HESI practice 13
The nurse is collecting a sterile urine specimen using a straight catheter tray for culture. In what order should the nurse implement these actions? (Arrange from first action on top to last on the bottom). A. Drape the client in a recumbent position for privacy. B. Use forceps and swaps to clean the urinary meatus. C. Open the urinary catheterization tray. D. Don sterile gloves using aseptic technique.
Answer 1. Drape the client in a recumbent position for privacy. 2. Open the urinary catheterization tray. 3. Don sterile gloves using aseptic technique. 4. Use forceps and swaps to clean the urinary meatus. Rationale To prevent the risk of infection, urinary catheterization is a sterile technique. First the client should be placed in a recumbent position and draped for privacy. Once the client is prepared, the catheterization tray is opened and the gloves donned using aseptic technique, keeping the equipment inside the straight catheterization tray. Lastly, the urinary meatus is cleansed using swabs and a sterile antiseptic solution which are provided inside the disposable tray.
The nurse is caring for a client who has a continuous bladder irrigation after a transurethral prostatectomy. The client's IV is infusing at 75 mL/hr, and a 3-way indwelling catheter with a continuous bladder irrigation is infusing at 200 mL/hr. At the end of the 12-hour shift, The bedside urinary drainage bag contains 3,000 mL. How many mL is the client's urine output for the 12-hour shift?
Answer 600 Rationale If continuous bladder irrigation is infusing at 200 ML/hr, the total for the 12 hour shift is 2,400 mL. The actual year and output is calculated by subtracting the total continuous bladder irrigation infused (2,400 mL) from the total volume in the bedside drainage bag (3,000 mL): 3000 - 2400 = 600 mL
While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide? A. "You sound angry. Would you like to tell me about it?" B. Ignore the angry outburst and continue with the history questions. C. Move closer and place a hand on his shoulder to demonstrate concern. D. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."
Answer A. "You sound angry. Would you like to tell me about it?" Rationale Anger is best dealt with by acknowledging it and allowing the client to express the feeling (A). Ignoring the behavior (B) often fuels the anger. Physical touch (C) can be interpreted as an aggressive move and may provoke an escalation in the anger. (D) might be implemented if (A) fails to elicit an appropriate response from the client.
The nurse is conducting a physical assessment. In examining the clients eyes, what client complaint should be reported to the health care provider immediately? A. A curtain coming across the client's vision today. B. A black hole in the center of the client's vision. C. Yellow, watery drainage from one eye. D. Decreased peripheral vision for a year.
Answer A. A curtain coming across the client's vision today. Rationale (A) is a classic description of retinal detachment, and the sight can sometimes be saved if emergency treatment is initiated. (B) is a sign of macular degeneration, and (D) of chronic glaucoma. Both are long-term conditions with limited, non-emergency treatment options. (C) is a probable indication of conjunctivitis, which requires antibiotic eyedrops, but does not have the serious consequences of a retinal detachment.
Which client is best to assign a newly hired unlicensed assistive personnel (UAP) on a psychiatric unit? A. A schizophrenic client who has been taking antipsychotics for 2 weeks. B. A teenager who was admitted during the night following a suicide attempt. C. A bipolar client who is receiving lithium and is dressed in a sexually provocative manner. D. A client who is experiencing frequent auditory and visual hallucinations.
Answer A. A schizophrenic client who has been taking antipsychotics for 2 weeks. Rationale A schizophrenic client who has been compliant with medications (A) for several weeks is the most stable of the clients described. (B, C, and D) are less stable than (A).
Shortly after admission to the intensive care unit, a male client's heart begins to fibrillate while his wife is sitting at his bedside. When the resuscitation team arrives, the wife refuses to leave her husband's room. What action should the nurse implement? A. Allow the wife to stay in the room and away from the client's bed. B. Ask the chaplain to escort the wife to go to the waiting area. C. Seek administrative assistance until resuscitation is completed. D. Explain that watching the resuscitation is likely to be upsetting.
Answer A. Allow the wife to stay in the room and away from the client's bed. Rationale Although it may be difficult for the wife to witness the resuscitation, the nurse should advocate for her and allow her to stay (A) as long as her presence does not negatively affect the client's care. (B) does not advocate for the client or his family. Administrative assistance (C) may be helpful while the nurse is taking care of the client's critical needs, but this action does not address the problem at hand. (D) is an attempt to manipulate the wife into leaving her husband, which she has already said she did not want to do.
