing the clients laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. IV Human albumin b. Lactulose c. Furosemide d. Loperamide

b. Lactulose

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document the sound? a. Pericardial friction rub b. Murmur c. S1 S2 S3 d. S1 S2

b. Murmur

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration. The medical diagnosis severe exacerbation of asthma. Which assessment finding, obtained 10 minutes after the admission assessment, should the nurse report immediately to the emergency department health care provider? a. An apical pulse of 120 beats per minute b. No wheezing upon auscultation of the chest c. Client reports being anxious d. Extreme agitation with staff and family

b. No wheezing upon auscultation of the chest

The nurse inserts and indwelling urinary catheter as seen in the video. What action should the nurse take next? a. Remove the catheter and insert into urethra opening b. Insert the catheter further and observe her discomfort c. Observe for urine flow and then inflate the balloon d. Leave the catheter in place and obtain a sterile catheter

d. Leave the catheter in place and obtain a sterile catheter

A client who is hypotensive is receiving dopamine, and adrenergic agonist IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a. Initiate seizure precautions b. Assess pupillary response to light hourly c. Monitor serum potassium frequently d. Measure urinary output every hour

d. Measure urinary output every hour

A client is receiving a hypertonic solution for bladder irrigation in as at risk for dilutional hyponatremia. The nurse should plan to observe for which common sign of hyponatremia? a. Irregular heartbeats b. Bradycardia c. Muscle spasms d. Mental status changes

d. Mental status changes

The father of a four-year-old has been battling metastatic lung cancer for the past two years. After discussing the remaining options with his health care provider, the client request that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Provide the client written information about end-of-life care b. Reassure the client that his child would be allowed to visit c. Mark the chart with the clients request for no heroic measures d. Obtain a detailed report from the nurse transferring the client

d. Obtain a detailed report from the nurse transferring the client

The nurse instructs an unlicensed assistive personnel (UAP) to turn and immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Feed the client a snack c. Assess the breath sounds d. Offer the client oral fluids

d. Offer the client oral fluids

A client with a history of upper respiratory symptoms is admitted with chest tightness, productive cough, and difficulty breathing period the client's arterial blood gases indicate respiratory acidosis. An increase in which laboratory test result supports this finding? a. HCO3 b. Arterial pH c. PaO2 d. PaCO2

d. PaCO2

A client with a swollen right toe receives a prescription for colchicine to treat their present symptoms of gout and a prescription for allopurinol to control future attacks. What information is most important for the nurse to teach the client? a. Watch for thin hair b. Expect anorexia c. Anticipate fever d. Report diarrhea

d. Report diarrhea