hesi version 2

A nurse working on an Endocrine Unit should see which client first? A. An older client with Addison's disease whose current blood sugar level is 62 mg/dL B. An adult with a blood sugar of 284 mg/dL and a urine output of 350 mL in the last hour C. An adolescent male with type 1 diabetes who is arguing about his insulin dose D. A client taking corticosteroids who has become disoriented in the last two hours

d. a client taking corticosteroids who has become disoriented in the last 2 hours Sudden disorientation can be a sign of a severe complication, such as an infection, high blood sugar, or other metabolic disturbances, especially in a client on corticosteroids. This is potentially the most urgent situation due to the abrupt change in mental status, which could indicate a life-threatening condition.

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the *best* response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down. C. Reassure the spouse that the healthcare provider will notify when to call the children. D. Offer to discuss the client's health status with each of the adult children.

B. Explain that the client will start to lose consciousness and the body systems will slow down. in providing end-of-life care, it's important it communicate honestly and sensitively with family; explaining the expected changes in the client's condition as death approaches can help prepare them for what to expect; symptoms such as loss of consciousness, slowing of body systems, and changes in breathing patterns are common as the end of life nears

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local support HIV support groups D. Observe for adverse drug reactions

B. Monitor for secondary infections In a client with Kaposi's sarcoma and a history of intravenous drug use, monitoring for secondary infections is a crucial aspect of care. Kaposi's sarcoma is often associated with HIV/AIDS, and individuals with compromised immune systems are more susceptible to opportunistic infections. The nurse should closely monitor for signs and symptoms of infections and promptly intervene to prevent complications.

The nurse observes an unlicensed assistive personnel (UAP) applying in alcohol-based hand rub while leaving the client's room after taking vital signs. What action should the nurse take? A. Instruct the UAP to return to the client's room to perform handwashing B. Supervise the UAP and the next client's room to evaluate hand hygiene C. Remind the UAP to continue rubbing the hands together until they are dry D. Advise the UAP to wear gloves when obtaining vital signs for all clients

C. Remind the UAP to continue rubbing the hands together until they are dry Using an alcohol-based hand rub is an acceptable and effective method of hand hygiene in healthcare settings, especially when hands are not visibly soiled. The key to its effectiveness is ensuring that the hands are rubbed together until the alcohol-based solution is completely dry. This practice is in accordance with the guidelines provided by organizations like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) for hand hygiene in healthcare settings.

Which instruction should the nurse provide a pregnant client who is reporting heartburn? A. Eat small meals throughout the day to avoid a full stomach. B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Limit fluids between meals to avoid overdistension of the stomach.

a. eat small meals throughout the day to avoid a full stomach Eating small, frequent meals can help prevent the stomach from becoming overly full, which can exacerbate heartburn. During pregnancy, the digestive process slows down, and the growing uterus can also put pressure on the stomach, leading to increased occurrences of heartburn. Smaller meals are easier to digest and less likely to cause stomach acid to back up into the esophagus, which is what causes the sensation of heartburn.

The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.

c. schedule frequent rest periods Fatigue is a common symptom in clients with CKD, often related to the body's decreased ability to filter waste products effectively, anemia, and other metabolic imbalances associated with kidney disease. Scheduling frequent rest periods can help manage this fatigue, allowing the client to conserve energy and potentially improve their ability to concentrate.

The nurse caring for a child with mononucleosis can expect a child to exhibit which symptoms? A. Positive Epstein-Barr, and malaise B. Ear pain and fever C. Elevated WBC and sedimentation rate D. Increased BUN and serum creatinine

A. positive epstein-barr, and malaise Infectious mononucleosis is typically caused by the Epstein-Barr virus (EBV). A positive test for this virus along with symptoms of malaise (a general feeling of discomfort, illness, or uneasiness) are characteristic of mononucleosis.

The nurse is caring for four clients, Client A, who has emphysema and who's oxygen saturation is 94%. Client B, with the postoperative hemoglobin of 8.2 mg/dL (82 g/L). Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L) and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm3 (14 x 103/L). What intervention should the nurse implement? A. Move Client D into an isolation room 24 hours before surgery B. Increase Client A's oxygen to 4 L a minute per nasal cannula C. Ask the dietitian to add a banana to Client C's breakfast tray D. Verify that Client B has two units of packed cells available

D. Verify that Client B has two units of packed cells available Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L), has a low hemoglobin level indicating anemia. Verifying the availability of packed red blood cells is important to address the potential need for a blood transfusion.

A client with cirrhosis of the liver is admitted with complications related to end-stage liver disease. Which intervention should the nurse implement? (Select all that apply) A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling in edema D. Monitor abdominal girth E Increase oral fluid intake to 1500 mL daily

A. Report serum albumin and globulin levels C. Note signs of swelling in edema D. Monitor abdominal girth A: Monitoring and reporting serum albumin and globulin levels are important in a client with liver cirrhosis. These proteins are synthesized by the liver, and their levels can be altered in liver disease, affecting fluid balance and overall health. C: Cirrhosis of the liver often leads to fluid retention, resulting in swelling and edema, particularly in the abdomen (ascites) and lower extremities. Monitoring for these signs is crucial for assessing the severity of the condition and the effectiveness of treatment. D: In cirrhosis, fluid can accumulate in the abdomen, leading to ascites. Regularly measuring abdominal girth helps in monitoring the extent of ascites and the client's response to treatment.

A male client tells the nurse that he is concerned that he may have a stomach ulcer because he is experiencing heartburn and a dull gnawing pain. Which is the *best* response by the nurse? A. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer. B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food. C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet. D. Advise the client that he needs to seek immediate medical evaluation and treatment for these symptoms.

A. encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer This response is the most appropriate because it encourages the client to seek a professional medical evaluation, which is necessary to accurately diagnose and treat potential ulcers. While the symptoms described by the client could indeed be indicative of an ulcer, they could also be related to other gastrointestinal issues. A complete physical exam by a healthcare provider is necessary to determine the exact cause and appropriate treatment.

To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A. Have an alert family member administer medications B. Encourage taking medications at the same times daily C. Instruct the client so wear glasses when reading labels D. Provide education both verbally and in written format

A. have an alert family member administer medications Having an alert family member administer medications can significantly reduce the risk of medication errors in a client who experiences confusion. An alert and responsible family member can ensure that the correct medications are taken at the right times and in the correct dosages. This approach provides a level of oversight and assistance that is particularly valuable for clients with cognitive challenges.

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A. Urine specific gravity is 1.040 B. Systolic blood pressure decreases 10 points when standing C. The client denies being thirsty D. Skin tenting occurs when the clients forearm is pinched

A. urine specific gravity is 1.040 this indicates concentrated urine and is a significant indicator of dehydration; it reflects the kidney's attempt to conserve water in response to fluid volume deficit

Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy" B. "The dressing over my incision feels like it is too tight" C. "I'm most comfortable when the head of the bed is raised." D. "This IV infusion makes me urinate more often than usual"

B. "The dressing over my incision feels like it is too tight" After a thyroidectomy, it is crucial to monitor for signs of bleeding or hematoma formation, which could lead to compression of the trachea and airway compromise. The client's statement about the dressing feeling too tight raises concern for potential bleeding under the dressing or hematoma formation. This should be investigated immediately to ensure the client's airway remains patent and to prevent further complications.

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate invention? (Select all that apply) A. Sloughing tissue around wound edges B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses. D. Loss of sensation to the left lower extremity E. Weeping serosanguineous fluid from wounds

B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses. D. Loss of sensation to the left lower extremity B: This could indicate the development of compartment syndrome, especially in the case of circumferential burns. Compartment syndrome is a medical emergency where pressure builds up within the muscles, which can lead to muscle and nerve damage. Increased pain and pressure in the context of burns are concerning signs that require urgent evaluation and intervention. C: Change in the quality of peripheral pulses: A change in the quality of peripheral pulses can indicate compromised blood flow to the affected extremities. This can be due to swelling or other circulatory issues related to the burn injury. It's crucial to assess and address any changes in circulation to prevent further complications. D: Loss of sensation to the left lower extremity: Loss of sensation could be an indication of nerve damage or severe tissue damage. This is a concerning sign, especially in the context of full thickness burns, and requires prompt assessment and intervention

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A. Wire legs ever suddenly swollen, red, warm, and painful? B. Does the calf pain occur when walking short distances? C. Did you receive treatment for weeping ulcers on lower legs? D. Have you experienced ankle edema and varicose veins?