An elderly client tells the nurse that itching and excessive tearing caused by severe eye dryness has become increasingly bothersome. The client does not suffer from external eye disease, rhinitis, or hay fever, but does take several medications. Which medications are likely to have produced this client's problem? A. Antihypertensives an anticholinergics. B. Anticoagulants and antihistamines. C. Antiinfectives and antidepressants. D. Antiretrovirals and antivirals.
Answer A. Antihypertensives an anticholinergics. Rationale Antihypertensives an anticholinergics (A) have been implicated in causing eye dryness that can lead to excessive itching and tearing. Other classes of medications associated with this condition include sympatholytics and cholesterol inhibitors (statins). Antihistamines, but not anticoagulants, can also produce eye dryness (B). (C and D) are not associated with eye dryness.
The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse thought brought a luer-lock tipped syringe. What action should the charge nurse take? A. Direct the nurse to change the IV tubing. B. No corrective action is needed by the nurse. C. Suggest starting a secondary infusion at the IV tubing port. D. Send an unlicensed assistive personnel to gather equipment.
Answer B. No corrective action is needed by the nurse. Rationale An IV catheter should be irrigated without a needle by inserting the irrigating syringe's luer-lock tip into the IV catheter or IV tubing port. No action is needed by the nurse (B). (A, C, and D) are not indicated.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? A. Opening the package. B. Picking up the second glove. C. Picking up the first glove. D. Positioning of the table.
Answer B. Picking up the second glove. Rationale By picking up the upper end of the second glove (C), the PN risks contamination of the sterile gloved hand. Instead, the PN should carefully slide the first gloved hand under the cuff of the second glove. (A, B, and D) are correctly performed by the PN.
A senior female nursing student is working as an unlicensed assistive personnel (UAP) and is assisting an RN who is caring for five clients. While the RN is busy with a medical emergency, another client is incontinent and contaminates a sterile dressing. What action should the RN intake? A. Have the student call her instructor to supervise the skill. B. Tell the student to gather supplies for changing the dressing. C. Ask the student if she is comfortable changing the dressing. D. Instruct the student to reinforce the contaminated dressing.
Answer B. Tell the student to gather supplies for changing the dressing. The student is acting as a UAP and obtaining dressing supplies (B) is within the scope of practice for a UAP. The student's instructor cannot supervise the student when she is working as an employee (A). The senior nursing student who is functioning as a UAP cannot independently perform a sterile dressing change (C). Reinforcing the dressing (D) does not address the issue of contamination.
A mother who is HIV positive asks the nurse about her infant's positive ELISA test. What information should the nurse provide to the mother? The infant has A. converted to HIV positive status. B. received HIV maternal antibody transmission. C. developed CMV (cytomegalovirus). D. been infected with congenital syphilis.
Answer B. received HIV maternal antibody transmission. Rationale Positive ELISA at birth only indicates that antibodies from the mother passed to the fetus (B). The infant should be retested periodically based on CDC guidelines as maternal antibodies may persist in the client's system until 18 months of age. A polymerase chain reaction (PCR) has higher sensitivity and specificity than the ELISA, but is expensive and may have false negatives or positives based on the age of the infant when drawn. ELISA is not specific for (C or D). Added note: all infants of HIV positive mothers will be treated to decrease viral contamination risk.
A 55-year-old female client with symptoms of osteoarthritis asks what form of exercise would be most beneficial for her. What is the best response by the nurse? A. "Limit your exercise to just your daily activities." B. "Jogging or running are excellent aerobic exercises. C. "Swimming is an excellent exercise for you." D. "Tennis or racquetball will increase your muscle strength."
Answer C. "Swimming is an excellent exercise for you." Rationale Clients with osteoarthritis should be encouraged to maintain joint motion and muscle strength with minimal joint loading to prevent further wear and tear on the joints. Swimming (C) is ideally suited to accomplish this. Exercise is important (A) and should not be discouraged. (B and D) well both increase the risk of trauma to the joints.
When triaging emergency room clients, which client should the nurse assessed first? A. A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak. B. An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating. C. A female client with severe right lower abdominal pain who is febrile and vomiting. D. A child who has a cold for two days and is now coughing up green sputum.
