Hesi Exit

The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4

The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

75

152. The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin? A. Reddened skin areas disappear within 15 minutes of being turned and positioned. B. No complaints of pressure or pain are verbalized by the client after being turned C. Only small areas of redness remain longer than 30 min after the client is turned. D. The client verbalizes feeling better after being turned and positioned

A

A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? A.) Negative pressure environment B.)contact precautions C.)droplet precautions D.)protective environment

A

A client who had a below-the-knee amputation is experiencing severe phantom limb pain and asks the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful. A. Research indicated that mirror therapy is effective in reducing phantom limb pain B. you can try mirror therapy, but do not expect complete elimination of the pain C. Transcutaneous electrical nerve stimulation (TENS) has been found to be more effective D. Where did you learn about the used of mirror therapy in treating phantom limb pain?

A

A gravida 2 para 1, at 38 weeks gestation , scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mother enters the labor suite and says in a loud voice "I've had 8 children and I know she is in labor. I want her to have her cesarean section right now" What action should the nurse take? A. Request the mother to leave the room B. tell the mother to stop speaking for the client C. request security to remove her from the room D. Notify the charge nurse of the situation

A

A male client who weighs 325 pounds (148kg) is admitted because of ureteral colic and is now complaining of sharp pain radiating toward his genitalia. He has hematuria and is hypertensive. Which intervention is most important for the nurse to include in the client's plan of care A. Manage Pain B. Encourage low calorie diet C. monitor hematuria D. Document blood pressure

A

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 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) Stroke secondary to hemorrhage B.) MI C.) stress ulcer D.)DIC

A

A male client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports a tingling sensation. How should the nurse respond? A. Determine if the sensation feels uncomfortable. B. Decrease the strength of the electrical signals. C. Remove electrodes and observe for skin redness. D. Check the amount of gel coating on the electrodes.

A

A morbidly obese woman is scheduled for bypass surgery, she complete the required post-operative nutritional counseling and signs the operative permit. to promote effective discharge planning, which intervention is the most important for the nurse to implement? A. Discuss small, low fat, low sugar meal preparation techniques B. Encourage the client to keep a daily dietary diary for two weeks C. Suggest that the client's husband do the family grocery shopping. D Advise the client to arrange for dietary counseling after discharge

A

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? A.) Cleanse the foot with soap and water and apply an antibiotic ointment B.)Provide teaching about the need for a tetanus booster within the next 72 hours. C.)have the mother check the child's temperature q4h for the next 24 hours D.) transfer the child to the emergency department to receive a gamma globulin injection

A

After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? A.) Capillary refill of 8 seconds B.)bruises on arms and legs C.)round and tight abdomen D.)pitting edema in lower legs

A

An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? A.) Start an intravenous (IV) infusion of normal saline B.)obtain a serum potassium level C.)administer the client's usual dose of insulin D.)assess pupillary response to light

A

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? A.) "I have a headache that gets worse when I sit up" B.) "I am having pain in my lower back when I move my legs" C. "My throat hurts when I swallow" D. "I feel sick to my stomach and am going to throw up"

A

The client with which type of wound is most likely to need immediate intervention by the nurse? A.)Laceration B.)Abrasion C.)Contusion D.)Ulceration

A

The healthcare provider prescribes a low fiber diet for a client with ulcerative colitis Selection of which food items indicated to the nurse that the client understands the prescribed diet? A. Roasted turkey, canned vegetables. B. Baked potato with skin, raw carrots C. Pancakes, whole-grain cereals. D. Roast pork, freash strawberries.

A

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? A. Explain that memory loss and confusion are common with vitamin B12 deficiency B. Ask if the client is experiencing any change in bowl habits C. determine if the client is taking iron and folic acid supplements D. Encourage the husband to bring the client to the clinic for a complete blood count

A

The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? A.) Auscultate the client's bowel sounds B.) Observe for edema around the ankles C.) Measure the client's capillary glucose level D.)Count the apical and radial pulses simultaneously

A

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A.) To reduce abdominal pressure on the diaphragm B.) to promote retraction of the intercostal accessory muscle of respiration C.) to promote bronchodilation and effective airway clearance D.) to decrease pressure on the medullary center which stimulates breathing

