HESI test 2
What action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client? A. Check residual volume every four hours. B. Stimulate the gag reflex every eight hours. C. Administer small amounts of the formula. D. Give the feeding while the client is supine.
A. Check the residual volume every four hours.
Which responsibility best describes the role of the nurse as a manager? A. Delivery of client care while meeting agency goals. B. Maintenance of harmony within the agency. C. Assignment of nursing personnel and resources. D. Development of long range career goals.
A. Delivery of client care while meeting agency goals.
When making a home visit to a family with a teething 4 month old , what information is most important for the nurse to provide the parents? A. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. B. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. C. No actions is required for the common symptoms associated with teething, which includes drooling, irritability, and poor sleeping. D. Providing cooled teething toys can help decrease the discomfort associated with teeth eruption.
A. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention.
Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? A . An adult who had a colon resection yesterday and has an IV. B An older adult who has a fever of unknown origin. C. A teenager with a femoral fracture who is in traction. D. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
A. An adult who had a colon resection yesterday and has an IV.
The mother of an 8-year old child with a chronic illness and tracheotomy is rooming in during this hospitalization. The mother insists on providing all the child's care and tells the nurse how to care for the child. The nurse should recognize that the mother plays which function when planning this child's care? A. An expert in care of the child. B. Supervisor of nurses providing care. C. Source of the child's safety. D. The nurse's role.
A. An expert in care of the child.
Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? A. Attempt to arouse the client to stimulate respirations. B. Auscultate the client's breath sounds bilaterally. C. Assess the client's current oxygen saturation level. D. Prepare to administer a dose of naloxone (Narcan) IV.
A. Attempt to arouse the client to stimulate respirations.
A patient who is malnourished is being administered an intravenous fat emulsion. The nurse's assessment findings include an elevated body temperature, increased triglyceride levels, and a decreased respiratory rate. Which action should the nurse take? A. Discontinue the emulsion B. Slow the rate of the emulsion administration C. Change the infusion to parenteral nutrition D. Document the findings and continue the infusion
A. Discontinue the emulsion
Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (select all that apply) A. Economics B. Socio-economic status C. Workforce D. Legislation/regulation E. Interventions F. Technology
A. Economics D. Legislation/regulation F. Technology
Which components are characteristic of practice context? A. Factors and systems that contribute to delivery of nursing care. B. Specific group of clients who receive care in a particular setting. C. Type of health care delivery system currently in place in a setting. D. Policies, procedures, and staffing patterns of a nursing unit.
A. Factors and systems that contribute to delivery of nursing care.
A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload? A. Increase in size. B. Increase in number. C. Decrease in excitability. D. Decrease in length.
A. Increase in size.
The nurse inflates the cuff on a tracheotomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? A. Inject air until no air is auscultated over the larynx during a deep breath. B. Check the pilot balloon to ensure that it is firm. C. Use a manometer to maintain cuff pressure between 25 and 30mmHg. D. Verify the healthcare provider's prescription for the required cuff pressure.
A. Inject air until no air is auscultated over the larynx during a deep breath.
The nurse is catheterizing a 7-year old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort? A. Insert 5ml of 2% lidocaine lubricant to the urethra. B. Apply sterile lubricant to catheter tip prior to insertion. C. Wait 2 to 5 minutes before insertion of the catheter. D. Compress the glans to retain the lidocaine lubricant.
A. Insert 5ml of 2% lidocaine lubricant to the urethra.
The nurse is teaching a client how to self administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? A. Method used to aspirate medication from a vial. B. Hand washing prior to preparation of the injection. C. Selection and rotation of the injection sites. D. Proper disposal of injection equipment.
A. Method used to aspirate medication from a vial.
A client with an open reduction and application of an external fixator for open, comminuted fractures of the tibia and fibula begins to complain of severe pain in the affected leg, which is not relieved by analgesics. The client says the toes are numb and tingling, although they appear pink. What action should the nurse implement? A. Notify the healthcare provider. B. Elevate the extremity with ice at the wound site. C. Loosen the screws on the external fixator pins. D. Check the client's temperature.
A. Notify the healthcare provider.
The nurse manager is explaining to a new nurse that the nursing units at the hospital are managed by the nursing staff who control self-scheduling of shift work, implement unit quality improvement program, and participate in unit recruitment-retention programs. What type of management model is the nurse manager describing? A. Operational shared governance. B. Centralized nursing division. C. Clinical career ladder program. D. Nursing staff unions.