Answer C. A female client with severe right lower abdominal pain who is febrile and vomiting. Rationale Severe right lower abdominal pain (C) accompanied by a temperature and vomiting may be indicative of appendicitis and may require emergency surgery. A STAT CBC needs to be drawn immediately. (A) could be suffering an electrolyte imbalance, however, with a duration of 12 hours in an adolescent, fluid replacement should be sufficient to decrease the symptoms. Severe leg pain (B) is expected in a client with peripheral vascular disease (intermittent claudication). (D) could possibly be pneumonia, but this would not be a priority over (C).
The vital signs for a client with heart failure (HF) who is admitted to the intensive care unit include: temperature 98.6° F, pulse 125 beats/minute, respirations 22 breaths/minute, and blood pressure 140/50. The nurse determines that the client's central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are elevated. Which intervention should the nurse implement? A. Encourage a liberal PO fluid intake. B. Titrate IV dopamine at 8 mcg/kg/minute. C. Administer furosemide (Lasix) 40 mg IV. D. Give an IV bolus of 500 mL normal saline.
Answer C. Administer furosemide (Lasix) 40 mg IV. Rationale Preload is affected by the circulating blood volume, the amount of blood returning to the heart, and ventricular filling time, so to decrease the client's preload, Lasix, a loop diuretic, should be given (C). Additional fluid intake (A and D) increases the circulating intravascular volume and contributes to an increase in the CVP and PAWP. Dopamine (B) is a vasoconstrictor, which decreases the intravascular space, causing the afterload to increase.
The nurse observes an unlicensed assistive personnel (UAP) begin to remove exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. What action should the nurse implement? A. Remind the UAP to discard the gloves in the biohazard container after removal. B. Suggest that the UAP roll both of the gloves off and inside out at the same time. C. Advise the UAP that the technique being used will result in hand contamination. D. Instruct the UAP to use two pairs of gloves when fecal contamination is likely.
Answer C. Advise the UAP that the technique being used will result in hand contamination. Rationale By sliding gloved fingers inside the other glove, the UAP's hand becomes contaminated (C). Gloves should be discarded in the trash (A) unless heavily contaminated with body fluids. (B) is likely to result in contamination of both hands. Double gloving (D) is not necessary when performing activities such as emptying a bedpan.
A client is admitted to the emergency room with anaphylactic shock. What treatment should the nurse prepare to administer? A. Rapid replacement of lost fluids. B. Transfusion of packed red blood cells. C. An intravenous vasoconstricting agent. D. An intravenous opioid antagonist.
Answer C. An intravenous vasoconstricting agent. Rationale Anaphylactic shock results from an allergic reaction that causes the release of inflammatory mediators that cause arteriolar dilation and sequestration of blood in small veins. Anaphylactic shock is treated immediately with epinephrine, which results in vasoconstriction (C) and an increase in blood pressure. (A or B) are indicated in hypovolemic shock, not anaphylactic shock. (D) is not beneficial in reverting anaphylaxis.
The nurse is admitting a client from the post anesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? A. Complete blood cell count (CBC) in AM. B. Straight catheterization if unable to void. C. Cefazolin 1 g IVPB q5 hours. D. Advance from clear liquids as tolerated.
Answer C. Cefazolin 1 g IVPB q5 hours. Rationale To reduce the possibility of developing a postoperative infection, prophylactic administration of cefazolin (C) takes precedence over the other prescriptions. The CBC is scheduled for morning (A). (B and D) do not have the priority over initiating prophylactic antibiotics.
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned about this regression in toileting. Which information should the nurse provide the parents? A. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers. C. Children usually resume their toileting behaviors when they leave the hospital. D. A potty chair will be brought from home so he can maintain his toileting skills.
Answer C. Children usually resume their toileting behaviors when they leave the hospital. Rationale The parents should be reassured that once the child is back in his familiar environment, he is likely to resume using the toileting behaviors (C). Retraining (A) is unlikely to be needed and such information might be distressing to the parents. (B) does not address the parents' concern. Bringing a potty chair from home (B) is likely to increase the child's stress because he is being encouraged to perform toileting skills while he remains in unfamiliar surroundings.