B. Does the calf pain occur when walking short distances? Calf pain that occurs during walking and is relieved by rest is a classic symptom of intermittent claudication, a common manifestation of PAD. This type of pain is caused by inadequate blood flow to the muscles during exercise. Asking about the relationship of the pain to physical activity can help assess the severity and impact of PAD.

An older adult who is in his early 70s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living well. Which action should the nurse take? A. Facilitate a family meeting with the palliative care team B. Notify the healthcare provider of the clients wishes C. Place a certified copy of the living well in the client's room D. Alert the nursing staff of the clients do not resuscitate status

B. Notify the healthcare provider of the clients wishes when a living will or advance directive is presented, the nurse should communicate this information to the healthcare provider promptly; the healthcare provider will review the document and make decisions based on the client's expressed wishes

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A. Report any allergies to shellfish or iodine B. Report any painful urination, blood in urine, or fever C. Lay prone for 24 hours after the procedure D. Avoid strenuous activity and sports for at least two weeks

B. Report any painful urination, blood in urine, or fever When preparing a client for a cystoscopy, it's important for the client to report any symptoms such as painful urination, blood in the urine, or fever, which could indicate a potential complication or infection after the procedure. This information is crucial for the healthcare provider to assess the client's post-procedure status and intervene if necessary.

A client is admitted with a diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? A. Depression B. Peripheral neuropathy C. Confusion D. Right lower abdominal pain

C. Confusion Wernicke's syndrome, also known as Wernicke's encephalopathy, is a serious neurological disorder typically caused by a severe thiamine (vitamin B1) deficiency. It is characterized by a classic triad of symptoms: confusion, ataxia (impaired balance or coordination), and ophthalmoplegia (eye movement abnormalities). Confusion is a key feature of this condition and can range from mild disorientation to severe cognitive impairment. The nurse's care plan should focus on addressing the confusion, providing a safe environment, and managing the underlying thiamine deficiency.

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? A. Take prednisone doses before meals on an empty stomach B. Wear sunglasses when exposed to bright sunlight C. If sequential doses are missed, notify the healthcare provider D. Schedule a monthly laboratory visit for a complete food count

C. If sequential doses are missed, notify the healthcare provider It's important for the client to take prednisone as prescribed, but if doses are missed, the healthcare provider should be notified for guidance. Abruptly stopping corticosteroid medications can lead to adrenal insufficiency, so any changes in the medication regimen should be managed under the supervision of the healthcare provider.

The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) A. Insert a bite block B. Restrain the client C. Loosen restrictive clothing D. Note the duration of the seizure E. Ease the client to the floor

C. Loosen restrictive clothing D. Note the duration of the seizure E. Ease the client to the floor C: Loosening clothing around the neck and chest can help facilitate breathing and prevent any restriction that might cause additional harm. D: It's important to keep track of how long the seizure lasts. This information is crucial for medical assessment and treatment decisions. Prolonged seizures (generally those lasting more than 5 minutes) require immediate medical intervention. E: If the client is seated, the nurse should gently guide them to the floor to prevent injury from falling. Place the client on their side, if possible, to help maintain an open airway and allow any secretions to drain from the mouth.

When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past eight hours the client's GCS score has been 14. What does this GCS finding indicate about the client? A. Rehabilitative prognosis is an expected full recovery B. Risk for a reversible cerebral damage related to increased ICP C. Insertion of an ICP monitoring device is necessary D. Neurologically stable without indications of an increased ICP

D. Neurologically stable without indications of an increased ICP The Glasgow Coma Scale (GCS) is used to assess a person's level of consciousness after a traumatic brain injury. It evaluates three aspects: eye opening, verbal response, and motor response. The total score ranges from 3 (deeply unconscious) to 15 (fully alert). A score of 14 is quite high and indicates that the client is neurologically stable and likely does not have severely impaired consciousness. However, it's important to note that the GCS score alone cannot provide a comprehensive picture of the client's overall neurological status or predict their long-term outcome. This score suggests that the client is relatively alert and responsive, which is a positive sign in the context of TBI and post-craniotomy for increased ICP. However, continuous monitoring is still crucial, as conditions can change rapidly.

An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebral vascular accident (CVA). Which action should the nurse include in the plan of care? A. Use hands and arm gestures to improve communication and comprehension B. Provide additional light in the room to promote sensory stimulation C. Place a clock and calendar in the room to improve orientation D. Teach the client to turn his head from side to side to visual scanning

D. Teach the client to turn his head from side to side to visual scanning Unilateral neglect syndrome is a condition in which a person is unaware of or neglects one side of the body or one side of the visual field. To address unilateral neglect, strategies often involve encouraging the individual to actively engage the neglected side. Teaching the client to turn his head from side to side for visual scanning is a specific intervention aimed at increasing awareness of the neglected side.

A male client who fell off a roof has right and left femur fractures and crushing injuries to both ankles. He is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2 mg IV hourly. His vital signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention is most important for the nurse to implement? A. Request the healthcare provider to consider a different analgesic B. Evaluate the traction for amount of tension applied to each extremity C. Determine if client is experiencing cumulative effects of the total dosage D. Assess the extremities for signs of compartment syndrome q2 hours

D. assess the extremities for signs of compartment syndrome q2 hours Given the nature of the injuries (bilateral femur fractures and crushing injuries to both ankles) and the extreme level of pain reported, there is a high risk of developing compartment syndrome. Compartment syndrome is a serious condition where pressure builds up within the muscles, which can decrease blood flow and lead to tissue damage. It is a medical emergency. Signs of compartment syndrome include extreme pain (often out of proportion to the injury), swelling, and changes in sensation. The client's vital signs may also reflect the severity of his pain and the potential for serious complications.

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute. In addition to reporting the findings to the surgeon, which action should the nurse implement *first?* A. Measure and document the client's urinary output. B. Request the client's reserved unit of packed red blood cells. C. Prepare for the placement of central venous catheter. D. Increase the infusion rate of Lactated Ringer's solution.

D. increase the infusion rate of Lactated Ringer's solution The client's symptoms are indicative of acute blood loss and potential hypovolemia. Increasing the infusion rate of IV fluids, such as Lactated Ringer's solution, is a critical first step in managing potential hypovolemic shock. This will help to maintain circulatory volume and perfusion until blood products can be administered or other interventions can be performed.

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the clients compliance with self-care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with a client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration

D. provide written instructions for eye drop administration Providing written instructions is crucial, especially for a client with hearing difficulties. Written instructions for eye drop administration will allow her to review the care steps at her own pace and ensure that she understands how to properly care for her eye post-surgery. This approach is less reliant on her ability to hear and comprehend verbal instructions at the time of discharge.

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? A. Document neurologic changes B. Reduce environmental stimuli C. Administer prescribed neuroleptic D. Review medications for interactions

a. document neurologic changes A sudden change in mental status in a client with a history of TIAs could indicate an acute neurological event, such as a stroke. The nurse should first document the specific changes observed in the client's neurological status. This documentation should include details about the client's level of consciousness, orientation, speech, motor function, and any other relevant neurological signs. This information is crucial for informing immediate medical assessment and intervention.

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

a. drank a glass of water in the past 2 hours Before undergoing a cardiac catheterization, patients are typically required to fast for a certain period (usually 6-12 hours) to reduce the risk of aspiration and to prepare for the possibility of sedation or anesthesia. Drinking water or any fluids within this fasting period can potentially delay or complicate the procedure. The nurse should report this to the healthcare team immediately, as it may impact the timing or approach to the procedure.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. Explain that counseling will be provided to give her information about her cancer risk B. Offer assurance that there are a variety of effective treatments for breast cancer C. Gather additional information about the client's family history for all types of cancer D. Provide information about survival rates for women who have this genetic mutation

a. explain that counseling will be provided to give her information about her cancer risk BRCA1 gene mutation significantly increases the risk of developing breast and ovarian cancer, among other types of cancer. Genetic counseling is a crucial next step for individuals who test positive for this mutation. A genetic counselor can provide detailed information about the specific risks, discuss screening options, and talk about preventive measures. Counseling can also offer support in making decisions about future health care and family planning.

the nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. which recommendations should the nurse provide this client? (SATA) a. inspect skin for redness b. avoid range of motion exercises c. apply alcohol to the stump after bathing d. use a residual limb shrinker e. wash the stump with soap and water

a. inspect skin for redness d. use a residual limb shrinker e. wash the stump with soap and water a: It's important for the client to regularly inspect the skin on the stump for any signs of redness, irritation, or breakdown. Early detection of skin issues is crucial for preventing complications. d: A residual limb shrinker is commonly used after amputation to help shape the stump and reduce swelling, preparing it for a prosthesis fitting. e: Keeping the stump clean is essential to prevent infection. The client should be instructed to gently wash the stump with mild soap and water and to dry it thoroughly.