A. Operational shared governance.
What clinical problem is a suitable for research utilization in nursing? A. Patient-controlled analgesia. B. The value of calcium channel blockers use over ACE inhibitors. C. Medication errors associated with incorrect dispensing. D. Computerized client billing.
A. Patient- controlled analgesia.
On the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism? A. Petechiae of the anterior chest wall. B. Warm, reddened areas in the legs. C. Restlessness and confusion. D. Hypotension.
A. Petechiae of the anterior chest wall.
The nurse is caring for a patient in the postanesthesia care unit (PACU) when they become agitated. What is the priority action by the nurse? Select all that apply A. Put the side rails up B. Evaluate respiratory status C. Monitor fluid intake and output D. Use clocks to reorient the patient if needed E. Sedate the patient, if the patient is not hypoxemic
A. Put the side rails up B. Evaluate respiratory status D. Use clocks to reorient the patient if needed E. Sedate the patient, if the patient is not hypoxemic
A mother asks the nurse to explain how using a "time-out" to discipline her 2-year old child is an effective method. Which rationale should the nurse provide? A. Removes a reinforcer that a child is receiving B. Extinguishes the behavior by ignoring it C. Offers positive reinforcement D. Provides a consequence to behavior
A. Removes a reinforcer that a child is receiving
Which biological practices are federally regulated for healthcare workers? (select all that apply) A. Standard precautions B. Biological product exposure limit (BPEL) C. N-95 Tuberculosis standard D. As low as reasonably allowable standard (ALARA) E. Blood-borne pathogen standard F. Resource conservation and recovery act (RCRA)
A. Standard precautions C. N-95 tuberculosis standard E. Blood-borne pathogen standard F. Resource conservation and recovery act (RCRA)
A patient with heart failure has a pulmonary arterial pressure of 28 mmHg when at rest. Which intervention helps in comforting this patient? A. Supplying oxygen to the patient B. Infusing intravenous fluids to the patient C. Applying warm and cold compresses to the patient D. Positioning the patient at an angle of 90 degrees
A. Supplying oxygen to the patient
A client is transferred to the postanesthesia care unit (PACU). What is the priority nursing action? A. Take the client's vital signs. B. Determine the client's pain level. C. Check the post-op prescriptions. D. Calculate the IV infusion rate.
A. Take the client's vital signs.
To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.) A. Vitamin C tablets B. Ibuprofen (Advil) C. Fish D. Turkey E. Coffee F. Beef
A. Vitamin C tablets B. Ibuprofen (advil) C. Fish F. Beef
The nurse administers dopamine (Intropin) IV infusion at 3mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase A. urine output to 55ml/hr B. blood pressure to 140/80 C. pulse to 132 beats/min D. respirations to 24 breaths/min
A. urine output to 55ml/hr
A 32-year old male client is admitted with paranoid schizophrenia. The nurse observes the client walking around the unit muttering to himself and gesturing as if he is having auditory hallucinations. Which action provides the most effective psychotherapeutic management? A. Use behavior modification to decrease the frequency of hallucinations. B. Give a PRN anxiolytic medication before interacting with the client. C. Reassure the client that he is safe and should rest. D. Minimize the client's social contact with other clients.
C. Reassure the client that he is safe and should rest.
A client with ulcerative colitis is scheduled for surgical creation of a J pouch. As part of preoperative teaching, what information should the nurse provide? A. Easily removable appliances allow for independence in self-care. B. The transverse loop ostomy is permanent. C. Stool is eventually expelled through the rectum. D. Daily irrigation is started after the J pouch heals.
C. Stool is eventually expelled through the rectum.
A patient reports frequent itching and a thick, white curd-like vaginal discharge. What does the nurse expect to find while examining the patient? A. Macules in the vulva B. A beefy red-colored vulva C. Firm ulcers within the vulva D. A warty appearance in the vulva
B. A beefy red-colored vulva
The nurse places a heating pad on the lower leg of a client with peripheral vascular disease (PVD). When the heating pad is removed, the client's skin is blistered and a full-thickness burn is evident. What consequence can occur based on the nurse's action? A. Client harm occurred which is enough evidence to prove liability. B. All elements are present to find the nurse liable for damages. C. The standard of care was not breached so the nurse is not liable. D. The injury was not foreseeable therefore the nurse is not liable
B. All elements are present to find the nurse liable for damages.
An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? A. Teach the girl the importance of practicing safe sex. B. Ask if she is going to the bathroom frequently. C. Encourage the girl to see the school counselor. D. Counsel the girl regarding hygiene.
B. Ask if she is going to the bathroom frequently.
A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? A. Atropine sulfate 0.4mg IM on call to operating room. B. Betaxolol (Betoptic) one drop in each eye the morning of surgery. C. Morphine sulfate 5mg IV on call to operating room. D. Benzodiazepine (Valium) 5mg PO the morning of surgery.
B. Betaxolol (Betoptic) one drop in each eye the morning of surgery.
The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic gel? A. Dislodge the fecal mass. B. Decrease the risk for bradycardia. C. Minimize hemorrhoidal trauma. D. Prevent rectal mucosal tearing.
B. Decrease the risk for bradycardia.
A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? A. Flush the catheter to maintain patency of the CVC access. B. Describe the placement and rationale for care of the catheter. C. Reassure the client that the TPN administration is temporary. D. Provide passive range of motion to the right arm and neck.
B. Describe the placement and rationale for care of the catheter.
Which interventions might the nurse anticipate implementing to prevent healthcare-associated infections for a patient suffering from multiple organ dysfunction syndrome (MODS)? Select all that apply A. Daily ABGs B. Early surgery to remove necrotic tissue C. Ambulating patient as soon as possible D. Daily assessment of continuing need for invasive lines and devices E. Strict use of aseptic and sterile technique in relation to lines and tubes.
B. Early surgery to remove necrotic tissue C. Ambulating patient as soon as possible D. Daily assessment of continuing need for invasive lines and devices E. Strict use of aseptic and sterile technique in relation to lines and tubes
When administering an intramuscular (IM) injection to an adult client using the ventro gluteal site, which landmarks should the nurse identify to locate the area for injection? A. The greater the trochanter and the posterior iliac spine. B. The greater trochanter and the knee. C. The anterosuperior iliac spine and the greater trochanter. D. The acromion process and the dorsal surface of the upper arm.
C. The anterosuperior iliac spine and the greater trochanter.
The nurse is caring for a patient with a ureteral catheter. Which intervention of the nurse needs correction? A. Check the catheter placement frequently B. Instructing the patient to tolerate pelvic pain C. Checking for drainage every one to two hours D. Clamping the ureteral catheter to avoid urine leakage
B. Instructing the patient to tolerate pelvic pain
The nurse is providing immediate post-procedural care to a patient who underwent endoscopic retrograde cholangiopancreatography (ERCP). Which actions by the nurse are beneficial to the patient? Select all that apply A. Providing oral foods B. Observing for signs of bleeding C. Maintaining the patient on bed rest D. Observing for any change in body temperature E. Encouraging the patient to drink plenty of fluids
B. Observing for signs of bleeding C. Maintaining the patient on bed rest D. Observing for any change in body temperature
The nurse is analyzing the waveforms of a client's electrocardiogram (ECG). What finding indicates a disturbance in electrical conduction in the ventricles? A. PR interval of 0.18 seconds B. QRS interval of 0.14 seconds. C. T wave of 0.16 seconds. D. QT interval of 0.34 seconds.
B. QRS interval of 0.14 seconds
The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? A. Ask another nurse to recheck the blood pressure to compare results. B. Retake the blood pressure in the same arm, deflating the cuff slowly. C. Use an electronic sphygmomanometer to take the BP every 30 mins. D. Obtain another blood pressure cuff and retake the blood pressure.
B. Retake the blood pressure in the same arm, deflating the cuff slowly.
The charge nurse assigns one nurse to care for a client with shingles and another nurse to care for a client with HIV/AIDS. Which client goal is addressed by the charge nurse's assignments? A. Physiologic integrity B. Safe and effective care environment C. Health promotion and maintenance D. Psychological integrity
B. Safe and effective care environment
Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? A. African-American women who are 30-35 years of age. B. Survivors of violence that occurred at least 5 years ago. C. Full-time students who are attending public colleges. D. Active armed forces reserve unit returning from Europe.
B. Survivors of violence that occurred at least 5 years ago.
The nurse is creating a plan of care for a patient with osteoarthitis. What would the nurse plan as an appropriate short-term goal for this patient? A. The patient will limit physical activity in the morning. B. The patient will participate in physical therapy activities. C. The patient will eliminate the use of narcotic analgesics if diarrhea develops. D. The patient will limit pain medications to nonnarcotic drugs to prevent addiction.
B. The patient will participate in physical therapy activities.
During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? A. Send the other clients out of the group setting. B. Summon assistance of other staff. C. Tell the client to leave the group to gain control of the behavior. D. Firmly inform the client that acting out in anger is not acceptable.
D. Firmly inform the client that acting out in anger is not acceptable.
A client with cellulitis is recovering at home after experiencing a severe reaction to a new prescription for ampicillin (Unisyn) that was administered by a home health nurse. The client's allergies to penicillin and sulfonamide are noted in all critical areas of the home health record. What consequence can occur based on the nurse's action? A. Disciplinary action initiated by the state's nurse licensing board. B. An intentional tort based on failure to note the client's allergies. C. A malpractice suit based on lack of reasonable and prudent care. D. None since the action did not result in the client's wrongful death.
C. A malpractice suit based on lack of reasonable and prudent care.
The nurse is working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? A. An older man who is always happy and chooses to view only the good in every situation. B. A successful businessman who is accustomed to handling highly-stressful situations. C. A teacher who seeks information about her disease and wants to continue teaching. D. A single mother who seeks the support of her two teenage daughters during difficult times.
C. A teacher who seeks information about her disease and wants to continue teaching.
The nurse is preparing a patient for a water deprivation test for central diabetes insipidus in the hospital. What intervention is required for this patient? A. Deprive the patient of water for six hours. B. Administer intravenous hypotonic saline or dextrose 5%in water C. Administer desmopressin acetate (DDAVP) subcutaneously. D. Provide the patient with a diluted solution of sodium.
C. Administer desmopressin acetate (DDAVP) subcutaneously.
Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? A. Notify the healthcare provider if the PTT time is longer than 50 seconds. B. Start instruction for self-administered SC heparin injections for long-term home therapy. C. Avoid any intramuscular medications to prevent localized bleeding D. Have vitamin K available in the event the client begins to bleed.
C. Avoid any intramuscular medications to prevent localized bleeding.
An older adult client begins wearing binaurial hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? A. Keep the volume on low until conditions with noises are audible. B. Use one hearing aid until comfortable, then add the second aid. C. Begin wearing the aids in quiet environments to experiment with adjustments. D. Wear the hearing aids for an hour a day at first, gradually increasing the time.
C. Begin wearing the aids in quiet environments to experiment with adjustments.
Which information is most accurate for the nurse to use when calculating safe drug dosages for a child? A. Height B. Weight C. Body surface area D. Age
C. Body surface area
What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply) A. Cherry anginomas B. White patches C. Border irregularity D. Lesion with color variations E. Lesion with asymmetry F. Lesion of 3-5mm diameter
C. Border irregularity D. Lesion with color variations E. Lesion with asymmetry
Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? A. I think I should talk about this in the group. B. I really wish my birthday wasn't so soon. C. The doctor won't talk to me about this. D. I don't talk about things like that anymore.
D. I don't talk about things like that anymore
The nurse enters a client's room to complete discharge preparations and finds the client in tears. The client states that someone from the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? A. Resume the discharge when payment occurs. B. Call the family to ask about the payment. C. Continue the client's discharge process. D. Notify the healthcare provider of the situation.
C. Continue the client's discharge process.
A client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect? A. Reduces the existing colony count. B. Prevents hearing loss as a possible complication. C. Decreases inflammation and pain. D. Slows the rate of organism growth.
C. Decreases inflammation and pain.
Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? A. Teach children the correct handwashing technique to use after toileting. B. Put a strip bandage on bleeding injuries to prevent contamination of others. C. Ensure that all enrolled children have been immunized for Hepatitis A. D. Promote hygiene by ensuring that children's faces and hair are kept clean.
C. Ensure that all enrolled children have been immunized for Hepatitis A.
A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? A. Maintenance of data related to the number of IV infiltration occurrences in the hospital. B. Provision of nursing staff education about safe administration of IV antibiotics. C. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. D. Determination of the compatibility of the intravenous fluids and prescribed antibiotics.
C. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes.
The nurse is caring for a client who is one-day post cardiac catheterization with stent placement. Assessment findings are: blood pressure 90/40, heart rate 45 beats/minute, and oxygen saturation at 95% on oxygen nasal cannula at 2L/minute. Which task should the nurse delegate to the UAP at this time? A. Report vital signs to the healthcare provider B. Assist with morning shower and oral care C. Obtain urine output for the last 4 hours D. Watch the client take an oral dose of aspirin
C. Obtain urine output for the last 4 hours
In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A. Complaints of any blind spots in the client's field of vision. B. Recent experience of seeing light flashes or floaters. C. Use of prescribed eye drops since the last exam by ophthalomologist. D. Length of time the client has been wearing prescription lenses.
C. Use of prescribed eye drops since the last exam by ophthalomologist.
The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for what common side effect that is most likely to occur during therapy? A. Akathisia B. Photosensitivity C. Weight gain. D. Dystonia.
C. Weight gain
When assessing a client's interior eye structures with an ophthamlmoscope, what action should the nurse use? A. dilate the client's pupils B. use a red-free filter C. adjust the diopters D. direct a wide-beam light
C. adjust the diopters
Which individual may legally sign an informed consent? A. The friend of an 84-year old married client. B. A 42-year old client who is sedated. C. A 56-year old who questions a proposed treatment plan. D. A 16-year old mother for her newborn.
D. A 16-year old mother for her newborn.
Which evidence supports the application of healthcare informatics and client care technology? A. The emergence of new and appropriate knowledge structures. B. The elimination of chaos in solving informatics problems C. A solution for informatics problems with data flow records and work flow documentation D. A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care
D. A new sense of order to a problem that facilitates cost-effective analysis and evaluation of care
The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client? A. Pituitary dysfunction, such as diabetes insipidus, can occur after a head injury or primary tumor that causes increased intracranial pressure. B. Hyperthyroidism is an autoimmune disease that causes an increased secretion of thyroxine resulting in an increased basal metabolic rate. C. End stage renal disease causes hypertension due to increased renal perfusion that results in an increased secretion of renin. D. Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex.
D. Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex.
A client with severe depression tells the nurse, " I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? A. You need to stop thinking negative thoughts. They get in the way of your recovery. B. You are feeling very pessimistic, but that is a part of your illness. It should go away as you recover. C. You are no bother to me or to the staff. We want you to get well and not feel sad anymore. D. I have known many clients with depression who have felt better after several weeks of treatment.
D. I have known many clients with depression who have felt better after several weeks of treatment.
A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to a Jackson-Pratt suctions bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action? A. Encourage looking at the colostomy site. B. Provide a low-residue diet C. Monitor drainage from the colostomy stoma. D. Maintain dry perineal dressings.
D. Maintain dry perineal dressings.
A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing SOB and associated anxiety. Which prescription should the nurse implement first? A. Oxygen 2-6 L/min using a nasal cannula B. Albuterol per nebulizer C. Prednisone 10mg PO D. Morphine sulfate 5-10 mg SL as needed
D. Morphine sulfate 5-10mg SL as needed
A hospitalized 5-year old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? A. Tell the child he can go outside after he drinks a full glass of water. B. Make a game of seeing who can finish a glass of water first- the nurse or the child. C. Ask the parents to participate in encouraging the child's fluid intake. D. Offer the child a popsicle and allow him to pick the flavor he prefers.
D. Offer the child a popsicle and allow him to pick the flavor he prefers.
Which action should the hospice nurse implement to assist a client maintain self-worth during the end-of-life process? A. Ensure the client's spiritual advisor protects support. B. Arrange for a grief counselor to visit with the client. C. Allow the client time alone to finalize personal affairs. D. Plan regular visits with the client throughout the day.
D. Plan regular visits with the client throughout the day.
The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? A. Pump every 2 to 3 hours, including during the night, to increase breast milk volume. B. To promote maternal production with neonatal demand, pump only the volume the newborn takes. C. A glass of wine prior to pumping reduces anxiety and increases breast milk production. D. Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.
D. Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.
The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? A. Systolic BP 80mmHg after 2 fluid boluses. B. Sinus bradycardia at 50 beats/min C. Flaccid paralysis below the level of injury. D. SpO2 of 88% with shallow, slow respirations
D. SpO2 of 88% with shallow, slow respirations
Which description encompasses the role in client care management played by nursing informatics? A. The processing of electronic nursing data that is used to support nursing practice and knowledge. B. A computer system design to analysis client health data during hospitalization. C. The specialty of hospital nursing management of computerized client care. D. The input and retrieval of electronic data about a client's medical history.
D. The input and retrieval of electronic data about a client's medical history.
Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider? A. Drinks alcoholic beverages twice a week. B. Receives carvedilol (Coreg) for heart failure. C. Works outdoors as a construction site supervisor. D. Has a family history of diabetes mellitus, type 1.
Receives carvedilol (Coreg) for heart failure.