An older client with atrial fibrillation receives a new prescription for dabigatran trying to reduce the risk of blood clot formation. What information should the nurse include in this client's medication teaching plan? (Select all that apply.) A. Medication injections are self-administered daily. B. Plan to monitor and record the pulse rate daily. C. Contact the healthcare provider if bruising occurs. D. Reports bleeding in the urine or stool right away. E. Inform dentist of medication usage before procedures.
Answer C. Contact the healthcare provider if bruising occurs. D. Reports bleeding in the urine or stool right away. E. Inform dentist of medication usage before procedures. Rationale Dabigatran is an oral anticoagulant used to decrease clot formation in atrial fibrillation, thus reducing the risk for stroke. As an anticoagulant, excessive bleeding may occur and bruising (C) and bleeding (D) should be reported to the healthcare provider promptly, as well as all practitioners, such as dentists (E), who should be aware of the increased risk for bleeding prior to any scheduled procedures. The medication is taken orally rather than by self injection (A) and monitoring the pulse rate daily (B) is not necessary.
When obtaining subjective data from a client, what intervention should the nurse implement first? A. Clarify inferences. B. Validate objective data. C. Establish rapport. D. List client problems.
Answer C. Establish rapport. Rationale The nurse should first establish rapport (C) with the client, so that a trusting relationship is initiated. The nurse should then use interview techniques, such as (A). (B) is completed throughout the interview process. Once the data has been obtained, a problem list can be developed (D).
When entering the room of a sedated postoperative client, which assessment requires the most immediate intervention by the nurse? A. Oxygen is being administered via nasal cannula at 4 L/min without humidification. B. The urinary catheter drainage bag is almost completely full of amber urine. C. Low intermittent suction prescribed for the nasogastric tube is turned off. D. A Hemovac drain is partially full of serous drainage and is not compressed.
Answer C. Low intermittent suction prescribed for the nasogastric tube is turned off. Rationale If the nasogastric tube suction is turned off (C) the risk for vomiting is increased, which places this sedated client at risk for aspiration, so the nurse should first respond to this problem. (A) will dry the mucosa and (D) prevents effective postoperative wound drainage, problems that require intervention, but are of lesser priority than (C). (B) also requires intervention, but is not an immediate concern.
The nurse is caring for a 14-year-old whose fractured femur is immobilized using 90-90 skeletal traction. What intervention is most important for the nurse to implement daily? A. Give skin and back care with each linen change. B. Encourage adequate bulk and liquids in the diet. C. Provide opportunities for diversion and peer interaction. D. Cleanse pin sites using topical antiseptic an antibiotic.
Answer D. Cleanse pin sites using topical antiseptic an antibiotic. Rationale Skeletal traction is applied directly to the skeletal structure (distal end of femur) using externally inserted pins into the bone so that the traction pulls, aligns, and immobilizes the fracture. The risk for local infection and osteomyelitis is reduced by daily application of a topical antiseptic and antibiotic at the entrance site of the pins (D). Although (A and B) should be implemented to prevent complications related to immobility, the greatest risk associated with skeletal traction is infection. The value of peer interaction and diversion (C) is a component of care for the adolescent who is isolated by the immobilization, but prevention of infection with pin site care is most important.
Twenty-four hours after admission for hemiparesis and unilateral blindness, a male client's condition resolves and he tells the nurse that he "feels fine" and is ready to go home. What action should the nurse take? A. Arrange transferred to a rehabilitation unit. B. Add "Ineffective coping" to the plan of care. C. Maintain bedrest to prevent injury from falls. D. Document the resolution of the symptoms.
Answer D. Document the resolution of the symptoms. Rationale The nurse should document that the symptoms (D) have resolved because hemiparesis and hemianopsia related to transient ischemic attacks (TIA) characteristically disappear within 24 hours. (A, B, and C) are not indicated because the symptoms have resolved.
To reduce risk of an episode of diverticulitis, the nurse should encourage which snack choice for a client with diverticulosis? A. Tuna with low fiber crackers. B. Fruit-flavored Greek yogurt. C. Low-fat cheese cubes. D. Fresh vegetable slices.
Answer D. Fresh vegetable slices. Rationale Nutritional management of diverticulosis focuses on increased fiber and fluid intake to reduce risk for constipation and related inflammation of the diverticula. Fresh fruits and vegetables provide fiber. The other options do not provide high fiber for diverticulosis.