A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement during the admission process for this client? (SATA) A. Obtain psychiatric and medical admission records B. Hold psychotropic medications until glucose is regulated C. Interview client about reason for admission to hospital D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages

a. obtain psychiatric and medical admission records c. interview client about reason for admission to hospital e. review the list of home medications and dosages a: It's important to have a comprehensive understanding of the client's medical and psychiatric history. This information can provide valuable insights into their current health status, previous treatments, and any potential challenges in managing their care. c: Conducting an interview with the client about their reason for admission is crucial. This helps in gathering information directly from the client about their current health concerns and symptoms, which is important for planning their care. e: Knowing the client's home medications, including any psychotropic and diabetes medications, is essential for continuity of care. This information will help in managing the client's schizophrenia and diabetes, and in determining any necessary adjustments to their medication regimen during the hospital stay.

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Postpone the feeding until the infant's vital signs are stable B. Continue the insertion since this is a typical response C. Insert the feeding tube into the infant's nasal passage D. Pause and monitor for a continued drop of the heart rate

a. postpone the feeding until the infant's vital signs are stable A significant drop in heart rate (bradycardia) during a procedure like orogastric tube insertion is a concerning sign and could indicate vagal nerve stimulation or other distress. The nurse should immediately stop the procedure, remove the tube, and take measures to stabilize the infant's vital signs. Once the infant is stable and the cause of the bradycardia is assessed and addressed, the feeding can be reconsidered.

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease (CKD) C. A restaurant chef who was diagnosed one year ago with hepatitis A D. A salesperson who travels internationally and eats food in foreign countries.

b. an office worker who requires hemodialysis for chronic kidney disease (CKD) Individuals on hemodialysis are at increased risk for hepatitis B due to potential exposure to blood and blood products. The Centers for Disease Control and Prevention (CDC) recommends hepatitis B vaccinations for hemodialysis patients because of their higher risk of exposure to blood-borne pathogens. Regular hemodialysis often involves repeated access to the bloodstream, which can increase the risk of transmission of hepatitis B virus (HBV).

A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.

b. antidepressants usually begin to improve your mood after 2 to 4 weeks It's important for the client to understand that while it's great he's feeling better, most antidepressant medications typically take several weeks (often 2 to 4 weeks) to achieve their full effect. This understanding can help manage expectations and ensure that the client continues to take the medication as prescribed, even if immediate improvements in mood are not observed.

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A. Swaddle the infant in a blanket for sleeping B. Ensure that the infant's crib mattress is firm C. Place the infant in a prone position whenever possible D. Prop the infant with a pillow when in a side-lying position

b. ensure that the infant's crib mattress is firm A firm crib mattress is a key recommendation to reduce the risk of SIDS. The mattress should be covered with a fitted sheet and free from loose bedding, pillows, stuffed animals, and bumper pads, as these can increase the risk of suffocation and overheating, both of which are associated with SIDS.

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements

b. give a dose of regular insulin as prescribed DKA is a serious condition that occurs when the body starts to run out of insulin, leading to high blood sugar levels and the production of ketones. Increased thirst is a symptom of high blood sugar. Administering a dose of regular insulin, as prescribed by their healthcare provider, can help lower blood sugar levels and address the underlying cause of DKA. However, it's essential that the client has a clear understanding of how to adjust insulin dosing and should have a specific plan from their healthcare provider for situations like this.

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Increase the heparin dose and decrease the warfarin dose

b. increase the warfarin dose Since the INR is still 1, which is within the normal range and below the therapeutic target for someone being treated for a PE, the warfarin dose likely needs to be increased. It is important for the INR to reach the therapeutic range to ensure effective long-term anticoagulation.

A client with metabolic syndrome plans to begin an exercise program. Which instruction is most important for the nurse to provide this client? A. Wear long sleeves and a hat when exercising outdoors in direct sunlight B. Monitor blood pressure and heart rate as exercise activity is increased C. Weight bearing exercises are most effective in improving bone strength D. Use hand-held weights to strengthen muscles and build muscle mass

b. monitor blood pressure and heart rate as exercise activity is increased Metabolic syndrome is a cluster of conditions that increases the risk of heart disease, stroke, and type 2 diabetes. These conditions typically include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Monitoring blood pressure and heart rate during exercise is crucial for clients with metabolic syndrome, as they are at an increased risk for cardiovascular complications. Keeping track of these vital signs will help ensure that the client exercises safely and does not overexert themselves, which could lead to adverse events.

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease" D. "You should not worry about the growth tables. They are only averages for children."

c. "his smaller size is probably due to the heart disease" Children with congenital heart defects often experience growth delays. This can be due to various factors, including decreased cardiac output leading to reduced oxygen and nutrient delivery to the body's tissues, increased caloric needs due to the heart condition, or feeding difficulties related to the child's illness. Explaining that the child's smaller size is likely related to his heart condition provides a relevant and medically accurate explanation without placing blame or causing undue worry.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? A. Pain (acute) B. Knowledge deficit C. Anxiety D. Anticipatory grieving

c. anxiety The client's emotional response and expressed concern about their ability to handle pain indicate a high level of anxiety related to the upcoming surgery and anticipated pain. Addressing this anxiety is crucial as it can affect the client's overall experience, including their perception of pain and their recovery process.

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill". What question should the nurse ask the client next? A. When did these voices begin? B. Have you taken any hallucinogens? C. Are you planning to obey the voices? D. Do you believe the voices are real?

c. are you planning to obey the voices? This question is critical because it assesses the client's risk of harm to themselves or others, which is a primary concern in this situation. Understanding whether the client has intentions to act on these auditory hallucinations is crucial for determining the immediate need for safety interventions.

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? A. Do you often have feelings of sadness? B. Are you having problems concentrating? C. Have you thought about taking your life? D. What problems are you facing right now?

c. have you thought about taking your life? This question directly addresses the risk of suicide, which is a critical safety concern. When a client mentions thoughts of self-harm, it's essential to assess for suicidal ideation, including any specific plans or intentions to act on these thoughts. Understanding the severity and immediacy of the risk will guide the necessary interventions and the urgency of the response.

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? A. The census report has not been completed B. A client's wife has asked to speak with the charge nurse C. One staff member has not reported to work D. A bucket of water was spilled in the hallway

d. a bucket of water was spilled in the hallway A spill in the hallway poses an immediate risk of falls and injuries to patients, staff, and visitors. Falls in healthcare settings can lead to significant harm, especially for vulnerable patient populations. Therefore, the spilled water should be cleaned up promptly to maintain a safe environmen

The nurse assesses a child in 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome? Click spot right on toes on injured foot. The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask and requiring staff to observe airborne, as well as standard precautions? A. A female adolescent admitted with multiple genital herpes simplex II lesions B. An older client with scabies who is admitted from an extended care facility C. Twin siblings admitted with scarlet fever that is complicated with pneumonia D. A client with a positive Mantoux and sputum cultures results positive for AFB

d. a client with a positive mantoux and sputum cultures results positive for AFB A positive Mantoux test (tuberculin skin test) along with sputum cultures positive for Acid-Fast Bacilli (AFB) are indicative of tuberculosis (TB). Tuberculosis is a highly contagious bacterial infection that primarily affects the lungs and is spread through airborne particles. Clients with suspected or confirmed TB should be placed in a room with negative airflow to prevent the spread of infectious particles, and healthcare personnel should use particulate respirator masks to protect themselves from inhaling the bacteria. Airborne and standard precautions are necessary to prevent the spread of TB.