A

Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? A.) Reduce risks factors for infection B.) Administer high flow oxygen during sleep C.) Limit fluid intake to reduce secretions D.) Use diaphragmatic breathing to achieve better exhalation

A

During change of shift report, the oncoming nurse learns that soft restraints were applied to a combative client at 0600 after multiple alternatives were attempted and the client's healthcare provider was notified. The nurse and UAP initially enter the client's room at 0800. In what order should the nurse implement these interventions. arrange from first action on top to last on the bottom A. assess the client's skin and circulation for impairment related to the restraints B. Assign the UAP to follow restraint protocol unit a new prescription is obtained C. Contact the client's healthcare provider to confirm continued use of restraints D. Evaluate the client's mentation to determine the need to continue the restraints

A, D, B, C

155. An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A. Teach client to use incentive spirometer q2 hours while awake. B. Remove urinary catheter as soon as possible and encourage voiding. C. Maintain sequential compression devices while in bed. D. Administer low molecular weight heparin as prescribed E. Assess pain level and medicate PRN as prescribed.

A,B

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A. Teach client to use incentive spirometer q2 hours while awake. B. Remove urinary catheter as soon as possible and encourage voiding. C. Maintain sequential compression devices while in bed. D. Administer low molecular weight heparin as prescribed E. Assess pain level and medicate PRN as prescribed.

A,B

1. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) A.) Fluid shifts from intravascular to interstitial area due to decreased serum protein B.) Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C.) Increased circulating aldosterone levels that increase sodium and water retention

A,B,C

After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) A.) The client voluntarily grants permission for the procedure to be done B.)The client is competent to sign the consent without impairment of judgment C.)The client understands the risks and benefits associated with the procedure D.) the client will be 100% ok

A,B,C

A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

Advise the client that assignments are not based on clients requests

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

Altered consciousness within the first 24 hours after injury.

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. Obtain a chest X-ray per protocol. B. Place a mask on the client's face. C. Assess the client's temperature. D. Determine the client's blood pressure

B

A 59-year-old female reports his concern over a lump that, "just popped up on my neck a week ago." in preforming an examination of the lump, the nurse palpates a large, nontender , hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest ? A. Lymphangitis B. Malignancy C. bacterial infection D. Viral infection

B

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? A.) Ask a chemotherapy-certified nurse to administer the Zofran B.) Administer the ondasentron (Zofran) after flushing the saline lock with saline C.)Hold the scheduled dose of Zofran until the client awakens D.) Awaken the client to assess the need for administration of the Zofran

B

A client with a history of dementia has become increasingly confused at nigh and is picking at an abdominal surgical dressing and the tape securing intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A. Replace the IV site with a smaller gauge B. Redress the abdominal incision C. Leave the lights on in the room at night D. Apply soft bilateral wrist restraints

B

A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? A.) Auscultate breath sounds B.)Measure vital signs C.)Palpate the abdomen D.)Observe the skin for bruising

B

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by rapid heartbeat, sweating, shaking and nausea while driving over the bay bridge. What action in the treatment plan should the nurse implement? A. Tell client to drive over the bridge until fear is manageable. B. Teach the client to listen to music or audio books while driving. C. Encourage client to have spouses drive in stressful places. D. Recommend that the client avoid driving over the bridge.

B

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 client's plan of care? A. Acute pain B. spiritual distress C.ineffective coping D. Complicated grieving

B

After reviewing the Braden scale findings of residents as a long-term facility, the charge nurse should tell the UAP to prioritize care for which client? A. An older adult who is unable to communicate elimination needs B. A older man whose sheets are damp each time he is turned C. A woman with osteoporosis who is unable to bear weight D. A poorly nourished client who requires liquid supplements

B

Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? A.) Confirm this as the correct action B.)Review with the client the need to avoid foods that are rich in milk and cream C.) Chart the teaching as successful D.) Inform the patient that he will need to ad 30 grams of protein

B

One hour ago, while walking on the treadmill in the cardiac rehabilitation unit, a client began to exhibit signs of a cerebrovascular accident (CVA). The client is transported to the emergency department. Which behavior is indicative of ICP and deteriorating condition? A. Calls out for family members who are outside the room B. Falls asleep while answering health history questions C. Becomes agitated when blood specimen is collected D. Cries and grasps the nurse's hand during vital signs