The nurse observes a client who is walking upstairs using crutches. The client is being assisted by an unlicensed assistive personnel (UAP) who is holding the client's gait belt securely, and is standing one step above the client. What is the best action for the nurse to implement? A. Reassure the client and the UAP that they are progressing up the stairs safely. B. Encourage the UAP to release the gait belt so the client will gain independence. C. Instruct the UAP to continue to hold the gait belt, but to stand next to the client at all times. D. Instruct the UAP to move to the step below the client while continuing to hold the gait belt.
Answer D. Instruct the UAP to move to the step below the client while continuing to hold the gait belt. Rationale To ensure client safety, the UAP should stand behind the client (D), and continue to hold the gate belt. (A, B, and C) may result in injury to the client.
The nurse identifies an electrolyte imbalance, an elevated central venous pressure (CVP) and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with full thickness burns. Which intervention should the nurse implement? A. Document abdominal girth. B. Record usual eating patterns. C. Measure ankle circumference. D. Measure and document urinary output.
Answer D. Measure and document urinary output. Rationale A client with full thickness burns initially experiences hypervolemia due to increased capillary permeability and cellular damage that causes electrolyte imbalances and shifts of fluid into the interstitial spaces. IV fluid resuscitation is required to manage shock during the initial emergent (resuscitative) phase and may result in fluid overload causing an elevated CVP and weight gain. The nurse should measure and document urinary output (D) to evaluate intravascular fluid volume replacement and renal perfusion. (A, B, and C) are not indicated at this time.
A client who is scheduled for an elective inguinal hernia repair today in day surgery is seen eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? A. Remove the food from the client. B. Explain that vomiting can occur during surgery. C. Review the surgical consent with the client. D. Withhold the preoperative medication.
Answer D. Withhold the preoperative medication. Rationale Nothing should be eaten six or more hours prior to surgery to prevent complications, such as aspiration. The preoperative medication (D) should be withheld, and the surgeon notified immediately. The client has already ingested the food, and removal of the client's food (A) only halts further consumption. Although vomiting is a risk during surgery (B), the priority is to delay the preoperative medication administration because the presence of solid food in the stomach will likely delay surgery. The consent form (C) should be reviewed, but the delay of the preoperative medication is now the priority.
At 0715, after receiving report on four medical clients, the nurse is preparing a prioritized "to do" list. Which actions should the nurse plan to do first? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical records.) A. Administer Met Forman 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 procedure for client to B.
Answer C. Complete a focused assessment for client A. Rationale The client with heart failure is exhibiting signs of worsening failure evidenced by his heart rate, respiratory rate, and scattered infiltrates on the chest x-ray, so a focused assessment is the highest priority (C). (A, B, and D) are of lower priority. Client D has an elevated blood glucose and is scheduled for the administration of metformin, which is the next priority. The IV infusion for client C, Who has an elevated white blood cell count (WBC) and temperature, should be inserted in A new site so they prescribed antibiotic is administered on time. Although client B's blood pressure is elevated, validation of this finding is the lowest priority.
An 82-year-old male client, a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information? A. If the client was compulsive about food when he was younger, the aging process can magnify this. B. The client probably has an organic brain disease and will likely have Alzheimer's disease within a few years. C. The daughter is under stress and should be encouraged to think about happier times. D. The family needs a social worker to talk to them about how to handle their father when he becomes annoying.
Answer A. If the client was compulsive about food when he was younger, the aging process can magnify this. Rationale Cerebral dysfunction at age 82 is not uncommon, because existing behavioral traits are magnified as a person ages. Compulsive young people tend to be more compulsive about certain things when they age. This client is a retired chef and has lost control of the food preparation in the hospital (A). If he has not developed Alzheimer's by age 82, he is unlikely to do so (B). (C) dismisses the daughters concern. (D) cannot recommend medication for a compulsive behavior. The healthcare provider needs to be notified.
A male client who weighs 325 pounds (148 kg) is admitted because of ureteral colic and is now complaining of sharp pain radiating towards 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 pressures.
Answer A. Manage pain. Rationale Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by urethral distention and smooth muscle spasm making pain relief (A) the priority intervention. (B, C, and D) are important and should be included in the plan of care, but they do not have the priority of (A).
A client with metabolic syndrome plans to begin an exercise program. What instruction is most important for the nurse to provide this client? A. Monitor blood pressure and heart rate as exercise activity is increased. B. Wear long sleeves and a hat when exercising outdoors in direct sunlight. C. Weight bearing exercises are most effective in improving bone strength. D. Use handheld weights to strengthen muscles and build muscle mass.
Answer A. Monitor blood pressure and heart rate as exercise activity is increased. Rationale Metabolic syndrome is characterized by hypertension and hypercholesteremia, which places the client at risk for cardiovascular pathology. Cardiovascular status should be monitored as activity increases (A) to prevent excessive workload on the heart. Limiting skin exposure to ultraviolet sunlight (B) is beneficial in reducing the risk of skin cancer, but this is not the priority instruction for this client. Instructions for improving bone strength (C) and muscle mass (D) are not a priority for a client with metabolic syndrome.
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? A. Monitor the client's cardiac activity via telemetry. B. Maintain venous access with an infusion of normal saline. C. Assess glucose via fingerstick q4 to 6 hours. D. Evaluate hourly urine output for return of normal renal function.
Answer A. Monitor the client's cardiac activity via telemetry. Rationale As insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias (A) related to abnormal serum potassium levels. IV access (B), assessment of glucose level (C), and monitoring urine output (D) are important interventions, but do not have the priority of monitoring cardiac function (A).
A client who is diagnosed with systemic lupus erythematosus (SLE) is admitted with proteinuia and glomerulonephritis. Which intervention should the nurse include in the client's plan of care? A. Provide client education about corticosteroid and immunosuppressant therapy. B. Implement seizure precautions. C. Place the client in protective isolation. D. Type and crossmatch two units of whole blood and place on hold in blood center.
Answer A. Provide client education about corticosteroid and immunosuppressant therapy. Rationale Approximately 50% of those with autoimmune processes SLE develop lupus nephritis (LN). To minimize the inflammatory progression of natural pathology, corticosteroid and immunosuppressant therapy are used to treat the underlying disease (SLE), so the client should be taught (A) about the pharmacological goals. Although SLE can manifest neurological disorders and infection, seizure precautions (B) and protective isolation measures (C) are not indicated. (D) is not indicated.
An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with pulmonary embolism. Which intervention is most important for the nurse to include in the this client's plan of care? A. for confusion and restlessness. B. Monitor for signs of increased bleeding. C. Instruct in the use of incentive spirometry. D. Administer intravenous opioids for severe pain.
Answer A. for confusion and restlessness. Rationale In PE, pulmonary parenchyma is destroyed and reduces the lungs' ability to adequately oxygenate the client. Signs of confusion and restlessness (A) are critical indications of hypoxia which is this client's highest priority problem. (B, C, and D) should also be implemented as needed, but do not have the priority of identifying the client's oxygenation (A).
In assessing a client's pain, which question or statement is likely to elicit the most information? A. "Does the pain occur in a specific area?" B. "Describe what the pain feels like." C. "Is the pain sharp or dull?" D. "Tell me how you respond when you feel the pain."
Answer B. "Describe what the pain feels like." Rationale An open ended question or request for information such as (B) is likely to elicit the most information about the client's pain. Cueing or suggesting responses to the client limits the information that will be obtained. (A, C, and D) gather only limited information.
What equipment should the nurse use to most accurately measure a 2 mL dose of a viscous liquid solution to be administered orally? A. 3 mL syringe and a sterile needle. B. 3 mL syringe. C. Tuberculin syringe. D. One ounce medicine cup.
Answer B. 3 mL syringe. Two mL of liquid is measured most accurately in a 3 mL syringe (B). Using a needle is appropriate for an IM injection, but not drawing up a viscous oral liquid (A). (C) only measures 1 mL. (D) is not calibrated under 5 mL, so an accurate dose could not be measured.
An older adult male with emphysema who continues to smoke cigarettes returns to the medical unit after a physical therapy session, and is complaining of being short of breath. The nurse notes that the client is lying supine with the head of the bed elevated to 45 degrees. Oxygen is flowing via nasal cannula at 3 L/minute, his pulse oximetry is 88%, his respiratory rate is 14 breaths/minute, and his vital signs are stable. Which intervention should the nurse implement? A. Notify the physician for the low pulse oximetry value. B. Administer a prescribed albuterol inhaler. C. Assess lung sounds for signs of infection. D. Encourage client to initiate a smoking cessation program.
