HESI RN Remediation Sprg 2020

A nurse is planning a presentation on food safety. Which basic, easily explainable principle is recommended to prevent foodborne illness? "First In, First Out (FIFO)." "Check Your Steps: Clean, Separate, Cook, and Chill." "Smoke It Low N' Slow." "Food, Acidity, Time, Temperature, Oxygen, Moisture (FAT TOM)."

"Check Your Steps: Clean, Separate, Cook, and Chill." Rationale The U.S. Department of Agriculture: Dietary Guidelines for Americans (2010) outlines four simple steps to keep individuals safe from food poisoning at home. These are clean, separate, cook, and chill.

A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available as a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

0.5

A client with a body mass index (BMI) of 27 asks the nurse how much weight she should gain during her pregnancy with a single fetus. Which range should the nurse recommend? 28-to-40 lbs (12.7 to 18.1 kg) 25-to-35 lbs (11.3 to 15.9 kg) 15-to-25 lbs (6.8 to 11.3 kg) 11-to-20 lbs (4.9 to 9.1 kg)

15-to-25 lbs (6.8 to 11.3 kg) Rationale With a body mass index (BMI) of 27, the client is considered overweight. A woman who is overweight should aim to gain 15 to 25 lbs (6.8 to 11.3 kg) during a single-fetus pregnancy.

The nurse is assessing a client with stage 4 chronic kidney disease and partially compensated metabolic acidosis. Which arterial blood gas result should the nurse anticipate? A) PaCO2 26, HCO3 19, pH 7.30. B) PaCO2 52, HCO3 24, pH 7.25. C) PaCO2 41, HCO3 20, pH 7.38. D) PaCO2 42, HCO3 25, pH 7.40.

A) PaCO2 26, HCO3 19, pH 7.30.

The home health nurse revises a student's documentation statement from "reports eating an appropriate lunch for nutritional value" to be "reports eating nutritionally adequate lunch including yogurt, jello, pre-made beef-pie with vegetables, and orange juice." Which characteristic is the home health nurse concerned about? Accuracy Completeness Currency Organization

Accuracy Rationale Quality documentation is important in home health care for reimbursement, continuity of care, avoiding errors or delays in care, and to improve outcomes. Five characteristics of quality documentation include accuracy, completeness, currency, factualness, and organizations. Accuracy is utilization of precise quantifications, which allows other providers to determine if outcomes are consistently being met ensuring continuity of care.

A client who has quadriplegia is experiencing constipation while receiving bolus enteral feedings via percutaneous endoscopic gastrostomy (PEG) tube. Which prescription should the nurse anticipate the healthcare provider to prescribed? Administration of 120 ml of water in-between feedings Placement of a glycerin suppository twice a day. Thickening of enteral feeds with rice cereal. Passive range of motion exercises three times a day.

Administration of 120 ml of water in-between feedings Rationale Clients with tube feedings can experience a wide variety of gastrointestinal symptoms, including constipation. Constipation can be caused by a not enough intake of free-standing water, medications, a low-fiber formula, or bed rest associated with the client's condition. Administration of water in between feedings can help soften and facilitate the passage of stool through the gastrointestinal tract, promoting bowel movements.

A client, who had a laparoscopy cholecystectomy two days ago, calls the clinic's triage nurse in the morning, complaining that they have been awake all night feel feeling restless and anxious, like something isn't right with them and are afraid of dying. Which is the most appropriate nurse's response? Questioned the client, if they are experiencing epigastric pain when eating. Advise the client to return to the clinic now to be seen by their gastric surgeon. Explained to the client, it may be discomfort from the gas used during the procedure. Instruct the client to monitor their temperature every four hours and report if temp >100.5°F (37.8°C).

Advise the client to return to the clinic now to be seen by their gastric surgeon. Clients status post invasive procedures are at risk of hemorrhaging. As a result of the hemorrhaging, the client could go into shock. A feeling of impending doom, accompanied with restlessness and anxiety could be a signs that the client may be hemorrhaging internally. The nurse needs to instruct the client to return to the clinic now to be seen by their gastric surgeon.

Select all that apply. Which statements are accurate about the nurse's use of an automated medication dispensing system? It ensures that the nurse administers the right medication to the right client. As medications are dispensed the system records and charges medications to the client. It is designed to help reduce the amount of medication errors made by a nurse. These systems are capable of verifying the appropriateness of client's medications. It logs the time, client, and medication each time the nurse accesses the system.

As medications are dispensed the system records and charges medications to the client. It is designed to help reduce the amount of medication errors made by a nurse. It logs the time, client, and medication each time the nurse accesses the system. Automated medication dispensing systems (AMDS) within a health care facility are networked with each other and with other computer systems in the facility to help record and charge the client. AMDS control the dispensing of medications and keeps track of the individual accessing the machine, client and the medication type, dose and time. The system is designed to help prevent medication errors, but it still requires a nurse to do the six rights of medication administration and review and check for appropriateness of medication for the client's condition.

The nurse is preparing to perform Leopold maneuvers on a pregnant client. Which action should the nurse take? Ask client to empty her bladder. Place the client in lateral recumbent position. Roll a small towel on the client's right or left knee. Place a pillow under the client's left hip.