B

The nurse is preparing to send a client to the cardiac catheterization lab for a angioplasty. Which client report is most important for the nurse to explore further prior to the start if the procedure? A. Drank a glass of water in the past 2 hours B. Experiences facial swelling after eating crab C. Reports left chest wall pain prior to admission D. verbalizes a fear of being in a confined space

B

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? A.) working together can decrease the risk for back injury B.)The technique is intended to maintain straight spinal alignment. C.)Using two or three people increases client safety. D.)turning instead of pulling reduces the likelihood of skin damage

B

Which client is at the greatest risk for developing delirium? A.) a middle-aged woman who uses a tank for supplemental oxygen B.) An adult client who cannot sleep due to constant pain. C.)an older client who attempted 1 month ago D.)a young adult who takes antipsychotic medications twice a day

B

While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? A. Inquire about an electric bed for the client's home use B. Submit a referral for an evaluation by a physical therapist. C. Explain the usual progression of osteoarthritis and HF D. Request social services to review the client's resources

B

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Bagel with jelly and skim milk

A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Baked apples topped with dried raisins

2. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? A.)capillary glucose B.)urine specific gravity C.)Serum calcium D.)white blood cell count

C

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with Isoniazid. Which information is most important for the nurse to note before administering the initial dose? A. Conversion of the client's PPD test from negative to positive. B. Length of time of the exposure to tuberculosis C. Current diagnosis of Hepatitis B D. History of intravenous drug abuse

C

A client with Gout experiences an acute attack. The client reports he has been trying to loose weight. Which information is the most important for the nurse to obtain? A. Serum cholesterol level B. Capillary glucose level C. Daily caloric intake D. Daily calcium intake

C

A client with cirrhosis is receiving a low protein diet. The nurse should explain to the family that this diet restriction is implemented to reduce the risk of which complication of cirrhosis? A. delirium B. abdominal ascites C. Hepatic encephalopathy D Esophageal varices

C

A female nurse who took drugs from the unit for personal use was temporarily released from duty. after completion of mandatory counseling, the nurse asked administration to allow her to return to work. when the nurse administrator approaches the charge nurse with the impaired nurse's request, what action is best for the charge nurse to take? A. Since treatment is completed, assign the nurse to routine RN responsibilities B. ask to meet with the impaired nurse's therapist before allowing her back on the unit C. allow the impaired nurse to return to work and monitor medication administration D. Meet with staff to assess their feeling about the impaired nurse's return to the unit

C

A male client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing ICP in the plan of care. Which signs indicate to the nurse that ICP has increased ? A. Increased Glascow coma scale score B. Nuchal rigidity and dystonia C. Confusion and papilledema D. periorbital ecchymosis

C

A male client with a c-6 spinal cord injury is in rehabilitation. in the middle of the night he reports a severe, pounding headache, an observed goose bumps. The nurse should asses for what trigger? A. loud hallway noise B. Fever C. Full bladder D. Frequent cough

C

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety 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.) Inform her that some antianxiety medications are safe to take while breastfeeding D.)Explain that anxiety is a normal response for the mother of a 3-week-old.

C

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? A. Report the incident to the local child protective services. B. Find a home health agency that specializes in brain injuries. C. Determine the mother's basic level in providing care. D. consult the ethics committee to determine how to proceed.

C

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement? A. Place the client in the Trendelenburg position. B. Instruct the client to take deep breaths C. Place a wedge under the client's hip D. Remove the client's legs from the stirrups

C

An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? A.) improvement B.)stats that he is feeling "sluggish" C.)Describes life without purpose D.)states that he stays inside most of the time

C

At 0715, after receiving report on four medical clients, the nurse is preparing a prioritized "to do" list. Which action should the nurse plan to do first? (based on charts) A. administer metformin to client D B. insert the IV in a new location for client C C. Complete a focused assessment for client A D. Validate the blood pressure for client B

C

The nurse is triaging victims of a tornado at an emergency shelter. an adult woman who has been wondering and crying comes to the nurse. What action should the nurse take? A. Check the client's temperature, blood sugar and urine output. B. Transport the client for laboratory test and electrocardiogram (EKG). C. Delegate the care of the crying client to an unlicensed assistant. D. send the client to the shelter's nutrient center to obtain water and food.