Answer B. Administer a prescribed albuterol inhaler. Rationale The immediate issue is the client's shortness of breath, probably due to physical exertion and fatigue after physical therapy. Albuterol (B), a short acting rescue inhaler, relaxes the airways quickly and is used for clients with asthma and COPD. (A) is unnecessary since a low pulse oximetry reading is common for clients with emphysema and provides the hypoxic drive to breathe. While clients with emphysema should be monitored for signs and symptoms of infection because they are at risk for pneumonia, infection (C) is not the primary concern at this time. Since the priority at this time is opening the client's airway, encouraging a smoking cessation program (D) is not indicated at this time.
A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, holds the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond? A. Affirm that the client is effectively performing the double voiding. B. Advise the client to empty her bladder fully when she first voids. C. Suggest that the client drink water between the two voidings. D. Explain that Kegel exercises helps promote full bladder emptying.
Answer B. Advise the client to empty her bladder fully when she first voids. Rationale Double voiding is a technique that promotes more complete emptying of the bladder in those with chronic urinary retention. The client should empty the bladder completely during the first void (B), then wait three minutes and void again. By partially voiding during the first void, the client is not using the most effective technique (A). (C and D) are not helpful in reducing urine retention.
A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? A. Initiate a perineal pad count. B. Catheterize for residual urine after next voiding. C. Assess for a perineal hematoma. D. Determine the client's usual voiding pattern.
Answer B. Catheterize for residual urine after next voiding. Rationale Voiding small amounts frequently is a sign of urinary retention that can lead to urinary tract infections. Catheterizing for residual urine after voiding (B) assess is for adequate emptying of the clients bladder. (A, C, and D) may identify complications that affect avoiding, but do not provide information about the amount of urine left in the bladder after voiding.
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? A. Drank a glass of water in the past two hours. B. Experiences facial swelling after eating crab. C. Reports left chest wall pain to admission. D. Verbalizes a fear of being in a confined space.
Answer B. Experiences facial swelling after eating crab. Rationale Determining if the client has an allergy to shellfish (B) is critical to the prevention of a life-threatening complication, anaphylactic shock, induced by iodine-based dyes used to visualize the coronary arteries during the cardiac catheterization. While NPO precautions are routinely taken prior to the procedure, (A) will not prevent the client from undergoing the angioplasty safely. Left chest wall pain (C) is an expected finding for a client who is undergoing a cardiac angioplasty procedure. Verbalizing fear of a confined space (D) is more likely to occur with clients who will be inside a magnetic resonance imaging (MRI) machine, but not for angioplasty.
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by Daley to check on her father. Which interventions should the nurse implement? (Select all that apply.) A. Speak loudly when teaching B. Face client when speaking. C. Encourage the client to attend a reading classes. D.Provide the daughter with written instructions. E. Include the family in discharge teaching.
Answer B. Face client when speaking. D.Provide the daughter with written instructions. E. Include the family in discharge teaching. Rationale (B, D, and E) are correct. Facing the client when talking (B) facilitates lip reading and is helpful for those with hearing loss. Providing the daughter with written instructions (D) is likely to be helpful, but the nurse should also verify that the daughter knows how to read. Including the family in the discharge teaching (E) helps ensure that the instructions are understood. For those with a hearing loss, a loud voice (A) is not as helpful as lowering the tone of voice. Encouraging the client to enroll in reading class (C) does not help with providing the discharge teaching and it may in fact encourage feelings of worthlessness.
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 client behavior is indicative of increased intracranial pressure (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.
Answer B. Falls asleep while answering health history questions. Rationale Increased ICP often occurs following a cerebral bleed or clot. A change in level of consciousness (B) is an early sign of changes in ICP, which requires immediate treatment. (A, C, and D) may indicate decreased control over emotions secondary to stroke, but these do not have the immediacy of a change in LOC.
When conducting diet teaching for a client who was diagnosed with chronic kidney disease, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Cheese. B. Fresh fish. C. Fresh chicken. D. Processed cheese. E. Fresh or frozen vegetables without sauce.
Answer B. Fresh fish. C. Fresh chicken. E. Fresh or frozen vegetables without sauce. Rationale (B, C, and E) are correct. A client with chronic kidney disease should adhere to a sodium restricted diet which includes fresh meats (B and C) and vegetables without sauce (E). Cheese and processed cheese products (A and D) contain salt, which increase the sodium content in foods.