Ask client to empty her bladder. Leopold maneuvers help determines the fetal positioning in the uterine fundus, where the fetal back is located, and what fetal part is presenting. The nurse should have the client empty her bladder prior to the maneuvers because a full bladder would be uncomfortable for the mother and could interfere with assessment.

The nurse educates a large audience at a community event using a lecture and incorporates an audience response system (ARS). Which benefit does this provide for the nurse? Directs participants to a specific message. Connects key concepts to life experiences. Reaches a large audience with minimal effort. Assesses participant understanding of materials.

Assesses participant understanding of materials. Rationale A lecture format for education limits audience participation and feedback. Incorporating an ARS increases interactivity, provides data collection and analysis, and allows for immediate assessment of the learner's understanding of the material.

Along with appropriate hand hygiene and respiratory etiquette, what nursing actions should be done next to prevent spread of a communicable disease from an infected client? Notify the client's healthcare providers and known contacts. Alert the public health authorities about the infection. Assist with rapidly identifying the disease and immediately isolating. Make a public announcement of the identified infectious disease.

Assist with rapidly identifying the disease and immediately isolating. The nursing actions that should be done next to prevent spread of communicable disease include rapid recognition of potentially infectious clients and immediate placement in appropriate isolation.

Which skill should the nurse teach a client with hypertension? Blood pressure measurement. Pulse measurement. Pulse pressure calculation. Body mass index calculation.

Blood pressure measurement

The critical care nurse is completing a physical assessment on a client admitted with diabetic ketoacidosis. Which assessment finding should the nurse anticipate? A) Cool, clammy skin. B) Hypertension. C) Kussmaul respirations. D) No change in LOC.

C) Kussmaul respirations.

While monitoring a client with adrenal insufficiency, the nurse notices that the client's vital signs are beginning to deteriorate. Which action should the nurse take? Call the physician. Complete a full physicial assessment. Encourage the client to ambulate. Decrease the rate of intravenous fluids.

Call the physician. Clients with adrenal insufficiency should be monitored closely. If deterioration of the client's vital signs or hemodynamics occurs, the nursing priority is to immediately alert the physician.

A nurse is assessing a client being ruled out for hypopituitarism as a result of a tumor. Which neurological symptom would occur first in this condition of hypopituitarism? A change in the sense of smell. Ringing and static noise in the ears. Changes in the vision, particularly peripheral. The sense of taste is diminished, especially salty.

Changes in the vision, particularly peripheral.

A client presents with swelling of bilateral lower extremities and darkening of the skin from the feet up into the lower legs. Which disease process should the nurse suspect? Chronic venous insufficiency. Arterial insufficiency. Deep vein thrombosis. Hypertension.

Chronic venous insufficiency Chronic venous insufficiency causes pooling of blood and stasis in the lower extremities. This condition is often marked by hyperpigmentation and swelling of the lower legs.

A client presents with swelling of bilateral lower extremities and darkening of the skin from the feet up into the lower legs. Which disease process should the nurse suspect? Chronic venous insufficiency. Arterial insufficiency. Deep vein thrombosis. Hypertension.

Chronic venous insufficiency. Chronic venous insufficiency causes pooling of blood and stasis in the lower extremities. This condition is often marked by hyperpigmentation and swelling of the lower legs.

The nurse is evaluating a client who is receiving parenteral nutrition. An assessment reveals decreased oxygenation saturation levels, shortness of breath, coughing, and decreased blood pressure. The nurse is correct to take which action? Remove the central catheter and insert a chest tube. Obtain an order for intravenous antibiotics. Clamp the catheter and position the patient in a left-sided Trendelenburg position. Perform blood glucose monitoring and retest the levels in 15-30 minutes.

Clamp the catheter and position the patient in a left-sided Trendelenburg position. Rationale The client's symptoms indicate a potential air embolism, which may result from part of the catheter system being open or removed without being clamped. The nurse should clamp the catheter, position the client on the left side in Trendelenburg position, call the health care provider, and administer oxygen as needed.

The nurse is caring for a client with anorexia nervosa. The nurse establishes a contract in which the client agrees to participate in measures specifically designed to promote a specific weekly weight gain. Which statement accurately describes the rationale for this contract? Client involvement in decision making increases a sense of control and promotes compliance Client permission is essential due to increased risk of physical problems with refeeding Objective and subjective data must be routinely collected to help assess anxiety issues The client's family usually does not follow up with the recommended treatment plan.

Client involvement in decision making increases a sense of control and promotes compliance Rationale Behavioral contracting is a supportive intervention to elicit desired weight gain or maintenance for individuals with an eating disorder. Encouraging the client's involvement with decision making will improve self-esteem and help them to feel more invested in the treatment plan, and also provide a sense of control over health issues.

When applying restraints, which action is most important for the nurse to take to prevent contractures? Pad skin and any bony prominences that will be covered by the restraint. Correct anatomical positioning where restraint is applied and is restricting movement. Assess the neurovascular status of the area which is restrained or has movement restrictied. Inspect the area where restraint is to be placed, ensuring there are no tubing or devices present.

Correct anatomical positioning where restraint is applied and is restricting movement. Correct anatomical positioning where the restraint is to be applied and restricting movement will help prevent contractures. Other options are important but do not directly address prevention of contractures.

Select all that apply. Which situations lead to exacerbation of acne in an adolescent female? The consumption of chocolate products. Cosmetics containing lanolin and lauryl alcohol. Food products containing high levels of caffeine. Frequent exposure to cooking oils and grease. The premenstrual days leading up to a menstrual cycle.

Cosmetics containing lanolin and lauryl alcohol. Frequent exposure to cooking oils and grease. The premenstrual days leading up to a menstrual cycle.

The nurse is providing medication education to an older client who was prescribed oxybutynin (Ditropan) for an overactive bladder. What is a common side effect of this medication? Diarrhea. Urinary incontinence. Dry mouth. Bradycardia.

Dry Mouth Rationale Oxybutynin (Ditropan) is a bladder relaxant that may be used to treat overactive bladder. The incidence of dry mouth in individuals taking this medication is very high, in part due to its anticholinergic effects.

The health care provider prescribes clobetasol propionate, a high-potency topical steroid, for an older client with severe poison ivy. Which area of the face should the nurse instruct the client to avoid when applying this medication? Oral mucosa. Nasal mucosa. Eyes. External ears

Eyes Rationale Caution must be taken to avoid the eyes when applying topical steroids. Direct application to the eyes may cause glaucoma and cataracts.

The nurse is caring the pregnant client who is lactose intolerant. Which food should the nurse recommend to ensure that the client receives sufficient amounts of calcium? Swordfish Egg yolks Bone meal Figs.

Figs Rationale Pregnant women who are lactose intolerant need to consume sufficient amounts of calcium from non-dairy sources. Recommended non-dairy sources of dietary calcium include low-mercury fish, greens, beans, and certain fruits, such as figs.

The nurse administers high-dose prednisone as prescribed to an older client with polymyalgia rheumatica (PMR). Which adverse effect of prednisone is the nurse likely to observe? Hyperkalemia Increased seizure threshold Hyperglycemia Hypotensive effects.

Hyperglycemia. Rationale Corticosteroids action reduces the inflammatory response of cells thus decreasing the client's discomfort from the polymyalgia rheumatica (PMR). Prednisone, a corticosteroid is a glucocorticoid often used to treat polymyalgia rheumatica (PMR). Glucocorticoids influence the metabolism of carbohydrates, proteins, and fats. The principal effect on carbohydrate metabolism is the elevation of blood glucose (hyperglycemia

The nurse is caring for a client who takes a sulfonylurea. Which is the greatest risk in taking this medication? Hyperglycemia Hypoglycemia. Hypocalcemia. Hypercalcemia.

Hypoglycemia.

Which treatment should the nurse plan to implement for a client diagnosed with septicemia? PO antibiotics and IV fluid resuscitation. IV antibiotics and IV fluids at a keep open rate. IV antibiotics and IV fluid resuscitation. PO antibiotics and IV fluids at a keep open rate.

IV antibiotics and IV fluid resuscitation. Sepsis is a life-threatening condition caused by an underlying systemic infection. This condition may be treated aggressively with IV antibiotics and IV fluid resuscitation.

The nurse is providing client teaching about the use of a patient-controlled analgesia (PCA) pump. Which statement by the client indicates the need for more instruction about the PCA pump? If I am asleep, one of my visitors can push the button for me The PCA is designed so I can try to maintain adequate pain relief I don't need to be afraid of overdosing because the pump has preset doses to prevent that The nurse will check the PCA pump syringe to check how often I am needing a dose.

If I am asleep, one of my visitors can push the button for me Rationale The only person who should be pushing the dosing button of the PCA pump is the client. The pump has several safety features, including dosing limits

Which action is the priority when caring for a client with diabetic ketoacidosis? Initiate an intravenous insulin infusion. Maintain blood glucose levels at 200 mg/dl or lower. Administer oral hypoglycemic medications. Manage potassium imbalance. Submit

Initiate an intravenous insulin infusion. Diabetic ketoacidosis is a diabetic complication caused by extremely high blood glucose levels. The nursing priority should be to initiate an intravenous insulin infusion.

A client indicates interest in completing a living will, specifically noting the possibility of do not resuscitate (DNR) desires. Before the nurse can provide the facility's living will documents or further information, the client experiences cardiac arrest. Which of the following demonstrates the most ethical response by the nurse? Treat the client for the cardiac arrest and document the client's wishes as soon as possible. Find family members that can confirm the client's wishes immediately before intiating resuscitation measures. Treat the client per the standard of care for cardiac arrest, and report the wishes to the health care provider afterward. Initiate the cardiac arrest resuscitation and inform the healthcare provider the client's conversation, and notify the family.

Initiate the cardiac arrest resuscitation and inform the healthcare provider the client's conversation, and notify the family. Rationale A living will may include "do not resuscitate" orders, or it may specify desired treatments and name a health care power of attorney. Ethically, the nurse must notify the family and health care providers of the client's interest in a living will and DNR orders; however, the client must also be treated per the standard of care and CPR must be initiated because the client had not yet made an informed decision. Delaying notification to the health care providers and family members could be considered an error of omission and an ethical violation of the client's wishes.

Select all that apply. Which nursing actions are required when performing a transcutaneous electrical nerve stimulation (TENS) procedure with a client? Place clients with pacemakers on cardiac monitors during procedure To avoid trauma, do not place the electrodes over or near injury site Instruct the client to adjust the intensity of TENS stimulation for pain relief Ensure and review there is a healthcare provider's prescription for the TENS Remove any hair or lotions from the skin where the electrodes are to be placed.

Instruct the client to adjust the intensity of TENS stimulation for pain relief. Ensure and review there is a healthcare provider's prescription for the TENS. Remove any hair or lotions from the skin where the electrodes are to be place Rationale TENS procedure requires a healthcare provider's prescription. Anything that could interfere with the electrical current pathway needs to be remove from the skin. The client is to adjust the intensity of the current until pain relief is achieved. Clients with pacemakers or arrhythmias are never to use TENS.

A client with Graves' disease has been prescribed methimazole. Which explanation by the nurse correctly describes how this medication works? It increases absorption of thyroid hormone. It increases availability of thyroid hormone. It helps the body use thyroid hormone more effectively. It interferes with production of thyroid hormone.

It interferes with production of thyroid hormone. Rationale: Graves' disease is an autoimmune condition that is characterized by elevated thyroid hormone(hyperthyroidism), Methimazole is used to treat overactive thyroid by interfering with production of thyroid hormone.

The nurse is providing discharge education for a client prescribed a tricyclic antidepressant. Which statement by the client indicates the need for additional teaching? "It is best for me to take the full dose of the medication when I get up each morning." "My mood should improve within 7-28 days after starting my medicine." "It may take up to 6-8 weeks for me to experience the full effect of the medication." "The side effects of drowsiness and dizziness usually go away after the first few weeks."

It is best for me to take the full dose of the medication when I get up each morning." Rationale If possible, the client should take the full dose of tricyclic antidepressants at bedtime to reduce the experience of side effects during the day.

The critical care nurse is completing a physical assessment on a client admitted with diabetic ketoacidosis. Which assessment finding should the nurse anticipate? Cool, clammy skin. Hypertension. Kussmaul respirations. No change in LOC.

Kussmaul respirations. Diabetic ketoacidosis (DKA) is a potentially life-threatening condition associated with hyperglycemic crisis, ketosis, acidosis, hypovolemic shock due to dehydration, and electrolyte imbalance. Due to low pH levels, the nurse should anticipate Kussmaul breathing, a condition marked by deep, rapid respirations.

The nurse is providing education for a client with pernicious anemia who asks, "How did I get this disease?" What should the nurse identify as the most common cause of the client's condition? Blood loss. Food insecurity. Blood type and Rh (-) factor. Lack of intrinsic factor.

Lack of intrinsic factor. Rationale Pernicious anemia is caused by a lack of vitamin B12 in the body. The most common cause is a lack of intrinsic factor; without it, the small intestine is unable to absorb vitamin B12. When pernicious anemia is suspected the healthcare provider can prescribed a serum test for the antibody of the intrinsic factor (IF).

Select all that apply. A client diagnose with scabies has been prescribed lindane lotion. What is the recommended method of administration of this medicated lotion? (Select of that apply.) Apply to affected areas twice a day for one week. Avoid placing lotion on skin areas when crusts are present. After the application of lotion, cover the affected areas. Leave the lotion on the skin for 8 to 12 hours and then wash off. Apply a thin layer of lotion on the skin from the neck to soles of the feet.

Leave the lotion on the skin for 8 to 12 hours and then wash off. Apply a thin layer of lotion on the skin from the neck to soles of the feet. To use lindane lotion: Caregivers should wear gloves when applying lotion to clients; cream/ointment and lotion are used for scabies only; skin should be clean before application; wait one hour after one bathing or showering before application; apply a thin layer of the lotion from neck to soles of feet; pay attention to rubbing lotion in between fingers and toes; leave in place for 8 to 12 hours, then wash off with soap and water.

On assessment, a client has diminished breath sounds and bilateral rhonchi. Radial pulses are thready and weak. The client's skin is pale and cool to the touch with capillary refill +4. The client's oral mucosa and conjunctivae are cyanotic. The nurse also notes shortness of breath and increased respiratory rate when the client ambulates. The nurse recognizes that the client is most likely exhibiting signs and symptoms of which condition? Aortic aneurysm Left-sided heart failure Respiratory distress syndrome Pulmonary artery stenosis

Left-sided heart failure. Rationale Fluid in the lungs as indicated by the rhonchi and diminished breath sounds is considered a prominent sign of left-sided heart failure. The heart failure causes the heart not to pump effectively leading to poor tissue perfusion and circulation as evidenced by fluid build-up in the lungs, paleness and cyanosis, and weak, thready pulses. Left-sided heart failure leads to shortness of breath due to ineffective perfusion in the lungs for O2/CO2 gas exchange.

To assess for the presence of a carotid artery bruit, which action should the nurse include? Shine a light on the neck and observe for pulsations. Lightly apply the bell of the stethoscope over the artery. Gently palpate the impulse and observe for movement. Use finger pads in a circular motion over the area.

Lightly apply the bell of the stethoscope over the artery A bruit indicates the presence of turbulent blood flow and is best assessed by lightly placing the bell of the stethoscope over the artery and listening for a blowing or whooshing sound.

What is the most important thing a nurse must do when working with an electronic medical record (EMR)? Navigate the EMR program correctly. Input client data in a timely manner. Log off the EMR when leaving the computer terminal. Update EMR applications and security features when prompted.

Log off the EMR when leaving the computer terminal. Rationale The most important thing a nurse must do when working with EMRs is to protect the confidentiality of protected health information of the client. Of the choices, logging off the terminal when leaving the area is most important.

Select all that apply. What steps should the nurse implement to ensure a client's confidentiality is maintained when working with electronic medical records (EMR)? Log off the computer when finished working on it. Do not give the log-on password to anyone. Give clients access to the computer to review their EMR. Protect computer screen from viewing by others. Allow student nurses to chart under the nurse's password.

Log off the computer when finished working on it. Do not give the log-on password to anyone. Protect computer screen from viewing by others. Rationale To protect a client's confidentiality, the nurse should log off the computer when finished working on it; never share their password to include giving, telling or allowing another nurse or student to work under their password; and never leave their computer screen open when not present or in a public area.

The nurse is caring for a client who takes metoprolol. The nurse should monitor the client for which side effect? Low heart rate. Unexplained weight loss. Hypersalivation. Mania.

Low heart rate Metoprolol belongs to a class of antihypertensive medications known as beta blockers, which lower heart rate and blood pressure. Use of beta blockers can cause an abnormally low heart rate. The client's blood pressure should be take periodically during initial treatment and an apical/radial pulse should be taken before administration and the medication should be held and healthcare provider notified if any significant or pulse rate less than 60 beats per minute.

The nurse is caring for a client who is frequently hospitalized due to INR level management issues. The nurse recommends a home INR monitoring machine for the client as part of the discharge planning. Which step of the Predict, Prevent, Manage, Promote (PPMP) approach is the nurse using to proactively reduce future risk? Predict. Prevent. Manage. Promote.

Manage The Predict, Prevent, Manage, Promote (PPMP) approach proactively manages client health concerns and reduces risk through four stages. A home INR monitoring device allows a client more control over Coumadin dosing and INR levels, thereby decreasing hospitalizations and complications. The manage stage aims to implement technologies and interventions that can reduce risk, improve accuracy, and increase efficiency.

The nurse is assessing a young adult client who reports joint discomfort and pain. Upon inspection the nurse notes the client has very long hands and feet, and a very tall, thin build. On physical assessment, the nurse identifies a mitral valve murmur and scoliosis. Which condition is consistent with the nurse's assessment? Marfan syndrome. Cushing's syndrome. Fibromyalgia syndrome. Polymyalgia rheumatic syndrome.

Marfan syndrome.

Which federally-funded health care plan provides services to low income families? Medicaid. Medicare. Managed care organization. Preferred provider organization.

Medicaid. Rationale Medicaid is a federally-funded program designated to provide health care services for low income families.

An older client has been diagnosed with pernicious anemia. The nurse should anticipate that the healthcare provider to prescribe which therapy? Blood transfusions. Dietary regimen of leafy green vegetables. Treatment with proton pump inhibitors. Monthly cobalamin (vitamin B12) injections.

Monthly cobalamin (vitamin B12) injections. Rationale Pernicious anemia is a type of vitamin B12 deficiency anemia caused by a lack of intrinsic factor, a substance normally secreted by the gastric mucosa that is needed for absorption of vitamin B12. This condition is generally diagnosed around the age of 60 years old. Clients with pernicious anemia are given vitamin B12 injections weekly at first, and then monthly thereafter.

A client is admitted to the coronary intensive care unit with a diagnosed acute heart failure (HF) and myocardial infarction (MI). Which medication would the nurse anticipate the healthcare provider to prescribed to the client to decrease the preload and afterload, slow down their respirations, and reduce their anxiety and pain due to the MI? Enalapril (Vasotec). Morphine sulfate (Contin, MSIR). Hydrochlorothiazide (HCTZ, Urozide). Diazepam (Valium, Diastat, Diazemuls).

Morphine sulfate (Contin, MSIR) Morphine sulfate is prescribed to decrease the preload and afterload, slow down respirations, and reduce anxiety and pain due to the MI in clients also diagnosed with acute heart failure.

A client who had an appendectomy 12 hours ago is being treated with three different intravenous antibiotics. At 0715 hr, the client had decreased urine output and appeared to be agitated and restless. The client was also complaining of increased abdominal pain and was demonstrating guarding of abdomen and was curled up in fetal position in the bed. The client's vital signs are temperature 101.4 o F (38.6 o C), pulse 100 beats per minute, respirations 24 breaths per minute, and blood pressure of 96/64 mmHg. What is the first action the nurse should take? Notify the healthcare provider. Encourage the client to drink cool fluids. Place cool compress on client's forehead. Administer meperidine hydrochloride as prescribed.

Notify the healthcare provider.

A client wanders into the emergency department confused and somnolent. The client is bleeding profusely from the first three digit sites which have been severed from the hand from a lawn mower accident. The nurse immediately applies pressure to the severed sites. Which nursing action should the nurse do next? Start an IV with two large bore needles and place supine on the gurney. Placed the client on a gurney with their feet elevated and their head flat and apply oxygen. Apply a tourniquet and ice to the site and have client sit upright with arm above heart level. Placed the client in a fowler's position with their arm elevated above their head and apply oxygen.

Placed the client on a gurney with their feet elevated and their head flat and apply oxygen. Rationale The nurse needs to continue applying pressure to the severed sites. Place the client on a gurney with their feet elevated and their head flat or no more than 30°angle, apply oxygen. Then proceed to have two large bore IV catheters put in place. It is not in the scope of practice for a nurse to apply a tourniquet.

A client wanders into the emergency department confused and somnolent. The client is bleeding profusely from the first three digit sites which have been severed from the hand from a lawn mower accident. The nurse immediately applies pressure to the severed sites. Which nursing action should the nurse do next? Start an IV with two large bore needles and place supine on the gurney. Placed the client on a gurney with their feet elevated and their head flat and apply oxygen. Apply a tourniquet and ice to the site and have client sit upright with arm above heart level. Placed the client in a fowler's position with their arm elevated above their head and apply oxygen. Rationale The nurse needs to continue applying pressure to the severed sites. Place the client on a gurney with their feet elevated and their head flat or no more than 30°angle, apply oxygen. Then proceed to have two large bore IV catheters put in place. It is not in the scope of practice for a nurse to apply a tourniquet.

Placed the client on a gurney with their feet elevated and their head flat and apply oxygen. Rationale The nurse needs to continue applying pressure to the severed sites. Place the client on a gurney with their feet elevated and their head flat or no more than 30°angle, apply oxygen. Then proceed to have two large bore IV catheters put in place. It is not in the scope of practice for a nurse to apply a tourniquet.

Select all that apply. The nurse is caring for a client who has a fiberglass long leg cast on the right leg. Which nursing actions should be implemented in the cast care of this client? Smelling the cast and feeling for the presence of hot spots on the cast. Checking neurovascular status of the right exposed foot and toes every four hours. Using a soft cotton-tipped 6-inch swab to help scratch beneath the cast. Placing the nurse's finger in the client's cast while performing cast care. Covering the perineal area of the cast with plastic before client uses the fracture bedpan.

Placing the nurse's finger in the client's cast while performing cast care. Covering the perineal area of the cast with plastic before client uses the fracture bedpan. Smelling the cast and feeling for the presence of hot spots on the cast. Checking neurovascular status of the right exposed foot and toes every four hours. Cast care should include ensuring the cast is not too tight, by placing a finger between the client's skin and cast; by protecting the cast from being soiled by placing a protective plastic covering in the perineal area before the client uses a bedpan; by smelling for a foul odor coming from the cast; by palpating for hot spots on the cast every shift; and by performing neurovascular checks distal to the cast every four hours. Nothing should be placed in the cast to facilitate scratching beneath the cast.

A school nurse is assessing rashes on a child's lower shins and forearms that appear streaked and inflamed and are blistered with clear oozing substance present. The child reports that it is painful. Based on these signs and symptoms, what most likely caused this condition? Shellfish. Penicillin elixir. Laundry detergent. Poison ivy or oak.

Poison ivy or oak.

A nurse who is caring for a client diagnosed with Graves disease suspects the client has progressed in to a thyrotoxicosis crisis. Which assessment finding would support this suspicion? Bradycardia. Hypertension. Profuse sweating. Hypothermia.

Profuse sweating. Thyrotoxicosis crisis can be a complication of Grave's disease and is considered a life-threatening emergency. The nurse should monitor the client for elevated temperature, excessive perspiration, vomiting and diarrhea, delirium, severe weakness, seizure activity, arrhythmias, hypotension and coma which are complications of this condition.

A nurse is assigned the care of a client who is presently experiencing hypovolemic shock. The client's MAP has decreased by 20 mmHg from its baseline, tissue ischemia and anoxia of non-vital organs is occurring, pulses are weak, urine output is absent and the client's skin is cool and moist. The client appears to be confused and extremely anxious. Which stage of hypovolemic shock do these clinical signs and symptoms indicate? Initial stage. Refractory Stage. Progressive stage. Non-progressive stage.

Progressive stage. The client is exhibiting the clinical signs and symptoms of the progressive stage of hypovolemic shock which if allowed to progress will lead into the refractory stage and eventually death. The clinical signs and symptoms of hypovolemic progresses in four stages, if the condition causing the shock and/or interventions is not done and/or successful. If the interventions and the cause of the shock are corrected within 1-2 hours after onset, then the effects are temporary and irreversible.

An older male client reports a painless, round and firm sore on the underside of his penis. Which diagnostic test will likely be prescribed? Rapid plasma reagin (RPR) test. Human papillomavirus (HPV) test. Nucleic acid amplification test (NAAT). Western blot test.

Rapid plasma reagin (RPR) test The client's signs and symptoms is indicative of syphilis. The usual screening/diagnostic tests for syphilis are the Venereal Disease Research Laboratory (VDRL) serum test and the more sensitive rapid plasma reagin (RPR). These tests are based on an antibody-antigen reaction that determines the presence and amount of antibodies produced by the body in response to an infection by Treponema pallidum. VDRL titers are also used to monitor treatment effectiveness.

An older client with osteoarthritis reports increased pain and stiffness in the right knee due to an arthritis exacerbation. Which should the nurse do to prevent deformities of the knee in this client? Keep the client on a regimen of bed rest Immobilize the joint with pillows until pain subsides Apply a brace on the involved knee Recommend exercises for joint mobility

Recommend exercises for joint mobility. Rationale Exercise of the involved joint(s) is important to maintain optimal mobility and prevent buildup of calcium deposits. Immobilization causes contractures and loss of joint mobility. Exercising will actually help minimize the stiffness and pain in joints. The exercise will help strengthen the surrounding muscles which in turn will help stabilize the arthritic joints. Weight lifting for muscle strengthening and range of motion exercises are beneficial for arthritic joints.

Select all that apply. The nurse should educate clients about which behavioral risk factors which are linked to the leading causes of death in the United States? Stressful work environment. Sedentary lifestyle. Poor dietary choices. Lack of sleep and relaxation. Excessive alcohol consumption.

Sedentary lifestyle Poor dietary choices Excessive alcohol consumption Rationale According to the Centers for Disease Control (CDC), behavioral risk factors such as smoking, poor diet, physical inactivity, and excessive drinking are linked to the leading causes of mortality in the U.S. population.

When doing an assessment of sensory nerve function, which test should the nurse omit if the pain sensation is normal? Temperature. Light touch. Vibration. Position.

Temperature Rationale The temperature assessment is conducted to determine if an individual can demonstrate a distinction between a "hot" and "cold" and is only appropriate to use for further evaluation if the pain test indicates any areas of numbness or increase sensitivity.

A client with delirium keeps attempting to get out of bed and has fallen twice, despite being under close-observation. The charge nurse calls the health care provider to obtain an order for mechanical restraints. Which statement is correct regarding the mechanical restraint policy? The client will need to remain on close-observation with a documentation note every 15 minutes. The client no longer require close-observation, but must be checked at regular intervals. The client may be sedated and left alone as long as the restraints remain in place. Restraints may be applied based on verbal orders received over the phone.

The client will need to remain on close-observation with a documentation note every 15 minutes. Rationale Restraints are the last option to use to ensure client safety. A written order is required by a health care provider and the client require continued close-observation, even if mechanical restrained.

A nurse is assigned a client who was being treated for early sepsis with IV antibiotics and IV fluids. During the client's assessment the nurse notes that the client's blood pressure which was 86/52mmHg is now 118/78mmHg; their skin which was cool is now appears pink and warm to touch and their heart rate has increased from 75-89 beats per minute. How should the nurse interpret these assessment findings? Select the most appropriate statement. The client appears to be responding well to the antibiotic therapy. The status of the client is improving as evident by the skin changes. The condition of the client may be getting worse rather than improving. The circulation is improving as evidenced of the increased blood pressure and skin.

The condition of the client may be getting worse rather than improving. In early sepsis the clients will exhibit mild hypotension; slight decrease in urine output and increase respirations which result in decrease cardiac output. Their skin on their extremities may appear slightly pale and cool to touch. If the sepsis does not respond to interventions, the client will shift into severe sepsis and the body will attempt to compensate by increasing the heart rate which will increase the stroke volume in turn increased the cardiac output, return the blood pressure and central venous pressure back to normal. The increased cardiac output and vasodilation will make the appearance of the skin to become pink and warm to touch. Unfortunately, this compensation is actually a sign of the client's condition worsening and is only temporary, in which the client's cardiac output will drastically reduce and the client then progresses into septic shock.

The nurse is interviewing for an open position at one of the city's older hospital . Which factor should make the nurse most suspicious that retention efforts may be lacking at this facility? There are many open positions. The equipment is outdated. There are minimal educational opportunities. The pay scale is comparatively low.

There are many open positions. Rationale Evidence indicates that nursing shortages and low staff satisfaction is directly related to a facility's inability or unwillingness to retain existing staff. Therefore, a large number of open positions in an established facility is the best evidence that reflects of poor retention efforts on the part of the facility.

An arterial blood gas (ABG) analysis is drawn for a client. The results show pH of 7.30; PaCO2 of 68 mm Hg and an HCO3 of 24 mEq/L. What should the nurse interpret this blood gas as? Compensated metabolic alkalosis. Uncompensated respiratory acidosis. Compensated metabolic acidosis. Uncompensated respiratory alkalosis.

Uncompensated respiratory acidosis Rationale The nurse should interpret the arterial blood gas (ABG) result as uncompensated respiratory acidosis due to the fact the pH is acidotic and the CO2 is hypercapnic and the sodium bicarbonate is within normal limits. This ABG result is reflective of acute respiratory distress.

The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan? Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment. The client will be weaned from the ventilator within 24-48 hours after initiation of treatment. Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment. The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.

Uncompensated respiratory acidosis. Compensated metabolic acidosis. Incorrect Uncompensated respiratory alkalosis. Rationale The nurse should interpret the arterial blood gas (ABG) result as uncompensated respiratory acidosis due to the fact the pH is acidotic and the CO2 is hypercapnic and the sodium bicarbonate is within normal limits. This ABG result is reflective of acute respiratory distress.

An ambulatory client has developed an ulcer as a result from chronic venous insufficiency that is non-healing and causing edema in the lower leg. The nurse should anticipate the healthcare provider's plan of care to include? Arterial revascularization. Cauterization of the wound bed. Surgical transplant of venous valves. Unna boot that has been moistened with zinc oxide.

Unna boot that has been moistened with zinc oxide Surgical transplant of venous valves for chronic venous insufficiency is usually not done due to limited successful attempts in the past. The plan of choice for ambulatory clients is usually the application of an Unna boot that has been moistened with zinc oxide. The boot is usually applied by a healthcare provider and can be left in place for a week. The client is able to ambulate with the Unna boot in place.

The nurse is caring for a client who reports painful, cracked nipples due to breastfeeding. Which action should the nurse recommend to the client? Use breast shells for protection. Wear a breast binder for support. Apply lotion to moisturize nipples. Transition to bottle feeding.

Use breast shells for protection. Breastfeeding clients often experience cracked, sore nipples during breastfeeding. The nurse should encourage the client to use breast shells to decrease irritation to the nipples.

The nurse is assessing the thyroid of a client with suspected hyperthyroidism. Which action should the nurse avoid while performing this assessment? Vigorous palpation of the gland. Displacement of the trachea. Auscultation of the carotid artery. Movement of the vocal cords.

Vigorous palpation of the gland.

A 28-year-old client is exhibiting signs and symptoms of confusion, severe muscle weakness, tachycardia and hypotension and episodic of vomiting and constipation. The client has asthma and has been prescribed prednisone (Rayos, Winpred) and albuterol inhaler for the past year. Their vital signs are T- 97.8° F (36.6° C); P- 90; B/P 86/48 with lab values of sodium 130mmol/L; potassium 5.9mmol/L and calcium 10.3mg/dL. Which condition is the client most likely experiencing? What have you eaten in the last 24 hours? How often do you have to use your albuterol inhaler? Are you currently taken any SSRI's or MAOIs medication? When was the last time you took the prednisone medication?

When was the last time you took the prednisone medication? The client is exhibiting signs and symptoms of acute adrenal insufficiency or commonly known as Addison crisis, based on the clients presentation of signs and symptoms. The use of glucocorticoid drugs (prednisone) can cause secondary adrenal insufficiency if they are stopped abruptly. These drugs must be tapered off, to allow for the pituitary production of ACTH and activation of the adrenal cells to produce cortisol.

A venous doppler study is ordered to determine the cause of swelling in a client's right lower leg. Which action should the nurse perform to prepare the client for this test? Advise the client to avoid eating or drinking. Insert a large bore IV. Administer sedation. Inform the client that the test is not painful.

inform the client that the test is not painful

A client is experiencing dyspnea, respirations 24 breaths/ minute, O2 saturation of 89% on room air, nasal flaring, and audible expiratory and inspiratory wheezing noted three feet away. Which set of arterial blood gas (ABG) results is consistent with the nurse's assessment of this client? pH 7.48; PaCO2 40; HCO3 29. pH 7.35; PaCO2 43; HCO3 24. pH 7.28; PaCO2 55; HCO3 24. pH 7.38; PaCO2 38; HCO3 22.

pH 7.28; PaCO2 55; HCO3 24 Rationale The client is experiencing respiratory acidosis so pH will be below normal, with elevated PaCO2.

A client is experiencing dyspnea, respirations 24 breaths/ minute, O2 saturation of 89% on room air, nasal flaring, and audible expiratory and inspiratory wheezing noted three feet away. Which set of arterial blood gas (ABG) results is consistent with the nurse's assessment of this client? pH 7.48; PaCO2 40; HCO3 29. pH 7.35; PaCO2 43; HCO3 24 . pH 7.28; PaCO2 55; HCO3 24. pH 7.38; PaCO2 38; HCO3 22.

pH 7.28; PaCO2 55; HCO3 24. Rationale: The client is experiencing respiratory acidosis so pH will below normal, with elevated PaCO2

Select all that apply. The client's lower extremity has an ulcer present. Which assesment findings would indicate to the nurse that the ulcer is the result of peripheral arterial disease? The ulcer is located on the great toe. The lower extremities pulses are bounding. The area where the ulcer is located is edematous. The ulcer site is painful and tender when manipulated. Dependent rubor is present in the extremity with the ulcer.

the ulcer is located on the great toe the ulcer site is painful and tender when manipulated dependent rubor is present in the extremity of the ulcer Arterial ulcers are located at the end of toes and/or between them. The great toe is often the site affected. Pain is present at the ulcer site. These ulcers are often deep in appearance, pale wound bed, with well-defined and even edges present. The extremity is often cold or cool to the touch, pulses are either decreased or absence. The extremity affected by the peripheral arterial disease and the extremity is pale when elevated and demonstrates dependent rubor when lowered.