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Signs of addiction to opioid pain medication B. Information about non-pharmaceutical pain relief measures C. Referral for social services for the child and family D. Instructions about how much fluid the child should drink

d. instructions about how much fluid the child should drink Hydration is crucial in managing sickle cell anemia. Adequate fluid intake helps prevent sickling of red blood cells by reducing blood viscosity and maintaining proper blood flow. This can help minimize the risk of sickle cell crises, which are painful episodes caused by the obstruction of blood flow due to sickled cells. Educating the parents on the importance of ensuring the child drinks enough fluids is essential for the ongoing management of the condition.

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Explain the purpose of each medication the client is currently taking C. Ask the client to write feelings in a journal and then review it together D. Play a board game with the client and begin talking about stressors

d. play a board game with the client and begin talking about stressors Playing a board game can be an excellent way to build rapport with a child. It creates a relaxed and engaging environment that can make the child feel more comfortable. During the game, the nurse can initiate conversation about stressors in a non-threatening manner. This setting is more likely to encourage the child to open up and discuss their feelings, thoughts, and potential coping strategies.

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mg/2.4 mL." How many mL should the nurse administer?

0.2

An adolescent receives a prescription for an injection of S-matriptan succinate 4mg subcutaneously for a migraine headache. Using a vial labeled, 6mg/0.5mL, how many mL should the nurse administer?

0.33 ml

A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/mL ampules. How many mL should the nurse administer?

0.38 mL

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? 1. Obtain blood glucose level 2. Verify the insulin prescription 3. Draw insulin into insulin syringe 4. Clean the selected site

1. verify the insulin prescription 2. obtain blood glucose level 3. draw insulin into insulin syringe 4. clean the selected site This is the first step to ensure the client is using the correct type and dose of insulin as prescribed by the healthcare provider. Before administering insulin, the client needs to know their current blood glucose level to determine the appropriate dose of insulin based on the sliding scale. Once the dose is determined based on the blood glucose reading and the sliding scale, the next step is to draw the correct amount of insulin into the syringe. The injection site should be cleaned with an alcohol swab before administering the insulin to reduce the risk of infection.

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to how many mL/hour?

18

A client is receiving a nitroglycerin infusion at 20 mcg/min. The pharmacy dispenses an IV solution of nitroglycerin 75 mg in 250 D5W. The nurse should program the infusion pump to deliver how many mL/hr?

4 mL/hr

The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest extension C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute

A. Diminished breath sounds over the trocar insertion site Diminished breath sounds over the site of a thoracentesis could indicate a pneumothorax (collapsed lung), a potential complication of the procedure. This finding necessitates immediate evaluation and intervention by the healthcare provider to prevent further respiratory compromise.

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? A. Prepare the client for spinal anesthesia B. Empty the client's bladder using a straight catheter C. Convey to the client that birth is imminent D. Prepare the coach to accompany the client to delivery

B. empty the client's bladder using a straight catheter During the second stage of labor, which is the stage where the baby is delivered, it's important to ensure that the bladder is empty. A full bladder can impede the progress of labor and the descent of the fetus. Emptying the bladder can provide more space for the baby to descend and can make the process of labor more efficient and potentially more comfortable for the mother.

The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the nurse take first? A. Instruct the UAP to raise the bed level B. Provide gloves for the UAP to apply C. Offer to help reposition the client D. Place the side rails in an up position

C. offer to help reposition the client

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information and a uniform packet. Which action should the nurse take? A. File a detailed incident report with the specific hiring facility B. Why did the colleague that their actions are unprofessional C. Comment anonymously about the action on a staff discussion board D. Communicate the colleague's actions to the unit charge nurse

D. communicate the colleague's actions to the unit charge nurse it is important to address concerns about potential breaches of client confidentiality and security of client information within the organization; the charge nurse can then take appropriate action, such as providing additional education on EHR security or addressing any policy violations

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (SATA) A. Gently close the eyes B. remove resuscitation equipment from the room C. Take out dentures and place in a labeled cup D. Apply a body shroud E. Place a small pillow under the head

a. gently close eyes b. remove resuscitation equipment from the room e. place a small pillow under the head

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

red bin

When conducting diet teaching for a client who is on a postoperative full fluid diet, which foods should the nurse encourage the client to eat? A. Lentils B. Potato soap C. Tea D. Cheese E. Whole grain breads

B. Potato soap C. Tea B: As long as it is blended or pureed to a liquid consistency without solid pieces, potato soup is suitable for a full fluid diet. C: Tea is a clear liquid and is appropriate for a full fluid diet. It's important to ensure that the tea does not contain any solid additives like leaves or herbs.

The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? (SATA) A. blurred vision B: headache C. Lack of appetite D. Urinary frequency E. Chills and fever F. Swollen hands

a. blurred vision b. headache f. swollen hands a: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia and should be reported. b: Persistent, severe headaches that are not relieved by over-the-counter medications can be associated with preeclampsia. f: Swelling, particularly sudden or severe swelling in the hands, face, or feet (edema), is a common symptom of preeclampsia and should be reported.

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (SATA) A. Canned fruit in heavy syrup B. Natural whole almonds C. Plain, air-popped popcorn D. Lightly salted potato chips E. Cheddar cheese cubes

b. natural, whole almonds c. plain, air-popped popcorn b: Almonds are a good source of healthy fats, fiber, and protein. They are a nutritious snack option. c: Plain, air-popped popcorn is a low-calorie, whole-grain snack that can be a healthier alternative to other snacks.

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest. B. These early signs of an infection may require medical treatment with antibiotics C. These are common side effects of the vaccines and will resolve in a few days D. Plans to move into the dormitory need to be postponed for at least a semester

A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest. Fatigue and visual problems can be symptoms of an MS flare-up or exacerbation. Certain vaccines, stress, or other health changes can potentially trigger a relapse in some individuals with MS. While vaccines are generally safe for individuals with MS, any unusual symptoms following immunization should be closely monitored. The nurse should recommend extra rest and also advise the patient to contact her healthcare provider to discuss these symptoms, as they may require medical evaluation.

The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience a decreased level of consciousness and the pupils do not respond equally to light. Which vital signs changes indicate the client is manifesting Cushing's triad? A. Blood pressure of 80/40 mmHg, weak heart rate of 40 beats/minute, Cheyne-Stokes respirations of 10 breaths/minute B. Blood pressure 180/120 mmHg, weak heart rate of 92 beats/minute, Kussmaul respirations of 18 breaths/minute C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/min, respirations of 30 breaths/minute with apneic episodes D. Blood pressure of 90/60 mmHg, strong heart rate of 60 beats/minute, eupneic respirations of 16 breaths/minute

C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/min, respirations of 30 breaths/minute with apneic episodes Cushing's triad is a classic set of vital sign changes associated with increased intracranial pressure (ICP) and potential brain herniation. It consists of the following: Hypertension (elevated systolic blood pressure): In response to increased ICP, the body may attempt to maintain cerebral perfusion pressure by increasing blood pressure. Bradycardia (slow heart rate): A compensatory response to increased ICP, the heart rate may decrease as a result of the pressure on the brainstem. Irregular and abnormal respirations: This can include Cheyne-Stokes respirations or apneic episodes, which occur due to pressure on the respiratory centers in the brainstem. Option C describes vital sign changes consistent with Cushing's triad, indicating increased intracranial pressure. It is crucial to recognize these signs promptly and seek immediate medical intervention to reduce intracranial pressure and prevent brain herniation.

The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of a FES? A. Confusion, restlessness B. Petechial rash C. Tachycardia, fever D. Pulmonary crackles

a. confusion, restlessness Fat embolism syndrome is a serious complication that can occur after long bone fractures, such as a femur fracture. It typically arises when fat globules are released into the bloodstream and become lodged in the lung vasculature and other organs. One of the earliest manifestations of FES is a change in mental status, which can include symptoms such as confusion, restlessness, or a decreased level of consciousness. These changes are thought to be due to the cerebral involvement of fat emboli.

An adult woman who was recently diagnosed with type 2 DM is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modifications should the nurse recommend? Labs: Creatinine 1.0 mg/dL BUN 16 mg/dl Diagnostics: Total cholesterol 250 mg/dl LDL 175 mg/dl HDL 35 mg/dl Triglyceride 250 mg/dl Flowsheets: Glucose 150 mg/dl A1c 9% A. Decrease processed carbohydrate in diet B. Eliminate alcohol intake except for special occasions C. Restrict protein to 10% of total calories in diet D. Increase dietary fiber such as whole grains E. Reduce daily fat intake to 10% of total calories

a. decrease processed carbohydrate in diet d. increase dietary fiber such as whole grain e. reduce daily fat intake to 10% of total calories a: High blood glucose levels (glucose 150 mg/dl and A1c 9%) suggest a need to control carbohydrate intake. Reducing processed carbohydrates and focusing on complex carbohydrates with a lower glycemic index can help manage blood sugar levels. d: Increasing dietary fiber, especially from whole grains, can help stabilize blood sugar levels and improve lipid profiles. e: Given the elevated total cholesterol (250 mg/dl), LDL (175 mg/dl), HDL (35 mg/dl), and triglycerides (250 mg/dl), it is advisable to recommend reducing daily fat intake. The client should focus on healthy fats and limit saturated and trans fats.

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? A. Ensure adequate IV and oral fluid intake B. Provide ice packs to major joint areas C. Space analgesics to prevent addiction to narcotics D. Re-enforce the importance of nutritional balance

a. ensure adequate IV and oral fluid intake In the care of a client experiencing a sickle cell crisis, the most important intervention is to ensure adequate hydration. Sickle cell crises can be triggered or exacerbated by dehydration, and maintaining proper fluid intake helps to prevent the sickling of red blood cells and the associated pain and complications. Adequate hydration is essential for improving blood flow and oxygen delivery to tissues.

Which type of leukocyte is involved with allergic responses and the destruction of parasitic worms? A. Eosinophils B. Neutrophils C. Lymphocytes D. Monocytes

a. eosinophils Eosinophils are a type of leukocyte (white blood cell) that is primarily involved in allergic responses and the destruction of parasitic worms. They are particularly important in the immune response against parasitic infections and play a role in the inflammatory response associated with allergies and asthma. Eosinophils contain granules filled with enzymes and proteins that are effective in combating parasites and modulating allergic reactions.

Which intervention is most important for the nurse to include in the plan of care for a client who is being mechanically ventilated and is receiving continuous enteral feedings? A. Maintain the head of the bed elevated at 45 degrees B. Check the feeding tube placement q8hours C. Assess the gastric residual volume q4hours D. Obtain a chest x-ray PRN for adventitious lung sounds

a. maintain the head of the bed elevated at 45 degrees Elevating the head of the bed to at least 30 to 45 degrees helps to reduce the risk of aspiration, which is a significant concern in patients receiving enteral feedings, particularly those who are mechanically ventilated. Aspiration can lead to pneumonia and other serious complications.

Which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partners B. Postmenopausal for 5 years with intermittent vaginal spotting C. Taking birth control pills after 40 years of age D. Multiparous delivery of infants more than 9 pounds

a. history of unprotected sex with multiple partners The highest risk factor for cervical cancer among the options provided is a history of unprotected sex with multiple partners. This is because certain strains of the human papillomavirus (HPV) are the primary cause of cervical cancer, and having multiple sexual partners without protection increases the risk of HPV exposure. HPV is a sexually transmitted infection that can lead to cervical cancer over time. Therefore, women with a history of unprotected sex with multiple partners are at an increased risk of developing cervical cancer and should be closely monitored and screened for cervical abnormalities. Regular cervical cancer screenings, such as Pap smears and HPV testing, are essential for early detection and prevention.

The nurse is caring for a client admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the client screaming. The client tells the nurse that the pain is "sharp, like something inside is ripping and tearing." The client also reports dizziness. Which of the following is the likely cause? A. Impending rupture of the aneurysm B. The client is having a panic attack C. Clotting of the aneurysm D. The client is hallucinating from the opioids

a. impending rupture of the aneurysm The sudden onset of severe, tearing, and ripping pain in the chest or back, often described as "ripping apart," is a classic symptom of aortic dissection, which can be caused by an aortic aneurysm. Aortic dissection is a life-threatening emergency in which there is a separation of the layers of the aortic wall, creating a false lumen within the vessel. The pain is usually excruciating and is often accompanied by other symptoms like dizziness.

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? A. Initiate seizure precautions B. Assess neurological status every 8 hours C. Limit oral water intake D. Administer a hypertonic IV fluids as prescribed

a. initiate seizure precautions In a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia, the most important intervention to protect the client from injury is to initiate seizure precautions. Hyponatremia can lead to neurological symptoms and seizures due to the imbalance in electrolytes, specifically the low sodium levels

The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? A. Measure ankle circumference B. Record usual eating patterns C. Evaluate for muscle cramping D. Document abdominal girth

a. measure ankle circumference This intervention is relevant because the presence of crackles on auscultation and elevated blood pressure in a client with heart disease suggests fluid overload or heart failure. Measuring ankle circumference can help assess for peripheral edema, which is a common sign of fluid retention and heart failure. Monitoring changes in ankle circumference can provide valuable information about the client's fluid status and the effectiveness of treatments.

The charge nurse in an extended care facility in organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? A. Measure the client's body weight each morning B. Establish blood pressure parameters for client monitoring C. Evaluate a staff member providing wound care D. Evaluate client teaching through return demonstration

a. measure the client's body weight each morning Measuring a client's body weight is a routine task that falls well within the scope of practice for a practical nurse. It does not require the advanced assessment skills or clinical judgment that a registered nurse (RN) would need to use.

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Move the client to a quiet place on the unit B. Encourage the client to use the punching bag C. Use firmness and direct the client to sit for a while D. Suggest to the client that he take a walk

a. move the client to a quiet place on the unit This approach aims to reduce environmental stimuli that could exacerbate the client's agitation or delusions. A quieter, more controlled environment can help in calming the client and reducing the intensity of his symptoms. It's important to maintain a safe environment for both the client and others on the unit.

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He found wandering into another client's room and is returned to his room by the unlicensed assistive personnel (UAP). Which actions should the nurse take? A. Review the client's most recent serum electrolyte values B. Assign the UAP to re-assess the client's risk for falls C. Report mental status changes to the healthcare provider D. Apply soft upper limb restraints and raise all four bed rails E. Assess the client's breath sounds and oxygen saturation

a. review the client's most recent serum electrolyte values c. report mental status changes to the healthcare provider e. assess the client's breath sounds and oxygen saturation a: This is a crucial step to rule out electrolyte imbalances, which can lead to altered mental status. Abnormal electrolyte levels (e.g., sodium, potassium) could contribute to confusion. c: The healthcare provider needs to be informed of the client's altered mental status to determine the appropriate diagnostic and treatment plan. e: Reduced oxygen levels or impaired respiratory function can also lead to confusion. Assessing breath sounds and oxygen saturation helps identify any respiratory issues.

An older male client was successfully treated for Herpes zoster (shingles) with an antiviral medication report that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? A. Review the medication record to determine when the last analgesic was administered B. Reassure the client that the infection is resolved, and the pain should soon disappear C. Teach the client about the importance of completing the full course of antiviral medication D. Contact the healthcare provider about the need to resume the client's antiviral medication

a. review the medication record to determine when the last analgesic was administered The older male client who has been successfully treated for Herpes zoster (shingles) and is now experiencing pain on his trunk may be experiencing postherpetic neuralgia (PHN). PHN is a common complication of shingles and can cause persistent pain in the area where the shingles rash was located. To manage PHN pain, analgesic medications are often prescribed.

Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions? A. Sugar cookies B. Pizza C. Chocolate milkshake D. Tacos

a. sugar cookies For a school-age boy with gastroesophageal reflux (GERD), selecting sugar cookies as a snack indicates an understanding of dietary restrictions. Sugar cookies are typically lower in fat and acidity compared to the other options listed (pizza, chocolate milkshake, and tacos), making them a milder choice for someone with GERD. Avoiding high-fat, spicy, acidic, and greasy foods is often recommended for individuals with GERD to help manage symptoms, and sugar cookies are a relatively safe option in this context. However, portion control and overall dietary choices should also be considered.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A. Assist the client to lie back in bed B. Administer a nebulizer treatment C. Call for an Ambu resuscitation bag D. Increase oxygen to 6 liters/minute

b. administer a nebulizer treatment Asthma exacerbations are typically managed with fast-acting bronchodilators, often delivered via a nebulizer. This treatment can help open the airways, reduce wheezing, and improve breathing. Since the client is already on supplemental oxygen and is showing signs of respiratory distress, administering a bronchodilator could be crucial in alleviating these symptoms.

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers B. Children usually resume their toileting behaviors when they leave the hospital C. A potty chair should be brought from home so he can maintain his toileting skills D. A retraining program will need to be initiated when the child returns home

b. children usually resume their toileting behaviors when they leave the hospital It is common for young children to experience temporary regression in toileting behaviors during stressful situations, such as hospitalization. The nurse should reassure the parents that this regression is often temporary, and children typically resume their toileting behaviors once they leave the hospital and return to a familiar and less stressful environment.

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take? A. Assess client for polyuria and polyphagia B. Give the client a glass of orange juice C. Notify the healthcare provider D. Collect a blood sample for hemoglobin A1c

b. give the client a glass of orange juice In a client with a fingerstick glucose of 35 mg/dL who is alert and diaphoretic, the priority action is to provide a rapid source of glucose to raise the blood sugar level promptly. Offering the client a glass of orange juice or another source of fast-acting carbohydrate, such as a glucose gel or a few glucose tablets, can help alleviate hypoglycemic symptoms and prevent further deterioration in blood glucose levels.

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? A. Peripheral pallor of the skin B. increased pulse rate C. clenched fists D. restlessness E. Increased temperature F. Increased respiratory rate

b. increased pulse rate c. clenched fists d. restlessness f. increase respiratory rate b: An increased heart rate can be a sign of pain, especially in infants who cannot verbalize their discomfort. c: Infants often exhibit physical signs of discomfort when in pain, and clenched fists can be one such indicator. d: Restlessness or inability to settle can indicate that the infant is uncomfortable or in pain. f: Like an increased pulse rate, an elevated respiratory rate can also be a sign of pain or distress in infants.

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care? A. Determine if the client is over-hydrating to feel satiated B. Maintain the client on an NPO status C. Encourage positive self-accolades for dietary adherence D. Administer daily vitamin supplements

b. maintain the client on an NPO status Given the symptoms of vomiting and intolerance to oral intake, placing the client on NPO (nil per os, or nothing by mouth) status initially is a prudent step. This approach allows the gastrointestinal tract to rest and can help prevent further vomiting and complications. During this time, the healthcare team can assess and address the underlying causes of the client's intolerance to food and liquids.

After the risks and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart beating during the procedure. What action should the nurse take? A. Postpone the procedure until the client understands the risks and benefits B. Notify the healthcare provider of the client's lack of understanding C. Explain the procedure again in detail and clarify any misconceptions D. Call the client's next of kin and have them provide verbal consent

b. notify the healthcare provider of the client's lack of understanding It's important that the client fully understands the procedure, including its risks and benefits, before giving informed consent. The client's question indicates a potential misunderstanding or lack of information about the nature of cardiac catheterization, which does not involve "wires keeping the heart beating" but rather involves the insertion of a catheter to diagnose and sometimes treat cardiovascular conditions.

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposal B. Place the implant in a lead container using long-handled forceps C. Reinsert the implant into the vagina D. Call the radiology department

b. place the implant in a lead container using long-handled forceps In the event of a dislodged internal radiation implant, it is crucial to handle the situation safely to minimize exposure to radiation. The nurse should not touch the implant directly. Instead, long-handled forceps should be used to carefully pick up the implant and place it in a lead container, which is designed to shield others from the radiation. The nurse should also limit the time spent handling the implant and maintain as much distance as possible to reduce radiation exposure.

The nurse is providing care for a child who is brought to the emergency department a few days after a laceration to the leg from a barbed wire fence. The child has not received any tetanus immunizations and is manifesting early signs of muscular rigidity with spasms and jaw clenching or trismus. Which intervention should be the nurse's highest priority for this child? A. Suction oropharyngeal secretions B. Prepare for intubation with mechanical ventilation C. Minimize stimulation from sound, light, and touch D. Monitor IV infusions

b. prepare for intubation with mechanical ventilation The child is exhibiting symptoms of tetanus (also known as lockjaw), which is a severe and potentially life-threatening condition caused by the toxin of the bacterium Clostridium tetani. Tetanus can lead to muscle rigidity, spasms, and difficulty in breathing due to muscle stiffness, including the muscles needed for ventilation.

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? A. Monitor your blood pressure regularly B. Report unusual bruising or bleeding C. Elevate your feet if swelling occurs D. Check your pulse rate every day

b. report unusual bruising or bleeding When teaching a client about dabigatran etexilate, an anticoagulant medication used to prevent blood clots in conditions like atrial fibrillation, it is essential to emphasize the importance of reporting any unusual bruising or bleeding to their healthcare provider. This is because anticoagulants like dabigatran can increase the risk of bleeding, and early detection of any abnormal bleeding can help prevent serious complications.

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum creatinine of 4.5 mg/dL C. Serum sodium of 145 mEq/L D. White blood cell count of 12,000mm3

b. serum creatinine of 4.5 mg/dL A serum creatinine level of 4.5 mg/dL is a critical finding and requires the most immediate intervention by the nurse. Elevated creatinine levels are indicative of impaired kidney function, and a level of 4.5 mg/dL suggests severe renal dysfunction. Ciprofloxacin is primarily excreted by the kidneys, and with impaired kidney function, the drug may not be properly eliminated from the body. This can lead to drug accumulation, potential toxicity, and a higher risk of adverse effects.

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement?A. Bring a bedside commode to the client B. Stand on the client's right side as he walks C. Walk directly behind the client to prevent a fall D. Give the client a cane to hold in his right hand

b. stand on the client's right side as he walks The nurse should stand on the client's weaker side (right side, in this case) to provide support and assistance as needed. The nurse can offer a steadying hand or arm and be ready to assist if the client starts to lose balance.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (SATA) A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. A low sodium diet tray was brought to the room E. The client is lying in a supine position in bed

c. a full pitcher of water is on the bedside table e. the client is lying in a supine position in bed c: Clients with heart failure often need fluid restriction to prevent fluid overload, which can exacerbate heart failure symptoms. Having a full pitcher of water readily accessible may encourage excessive fluid intake. e: For a client with heart failure and COPD, lying flat can exacerbate breathing difficulties due to increased pressure on the chest and diaphragm. It is generally advised to keep such clients in a semi-upright position, like Fowler's position, to ease breathing.

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Sterile vaginal exam revealing 3cm dilation C. Biophysical profile results showing oligohydramnios D. Fetal heart tones located in upper right quadrants

c. biophysical profile results showing oligohydramnios Oligohydramnios, a condition characterized by low amniotic fluid, can indicate potential complications such as fetal distress or placental insufficiency. It can increase the risk of cord compression during contractions, which might lead to fetal hypoxia. This finding is significant and should be communicated to the healthcare provider prior to the start of oxytocin, as it may alter the management plan for labor induction.

A 62-year-old male client tells the nurse that he has a high-density lipoprotein (HDL) level of 85 mg/dl. Which action should the nurse take? A. Encourage the client to reduce consumption of fatty foods B. Ask the client about hereditary cardiac risk factors C. Confirm that this value is helpful in reducing cardiac risk D. Explain that the client may need medication therapy

c. confirm that this value is helpful in reducing cardiac risk An HDL (high-density lipoprotein) level of 85 mg/dL is considered a high level, which is generally favorable for cardiovascular health. HDL is often referred to as "good" cholesterol because it helps remove excess cholesterol from the blood vessels, reducing the risk of plaque buildup in arteries. The nurse's action should be to confirm that this high HDL level is indeed beneficial in reducing cardiac risk. It's essential to provide positive reinforcement for healthy cholesterol levels and encourage the client to maintain a heart-healthy lifestyle. There is typically no need for medication therapy to lower HDL levels when they are within the normal or high range.

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A. Provide a list of alternative activities that are less likely to cause the child to experience fatigue B. Explain that their child is too young to understand the risks associated with swimming C. Encourage the parents to allow the child to continue attending swimming lessons with supervision D. Suggest that the child be encouraged to participate in a team sport to encourage socialization

c. encourage the parents to allow the child to continue attending swimming lessons with supervision Children with Duchenne muscular dystrophy (DMD) should be encouraged to stay active and participate in physical activities to the extent possible, while taking appropriate precautions. Swimming is often considered a beneficial activity for children with DMD because it is low-impact and can help improve strength, flexibility, and cardiovascular fitness.

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A. Instruct the PN that this technique promotes infection in elderly females B. Recommend a complete bath to cleanse the perineal area more fully C. Evaluate the effectiveness of this measure to stimulate client voiding D. Suggest contacting the healthcare provider for a prescription for catheter insertion

c. evaluate the effectiveness of this measure to stimulate client voiding Warm water over the perineal area is a common non-invasive technique used to stimulate voiding, especially in clients who may have difficulty initiating urination. It can help relax the bladder and urethral sphincter muscles, making it easier to void.

A female child is brought to the emergency department after awakening with a bark-like cough and stridor. upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? A. Prepare for emergency tracheotomy B. Assess the child for dehydration C. Examine oropharyngeal area for foreign body D. Collect midstream urine specimen

c. examine oropharyngeal area for foreign body However, it's important to note that examining the oropharyngeal area in cases of suspected epiglottitis should be done with extreme caution and typically by a trained healthcare provider (like an ENT specialist or pediatrician) in a setting where emergency airway management can be performed. Manipulating the throat in epiglottitis can provoke complete airway obstruction.

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped, and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A. Assess for discomfort when procedure is completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour cleansing solution onto the sterile cloth field

c. instruct the client to keep hands under the sterile field This intervention is crucial because maintaining the sterility of the field is important to prevent infection during the debridement procedure. A mildly confused client may not fully understand the importance of not touching or disrupting the sterile field. By instructing the client to keep their hands under the sterile field, the nurse can help minimize the risk of contaminating the area, thereby protecting the client from potential infection.

A new nurse is preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? A. Suggest the nurse use a 20-gauge needle B. Direct the nurse to change the IV tubing C. Instruct the nurse to remove the needle D. Prompt the nurse to apply povidone to the site

c. instruct the nurse to remove the needle Irrigation of an intravenous catheter typically does not involve attaching a needle to the IV tubing. If a nurse is attempting to irrigate an intravenous catheter and has attached a needle, it is essential to instruct the nurse to remove the needle immediately. The needle is not needed for irrigation and can pose a risk to the patient.

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? A. Blood pressure of 122/74 mmHg B. White blood count of 19,000mm3 C. Moderate amount of foul-smelling lochia D. Oral temperature of 100.2F

c. moderate amount of foul-smelling lochia Foul-smelling lochia (the vaginal discharge after giving birth) is a key sign of infection in the postpartum period. Normal lochia has a mild odor and should not be foul-smelling. Foul-smelling lochia can indicate a bacterial infection in the uterus, which is a significant concern after childbirth.

One day after abdominal surgery, a client with obesity reports pain and heaviness in the right calf. Which action should the nurse implement?A. Encourage ambulation in the room B. Palpate the femoral pulse C. Observe for unilateral swelling D. Apply a warm compress to the area

c. observe for unilateral swelling The most appropriate action for the nurse to take in this situation is to observe for unilateral swelling. If the client's leg is indeed swollen, it is essential to report this finding to the healthcare provider promptly. DVT is a medical emergency, and early detection and intervention are crucial to prevent complications such as pulmonary embolism.

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Start progressive mobilization B. Request a nutrition consult C. Request a wound culture and sensitivity D. Force oral fluids

c. request a wound culture and sensitivity In a postoperative wound with signs of infection, such as redness, swelling, purulent drainage, and a foul odor, the most important action for the nurse to take is to request a wound culture and sensitivity. This is critical for identifying the specific microorganisms causing the infection and determining the most effective antibiotic treatment.

Following a total knee replacement, a client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond? A. Discuss necessary fluid restrictions as well as food restrictions B. Explain that no dietary restrictions are needed with warfarin C. Review teaching about the effects of foods rich in Vitamin K D. Provide a written list of additional foods high in potassium K

c. review teaching about the effects of foods rich in vitamin K Warfarin is an anticoagulant medication that works by inhibiting Vitamin K-dependent clotting factors. Therefore, it's essential for clients taking warfarin to be aware of foods that are rich in Vitamin K and their potential impact on the medication's effectiveness. Foods high in potassium, such as bananas and melon, are not typically a concern with warfarin. Potassium and Vitamin K are different nutrients, and the client's statement about avoiding potassium-rich foods is unrelated to warfarin therapy.

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A. Notify the healthcare provider of the need to reposition the catheter B. Remove the catheter and apply direct pressure for 5 minutes C. Secure the catheter using aseptic techniques D. Initiate intravenous fluids as prescribed

c. secure the catheter using aspectic techniques The tip of a central venous catheter being located in the superior vena cava is actually the correct and desired position. This location ensures that infused fluids or medications are quickly diluted and distributed by the large blood volume in the vena cava, reducing the risk of irritation or damage to the vessel walls.

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. What action should the nurse implement first? A. Provide a printed health care assessment form B. Ask the family member to answer the questions C. Defer the health history until the client is less anxious D. Assess the surroundings for noise and distractions

d. assess the surroundings for noise and distractions When an older client is having difficulty responding to questions in a clear manner, it's essential to assess the immediate environment for potential sources of noise and distractions. Older adults may have difficulty hearing or focusing due to sensory impairments or cognitive changes, so reducing environmental distractions can help improve communication.

A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. the client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A. Explain to the family that they must accept their mother's decision B. Discuss success of clinical trials and ask the client to consider participating for one month C. Ask the client with her children present if she fully understands the decision, she has made D. Explore the client's decision to refuse treatment and offer support.

d. explore the client's decision to refuse treatment and offer support In this situation, the nurse should respect the client's autonomy and decision-making capacity. The client has the right to make decisions about her own medical care, including whether to participate in a clinical trial or refuse further treatments. It is not the nurse's role to try to convince the client to change her decision, especially if she has made an informed and voluntary choice. The nurse should engage in open and nonjudgmental communication with the client and explore her reasons for refusing treatment. This can help the nurse understand the client's perspective, provide emotional support, and ensure that the client's decision is based on well-informed choices. Additionally, the nurse can offer information about palliative care options and supportive services that can enhance the client's quality of life and address her needs.

A client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goose bumps". The nurse should assess for which trigger? A. Loud hallway noise B. Frequent cough C. Fever D. Full bladder

d. full bladder In a client with a C-6 spinal cord injury who suddenly reports a severe, pounding headache and exhibits observable piloerection or "goose bumps," a full bladder is a common trigger for autonomic dysreflexia (AD). AD is a potentially life-threatening condition that can occur in individuals with spinal cord injuries at or above the T6 level.

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Initiate the dosage lockout mechanism on the PCA pump B. Assess the client's ability to use a numeric pain scale C. Assess the abdomen for bowel sounds D. Instruct the client to use the medication before the pain becomes severe

d. instruct the client to use the medication before the pain becomes severe This is crucial because effective pain management using a PCA pump relies on the client's understanding of how to use the pump proactively. By using the medication before the pain becomes severe, the client can maintain better control over their pain levels, leading to more effective pain management. Morphine and other opioids are more effective in preventing pain from becoming severe than in treating pain once it has become intense.

The nurse should be most concerned about risk for injury (falls) after administering which medication? A. Pantoprazole B. Famotidine C. Clarithromycin D. Promethazine

d. promethazine Promethazine is an antihistamine with sedative properties and is often used for its antiemetic (anti-nausea) effects. One of the common side effects of promethazine is sedation or drowsiness, which can increase the risk of falls, particularly in older adults or those with mobility issues. Patients taking promethazine should be monitored for dizziness, sedation, and confusion, all of which can contribute to an increased risk of falling.

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. History of smoking over the past 6 months B. Sleep patterns during the previous few weeks C. Activity level prior to onset of symptoms D. Recent compliance with prescribed medications

d. recent compliance with prescribed medications For a client with chronic emphysema, understanding their recent medication compliance is crucial, especially in the context of acute symptoms like weakness, palpitations, and vomiting. These symptoms could be related to medication issues such as overuse, underuse, or interactions, particularly if the client is on medications for emphysema or other comorbid conditions. Noncompliance or incorrect use of medications can lead to exacerbations of chronic conditions and the onset of new symptoms.