C

The nurse preparing to administer 1.6 ML of medication IM to a 4-month-old infant. Which action should the nurse include? A. Select a 22 gauge 1 1/2 inch (3,8cm) needle for the intramuscular injection B. Administer into the deltoid muscle while the parent holds the infant securely C. divide the medication into two injections with volumes under 1ml D. use a quick dart-like motion to inject into the dorsogluteal site.

C

When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? A.) The client is too obese B.)Palpating in the wrong abdominal quadrant C.)Deeper palpation technique is needed D.)The gallbladder is normal

C

When should intimate partner violence (IVP) screening occur? A. As soon as the clinician suspects a problem B. only when a client presents with an unexpected injury C. As a routine part of each health care encounter D. Once the clinician confirms a history of abuse

C

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse? A. Diarrhea and flatulence B. Abdominal pain C. muscle pain D. Altered taste

C

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain? A. tell me about the activities that cause your pain? B. When did you first notice the pain in your chest? C. Does your pain occur when walking short distances? D. How do you feel when the pain becomes noticeable>

C

An older client with atrial fibrillation receives a new a new prescription for dabigatran to reduce risk of blood clot formation, What information should the nurse include in this client's medication teaching plan? (SATA) A. Medication injections are self-administered daily B. plan to monitor and record the pulse rate daily. C. Contact healthcare provider if bruising occurs D. Report bleeding in the urine of stool right away E. Inform dentist of the medication usage before procedures.

C,D,E

During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Check the client for lacerations or fractures

2. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? A.) An African-American senior citizens center B.) A daycare center in a Hispanic neighborhood C.)An after-school center for Native-American teens D.)A business and professional women's group.

D

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A.) Bradycardia and constipation B.) Lethargy and lack of appetite C.)Muscle cramping and dry, flushed skin D.) Palpitations and shortness of breath

D

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A.) Bradycardia and constipation B.) Lethargy and lack of appetite C.) Muscle cramping and dry, flushed skin D.) Palpitations and shortness of breath

D

A client had a subtotal parathyroidectomy two days ago, and is now preparing for discharge. Which assessment finding is most important for the nurse to provide to the healthcare provider prior to client discharge? A. No bowl movement since surgery B. Afebrile with a normal pulse C. no appetite for breakfast D. A positve Chvostek's sign

D

A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? A.)increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure B.)the antagonistic interaction among the various blood pressure medications has reduced their effectiveness C.)the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension D.)The additive effect of multiple medications has caused the blood pressure to drop too low

D

A client with a chronic health problem has difficulty ambulating short distances due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? A. A quad cane B. Crutches with 2-point gait C. Crutches with 3-point gait D. Crutches with 4-point gait

D

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

D

A nurse working on an endocrine unit should see which client first? A. An adolescent male with type 1 diabetes who is arguing about his insulin dose. B. A older client with Addison's disease whose current blood sugar level is 62 mg/dl C. An adult with a blood sugar of 384 mg/dl and a urine output of 350 ml in the last hour. D. A client taking Corticosteroids who has become disoriented in the last hour.

D

The nurse is collecting a sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. the nurse should obtain the sample from which site on the drainage system? A. Tubing located on the top of the suction chamber. B. Plastic tubing located at the chest insertion site. C. stopper port located above the water-seal level. D. Rubberized port at the bottom of collection chamber.

D

The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? A.) Alert the UAP side rails will be sufficient alone B.) Alert the UAP to lay the client flat C.) No action is needed D.) Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

D

Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Direct the nurse to continue the surgical hand scrub for a 5 minute duration

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?

Document the assessment data (Rational: reservoir bag should not deflate completely during inspiration and the client's respiratory rate is within normal limits.)

Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Eat small meal throughout the day to avoid a full stomach.

After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low-carbohydrate and high-protein diet

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame

A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

Further evaluation involving surgery may be needed

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

Have you noticed any changes in your fingernails? (Rationale: The pattern of reported manifestations is suggestive of hypothyroidism)

At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

Which action should the school nurse take first when conducting a screening for scoliosis?

Inspect for symmetrical shoulder height.

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

Listen with the bell at the same location

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Medicare

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Monitor blood pressure frequently

A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Observe the antecubital fossa for inflammation.

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Place the implant in a lead container using long-handled forceps

A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Rented movies and borrowed books to use while passing time at home

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

Respiratory apnea of 30 seconds

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

1. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide?

Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Toasted wheat bread and jelly

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity