HESI TUTORING QUESTIONS
The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? a. The axillary pads are torn and show signs of wear b. The client has a 30-degree bend at the elbow when walking c. The crutches and injured foot are moved simultaneously in a 3-point gait d. There is a 3 finger-width space noted between the axilla and axillary pad
A (Option 1) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating.
An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? a. Explore the client's knowledge of gun safety. b. Assess the client for a history of risk-taking behaviors. c. Refer the client to a firearm safety class sponsored by the hospital. d. Have the client watch a video on the tragedies of improper firearm use.
A A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall.
A After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.
An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? a. "He is critically ill and we are caring for his needs." b. "His heart has stopped and we are attempting to revive him." c. "I don't know how he is doing but you need to come." d. "I will have the health care provider talk to you once you arrive."
A Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely.
The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway. b. Check tubes or drains for patency. c. Check the dressing to assess for bleeding. d. Assess the vital signs to compare with preoperative measurements.
A The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.
The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? a. Continue teaching the client and verify understanding by return demonstration b. Discuss how important it is for the client to pay attention during the teaching c. Maintain eye contact during the teaching by following the client's movements d. Provide written instructions and a private place for the client to learn independently
A Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.
The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? a. Review intake and output records for the last 2 days. b. Prescribe daily weights starting on the following morning. c. Change the time of diuretic administration from morning to evening. d. Request a sodium restriction of 1 g/day from the health care provider (HCP).
A Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.
The nurse is preparing a dose of 10 units of regular insulin and 35 units of NPH insulin for a client with type 1 diabetes mellitus. The nurse obtains an insulin syringe, gently rotates the insulin solutions, cleans the tops of the vials of insulin, and injects an amount of air equal to the dose prescribed into each vial. What is the next nursing action? a. Draws up 10 units of regular insulin and checks the syringe contents with another nurse before drawing up the NPH insulin b. Draws up 10 units of regular insulin, draws up 35 units of NPH insulin, and checks the syringe contents with another nurse c. Draws up 35 units of NPH insulin and checks the syringe contents with another nurse before drawing up the regular insulin d. Draws up 35 units of NPH insulin, draws up 10 units of regular insulin, and checks the syringe contents with another nurse
A Insulin dosages are verified by another nurse before administration. When 2 types of insulins are mixed, the doses must be verified after each is drawn up so as to verify the dosage for each one. The regular insulin is drawn into the syringe first.
A hospitalized client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin, gr 1/4 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure remains stable, the nurse should take which action next? a. Administer another nitroglycerin tablet. b. Administer 10 L of oxygen via nasal cannula. c. Call for a 12-lead electrocardiogram (ECG) to be performed. d. Wait an additional 5 minutes, and then give a second nitroglycerin tablet.
A Nitroglycerin tablets are usually prescribed 1 every 5 minutes PRN (as needed) for chest pain for the hospitalized client, up to a total dose of 3 tablets. The nurse should administer the second tablet. The client with known angina pectoris should have low- flow oxygen at a rate of 1 to 3 L/min via nasal cannula. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.
The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? a. Client's temperature b. Expiration date on the bag c. Time of last dressing change d. Tightness of tubing connections
A Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change.
The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first? 1. Stop the IV infusion. 2. Apply ice to the catheter site. 3. Contact the health care provider. 4. Readjust the rate of IV administration.
A The IV must be stopped immediately because it has infiltrated. The remaining options allow the IV solution to continue to flow and further exacerbate the infiltration rather than intervene to stop it.
A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? a. Suction the client through the endotracheal tube. b. Instruct the client in the use of an incentive spirometer. c. Turn the client from a 30-degree lateral position to a supine position. d. Instruct the client to use a communication board to tell the nurse what is wrong.
A The client is choking on his secretions, which should be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing his airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.
A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? a. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" b. "We will do everything possible to prevent that from happening." c. "Well, we're all going to die sometime." d. "You should concentrate on getting better rather than thinking about death."
A The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?," the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings.
The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? a. Further insert the catheter 1-2 in (2.5-5.1 cm) b. Have the client hold his breath c. Immediately inflate the 5 mL balloon d. Secure the tubing to the client's leg
A Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation.
The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? a. Leave the catheter in place and insert a new catheter higher up in the perineal area b. Leave the catheter in place for 30 minutes and then recheck c. Notify the prescribing health care provider that there is an obstruction d. Remove the catheter and reinsert it at a position higher than the initial insertion
A Urine output would be expected as this client has not voided for 6 hours. The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra, which is located above the vagina. A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re- insert it into the same (wrong) opening.
The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? (SELECT ALL THAT APPLY.) a. Apply moisture barrier cream to skin b. Clean perineal area after incontinent episodes c. Massage bony prominences frequently d. Place foam-padded seat cushions on chairs e. Reposition clients in bed every 6 hours
A, B, D Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: • Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option 1). • Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option 4). • Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option 2). • Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. (Option 3) Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin. (Option 5) Clients must be repositioned and turned every 2 hours. Turning clients every 6 hours is too infrequent and will not confer the same protection against pressure and associated tissue ischemia.
A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? (SELECT ALL THAT APPLY) a. Epoetin alfa b. Fresh frozen plasma c. Homologous packed red blood cells d. Normal saline e. Platelet transfusion
A, D Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options 2, 3, and 5). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option 4). Recombinant human erythropoietin (epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option 1).
A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide-awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? a. "Please try not to worry, you have an excellent surgeon." b. "Tell me about how you feel about your surgery." c. "Why are you considering refusing the surgery?" d. "You have the right to make your own decisions and can refuse the surgery."
B "Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support. (Option 1) This statement is nontherapeutic as giving false reassurance minimizes the client's concerns and diminishes trust between the nurse and client. (Option 3) This statement is nontherapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering information. (Option 4) A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client's decision does not encourage the client to express concerns about the surgery.
The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? a. Lower the head of the bed. b. Test the drainage for glucose. c. Obtain a culture of the drainage. d. Continue to observe the drainage.
B After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.
A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? a. Sodium b. Calcium c. Potassium d. Magnesium
B After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek's and Trousseau's signs. The correct treatment is administration of calcium gluconate or calcium lactate. The remaining options are unrelated to the client's complaints.
The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action should the nurse perform when administering this test to the client? a. Inject the medication and place a pressure dressing over the medication site. b. Make a circular mark around the injection site after administration of the tuberculin test. c. Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle. d. Massage the area with an alcohol swab after injection to ensure that the medication is absorbed.
B An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb should form under the skin with injection. After withdrawing the needle, the area may be patted dry with a 2 × 2 sterile gauze pad, but pressure should not be applied. The area should not be rubbed because this will cause the medication to spread beyond the area of injection. The area of injection is outlined or circled for later reference and interpretation of the results of the test.
The nurse is caring for a client prescribed enteral feeding via a newly inserted nasogastric (NG) tube. Before initiating the enteral feeding, the nurse should perform which action first? a. Warm the feeding to 103°F (39.4°C). b. Confirm NG placement by x-ray study. c. Make sure the continuous enteral feeding tubing is primed. d. Position the head of the client's bed to 30 degrees or greater.
B Before initiating enteral feedings via a newly inserted NG tube, the placement of the tube is confirmed by x-ray. If the tube is not in the stomach, the client is at risk for aspiration. Formulas are administered at room temperature, not at 103°F. To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Although an important action, it is not the priority. Priming the enteral feeding tube is important prior to initiating the feedings; however, it is not the priority action.
The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? a. Use a 5⁄8-inch needle for the injection. b. Apply prolonged pressure to the IM site after the injection. c. Apply a 4 × 4 pressure dressing at the IM site after the injection. d. Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.
B Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply a pressure dressing to the IM site of injection. A 5⁄8- inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a health care provider (HCP).
With a finger sensor the nurse is measuring a client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action? a. Increase the client's oxygen to 4 L/min. b. Check the finger sensor's position and repeat the test. c. Notify the client's health care provider about the low reading. d. Check the client's chart to find out what the previous readings have been.
B Note that the low reading does not match the client's signs and symptoms. The first action by the nurse is to ensure that the test was done properly and the reading is accurate. The nurse should not increase the oxygen without a health care provider's prescription. The results of the test should be verified before any other actions are taken, and this can be done quickly.
The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? a. Immediately twist the catheter, and then slowly inflate the balloon.\ b. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. c. Insert the catheter until resistance is met, and then inflate the balloon. d. Withdraw the catheter approximately 1 inch (2.5 cm), and then inflate the balloon.
B The balloon is behind the opening at the catheter tip. The catheter is inserted 7 to 9 inches (18 to 23 cm) after urine begins to flow, providing sufficient space to inflate the balloon and ensuring that the balloon has passed through the entire urethra and into the bladder. Inflating the balloon in the urethra could produce trauma. The catheter should be neither withdrawn nor advanced until resistance is met.
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? a. Bilateral edema b. Increased calf circumference c. Diminished distal peripheral pulses d. Coolness and pallor of the affected limb
B The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.
When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain? a. Client's ethnic background b. Client's report of symptoms c. Client's vital signs d. Extent of client's injury
B The client's self-report of symptoms is always the most reliable indicator of the client's pain. The nurse does not have the ability to determine the extent of pain the client is experiencing—only the client can report this. (Option 3) Although changes in vital signs may occur in acute pain (generally increased respiratory rate and heart rate), these changes are not the most reliable source of information when determining pain. (Option 4) The extent of a client's injury is not a reliable source of information when determining pain because all clients experience pain differently. What one client may feel as excruciating pain another client may not.
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? a. Document the findings. b. Attempt to arouse the client. c. Contact the health care provider (HCP) immediately. d. Check the medication administration history on the PCA pump.
B The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump, and should continue to monitor the client closely to determine if further action is needed. The nurse should contact the HCP and document the findings after all data are collected, after the client is stabilized, and if an abnormality still exists after arousing the client.
A home health nurse is visiting a client with type 1 diabetes mellitus. The client tells the nurse that he is not feeling well and has had a "respiratory infection" for the past week, which seems to be getting worse. After interviewing the client, what should be the initial nursing action? a. Document the assessment data. b. Check the client's blood glucose. c. Notify the health care provider (HCP). d. Obtain the client's sputum for culture and sensitivity.
B Uncontrolled hyperglycemia may lead to the production of ketones, thus leading to diabetic ketoacidosis (DKA), a life-threatening condition. The most common precipitating factor for development of DKA is infection. Assessment data should be documented but are not a priority. The HCP may need to be notified if the client's blood glucose is elevated and the client has other symptoms of DKA or a respiratory infection. After determining the client's blood glucose, the nurse should obtain a sputum sample if the client is expectorating yellow, green, or bloody secretions.
The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? (SELECT ALL THAT APPLY) a. Dim lights to prevent overstimulation b. Post a hearing impairment sign on the client's door c. Raise voice to speak more loudly d. Speak directly facing the client e. Tell family to take hearing aids home so they will not be lost
B, D Effective communication is the key to ensuring the safety of clients with hearing impairment. To avoid startling the client, the nurse should approach the client from the front and visibly gain the client's attention before speaking. The nurse should stand directly facing the client so that the speaker's face can be seen clearly (Option 4). Facial expressions and gestures can help make the meaning clear. If clients communicate with sign language, a professional sign language interpreter should be used when needed. The nurse may post a hearing impairment sign at the head of the bed or on the door to inform all caregivers of the safety concern (Option 2). (Option 1) Many clients with hearing impairment will lip-read. The room lights should be on so that the speaker's lips and face are well illuminated. (Option 3) When speaking to a client with hearing loss, speech should be directed toward the least-affected ear and should be at a normal volume. Raising the voice to speak loudly creates a a higher pitch that is harder to understand. (Option 5) The nurse should ensure that any hearing aids are functional and in place before attempting to speak to the client.
A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention? a. Heating pad b. Positioning for comfort c. Rest from pain-aggravating activities d. Stretching exercises
C Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities. (Option 1) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms. (Option 2) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain. (Option 4) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided.
The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? a. Consult with the wound care nurse specialist b. Insert a rectal tube to contain the feces c. Provide perineal skin care with barrier cream d. Use incontinence briefs to protect the skin
C Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option 3).
The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? a. Prepare the child for tracheotomy. b. Prepare to administer epinephrine. c. Prepare the child for a chest radiograph. d. Assist the health care provider with intubation.
C If epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest radiograph to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway. Epinephrine is not used in the treatment of epiglottitis.
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? a. Remove the intravenous (IV) line. b. Run a solution of 5% dextrose in water. c. Run normal saline at a keep-vein-open rate. d. Obtain a culture of the tip of the catheter device removed from the client.
C If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep-vein-open rate pending further health care provider prescriptions. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not remove the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.
During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? a. Document this assessment finding. b. Call another nurse to verify this finding. c. Check skin turgor over the client's sternum. d. Call the health care provider (HCP) to obtain a prescription for fluid replacement.
C In an older adult, skin turgor should be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.
The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching? a. "I will avoid naps later in the day." b. "I will keep the bedroom temperature cool." c. "I will read I bed before trying to go to sleep." d. "I will try to go to bed and wake up at the same time each day."
C Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep- related activities (reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed (Option 3). The nurse should encourage the following healthy sleep habits: Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep. Exercise daily but avoid exercise or strenuous activity within 4- 6 hours of sleep. Avoid going to bed hungry or eating a heavy meal just before bed. Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia.
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? a. Endotracheal intubation b. 100 units of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate
C The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.
A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client? a. Call the client's family. b. Increase the flow rate of oxygen. c. Contact the health care provider (HCP). d. Administer another nitroglycerin tablet.
D For the hospitalized client, nitroglycerin tablets are administered 1 tablet every 5 minutes, for a total of 3 tablets per episode of chest pain, as long as the client maintains a systolic blood pressure of 100 mm Hg or higher. Increasing the flow rate of oxygen may be prescribed by the HCP but would not be the next nursing action. If 3 nitroglycerin tablets do not relieve the client's chest pain, the HCP needs to be notified. It is premature to call the client's family.
A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy. What question from the nurse best evaluates the effectiveness of the prosthesis on body image? a. "Do you feel you are able to engage in sexual activity with your prosthesis?" b. "Do you wear the prosthesis all the time or only when out of the home?" c. "How do you cope with feelings of self-consciousness?" d. "Since receiving your prosthesis, how do you see yourself differently?"
D A breast prosthesis is an artificial appliance that is fitted to the external chest wall or inserted into a female client's undergarments to simulate previous symmetry after a mastectomy or breast trauma. This is an option for clients who are not interested in, or are not candidates for, breast reconstruction surgery. This appliance assists in the promotion of well-being, body image, and sexuality. When evaluating the use of a breast prosthesis, nurses should assess the client for body image disturbance using open-ended questions and therapeutic communication (Option 4). (Option 1) Sexual activity can be affected by the client's overall body image but is not a comprehensive evaluation. (Option 2) How often a prosthesis is used is not an indication of its effect on body image. Not all clients feel the need to wear a prosthesis for a healthy body image. (Option 3) Although assessing coping techniques and effectiveness is important to the client's ability to cope with the loss of a body part, this question does not evaluate the prosthesis' effect on body image. This question also assumes that the client is or should feel self-conscious.
A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? a. "Are you concerned about how the surgery will affect your sexuality?" b. "If you are concerned about infertility, you could always bank your sperm." c. "The cancer is at an early stage. You are going to be fine." d. "What have you and your future spouse discussed about your condition?"
D A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship.
The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? a. Call the surgeon immediately. b. Shake the client gently to arouse. c. Cover the client with a warm blanket. d. Recheck the vital signs in 15 minutes.
D A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. Warm blankets are applied to maintain the client's body temperature. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.
During routine nursing assessment after hypophysectomy, a client complains of thirst and frequent urination. Knowing the expected complications of this surgery, what should the nurse assess next? a. Serum glucose b. Blood pressure c. Respiratory rate d. Urine specific gravity
D After hypophysectomy, temporary diabetes insipidus can result from antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should assess urine specific gravity and notify the health care provider if the result is less than 1.005. Although the remaining options may be components of the assessment, the nurse would next assess urine specific gravity.
The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication? a. Cleanse the site of injection with an alcohol swab and fan the alcohol dry. b. Cleanse the site of injection with an alcohol swab and pat it dry with a tissue. c. Cleanse the site of injection with an alcohol swab and blow the alcohol dry. d. Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry.
D Before administering an intradermal medication, the site of injection is cleaned with an alcohol swab and allowed to dry. The actions in the remaining options are incorrect because they contaminate the site before the administration of the medication.
The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? a. Administer the prescribed as-needed milk of magnesia b. Ask dietary services to add more fruits and vegetables to the client's tray c. Notify the health care provider d. Perform a focused abdominal assessment
D Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client. The nurse can administer the as-needed laxative once it has been determined to be safe. The HCP is contacted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus. (Option 1) The nurse's first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions). (Option 2) The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the HCP has prescribed a new diet. (Option 3) The nurse should further assess the client before contacting the HCP.
A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of shakiness and is diaphoretic. Based on these findings, the nurse should perform which assessment next? a. Lung sounds b. Mental status c. Blood pressure d. Blood glucose level
D Hypoglycemia is one of the potential complications associated with TPN. Shakiness and diaphoresis are signs of hypoglycemia; therefore, based on these findings, the nurse should first check the blood glucose level. Lung sounds may provide information about refeeding syndrome, which is a complication of TPN causing fluid overload. However, the assessment findings do not indicate that this is occurring. Mental status could be affected by hypoglycemia; however, the nurse has enough information to suspect this complication already and therefore should assess the blood glucose before assessing mental status. Blood pressure is not specifically related to the information in the question and the associated complication of TPN.
A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? a. Arrange the client's service dog to come to the health care facility as soon as possible b. Describe the environment in detail so the client can ambulate safely with a cane c. Instruct the UAP to walk beside the client and lead by the hand d. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow
D On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option 1) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option 2) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option 3) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely.
A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? a. Thirst b. Polyuria c. Decreased blood pressure d. Crackles on auscultation of the lungs
D Optimal weight gain when the client is receiving PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention. This can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, peripheral edema, and weight gain more than desired. Thirst and polyuria are associated with hyperglycemia. A decreased blood pressure is likely to be noted in deficient fluid volume.
A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? a. Measure the heart rate on the rhythm strip. b. Administer prescribed nitroglycerin tablets. c. Obtain a 12-lead electrocardiogram immediately. d. Auscultate the client's apical pulse and obtain a blood pressure.
D Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the heart rate on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure.
A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? a. Nasal cannula b. Non-rebreathing mask c. Oxymizer d. Venturi mask
D The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD. (Option 1) The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed. (Option 2) The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation. (Option 3) An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TV's as the inspired oxygen concentration is not guaranteed.
A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? a. Prepare to administer an antidote. b. Draw a sample for type and crossmatch and transfuse the client. c. Draw a sample for an activated partial thromboplastin time (aPTT) level. d. Draw a sample for prothrombin time (PT) and international normalized ratio (INR).
D The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.
The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? a. Check a set of vital signs. b. Order the blood from the blood bank. c. Obtain Y-site blood administration tubing. d. Check to be sure that consent for the transfusion has been signed.
D After receiving a prescription for a blood transfusion, the first action the nurse should take should be to check to be sure that consent for the transfusion has been signed by the client. If the client has consented, the nurse should then check a set of vital signs to be sure there is no contraindication for a transfusion at that time, such as an elevation in temperature. If the vital signs are acceptable, the nurse can then gather supplies to administer the transfusion and order the blood from the blood bank.