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? A. Assess the client's oral cavity for ulcerations B. Monitor the client when using a straw for liquids C. Teach coughing and deep breathing exercises D. Request thick nectar liquids for the client

d. request thick nectar liquids for the client When a client with a history of aspiration pneumonia, which indicates difficulty in swallowing, begins coughing while attempting to drink through a straw, it suggests that thin liquids may be difficult for them to handle. Thickening the liquids can reduce the risk of aspiration. Thickened liquids move more slowly, allowing more time for the client to control the swallowing process.

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance? A. Encouraging the client to join a support group B. Wearing gloves when interviewing the client C. Allowing the client to ventilate feelings D. Shaking the client's hand during an introduction

d. shaking the client's hand during an introduction Shaking the client's hand during an introduction is a behavior that addresses the client's psychosocial need for acceptance. It is a simple gesture that conveys respect, acceptance, and normalcy, which can be especially important for someone with a visible skin condition like psoriasis. It sends a message that the nurse does not see the client's condition as a barrier to normal social interactions and is accepting the client as they are.

When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying B. Sitting upright C. Vomiting D. Straining on stool

C. Vomiting A bulging fontanel in an infant can be a concerning sign and may indicate increased intracranial pressure. In the context of vomiting, this finding could suggest potential issues such as dehydration or other conditions affecting intracranial pressure.

A client has both a primary IV infusion in a secondary infusion of a medication. An infusion pump is available. The nurse needs to change the rate of the flow of the secondary infusion.

Click on tube chamber just below yellow bag

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dL (2.97 mmol/L), and potassium 5.3 mEq/L(5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad-spectrum antibiotic D. Potassium chloride

A. Hydrocortisone Addison's disease is characterized by insufficient production of cortisol (and often aldosterone) by the adrenal glands. In the context of an acute illness, such as a viral infection, the body's demand for cortisol increases. The client's symptoms of weakness, confusion, and dehydration, along with low sodium, low glucose, and high potassium levels, are indicative of an Addisonian crisis, a life-threatening condition. Hydrocortisone, a synthetic form of cortisol, is the appropriate treatment to manage this crisis.

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent teacher meeting. What action is most important for the nurse to include in the meeting? A. Provide information on ways to increase activity for the family B. Have several teachers talk about health risks associated with obesity C. Distribute a shopping list of suggested healthy snack items D. Determine the parents degree of concern about...

A. Provide information on ways to increase activity for the family When addressing the issue of overweight students, promoting increased physical activity for the family is a proactive and positive approach. Encouraging families to engage in regular physical activities together can have a positive impact on overall health

An older woman with a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? A. Administer Vitamin K injection B. Start continuous heparin infusion C. Continue warfarin at same dose D. Transfuse unit of packed red blood cells

A. Administer Vitamin K injection The client's elevated INR value of 5.0 indicates that her blood is overly anticoagulated, putting her at risk for bleeding complications. The administration of Vitamin K is the antidote for warfarin (Coumadin) toxicity. Vitamin K helps reverse the anticoagulant effect of warfarin by promoting the synthesis of clotting factors.

A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 103/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain clients temperature q4 hours

A. Assess urine and stool for occult blood With a low platelet count, the client is at an increased risk of bleeding. Assessing urine and stool for occult blood helps identify any potential bleeding in these areas. This allows for early detection and intervention to prevent complications related to bleeding.

An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into the chamber D. Increase wall suction to eliminate fluctuation in water sea

C. manipulate blood in tubing to drain into the chamber The presence of bright red blood in the collection chamber, especially after a significant trauma like a 20-foot fall, indicates ongoing bleeding. The nurse should ensure that all blood in the chest tube is drained into the collection chamber to accurately monitor the client's bleeding. This can involve gently milking or stripping the tubing to facilitate drainage, although this must be done with care to avoid creating excessive negative pressure in the chest tube system.

When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? (SATA) A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheeseE. Pickled olives

a. fruits without sauce c. fresh or frozen vegetables without sauce a: Fruits are naturally low in sodium and are a healthy choice for individuals with hypertension. They also provide essential vitamins, minerals, and fiber. c: Similar to fruits, fresh or frozen vegetables are low in sodium and high in nutrients. It's important to choose varieties without added sauces, as these can contain high levels of sodium.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A. Keep the nails trimmed short B. Apply baby lotion to the skin twice daily C. Bathe the child with bath oil D. Allow the child to wear only 100% cotton clothing

a. keep the nails trimmed short Keeping the child's nails trimmed short is an important measure to reduce the damage caused by scratching. Short nails are less likely to cause skin abrasions or infections when the child scratches the itchy areas.

when entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. which action should the nurse implement? a. tell the client to stop the inappropriate behavior b. complete an unusual occurrence report c. leave the room and close the door quietly d. ignore the behavior and hang the IV antibiotic

c. leave the room and close the door quietly The nurse should respect the client's privacy and dignity. Leaving the room and closing the door provides the client and the visitor with privacy. The nurse can return at a later time to administer the IV antibiotic, ensuring that it is still given within an appropriate time frame to maintain the medication's efficacy.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit

c. neutrophil count Neutrophils are a type of white blood cell primarily responsible for fighting infections, particularly bacterial infections. An elevated neutrophil count (neutrophilia) can be indicative of an infection, which aligns with the clinical finding of purulent drainage at the surgical site. Monitoring the neutrophil count can provide valuable information about the client's immune response and the presence of an infection.

In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Assess skin elasticity of the stump B. Observe for swelling around the stump C. Note amount and color of wound drainage D. Evaluate closest proximal pulse

c. note amount and color of wound drainage Assessing the amount and color of wound drainage is a key indicator of tissue perfusion and healing following an amputation. Excessive drainage, or changes in the color of the drainage (such as becoming increasingly bloody or purulent), can indicate complications such as infection or poor healing.

During a clinic visit, a client with a kidney transplant asks, "What will happen if chronic rejection develops?" Which response is best for the nurse to provide? A. A different combination of immunosuppressant medications will be implemented B. Dialysis would need to be resumed if chronic rejection becomes a reality C. Dialysis may be necessary until the chronic rejection can be reversed D. The immunosuppressant medication will be increased until the rejection subsides

b. dialysis would need to be resumed if chronic rejection becomes a reality Chronic rejection in the context of kidney transplantation refers to a gradual loss of kidney function that can occur over months to years. This type of rejection is often not reversible and can lead to kidney failure. In such cases, the client might need to return to dialysis as a means of renal replacement therapy. While efforts are made to preserve the function of the transplanted kidney as long as possible, if chronic rejection progresses to the point of kidney failure, dialysis becomes necessary.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her; she keeps hoping that he will change. Which action should the nurse take first? A. Explore client's readiness to discuss the situation B. Discuss treatment options for abusive partners C. Report the finding to the police department D. Determine the frequency and type of client's abuse

a. explore client's readiness to discuss the situation The first step in addressing intimate partner violence is to establish a trusting relationship and provide a safe environment for the client to discuss her situation. The nurse should explore the client's readiness and willingness to talk about the abuse, ensuring that the conversation is conducted in a private and secure setting. This approach respects the client's autonomy and helps to build the trust needed for her to open up and potentially seek help.

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (SATA) A. Bring a heavy can close to body before lifting B. Locks knees while preparing food on the counter C. Widens stance while working near the sink D. Bends from the waist to pick trash off the floor E. Leans forward to pull a pan from a high shelf

a. brings a heavy can close to body before lifting c. widens stance while working near the sink a: This is a safe practice as holding objects close to the body helps maintain balance and reduces strain on the back. It keeps the weight centered and reduces the risk of losing balance. c: Widening the stance increases the base of support, which enhances stability and balance. This is especially important when performing tasks that require reaching or bending.

An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. Phobia B. Addiction C. Obsession D. Compulsion

d. compulsion Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. These behaviors or acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, they are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. In this case, the extensive handwashing and refusal to sit on chairs due to fears of contamination are compulsive behaviors typically associated with obsessive-compulsive disorder (OCD).

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin

A. Culture for sensitive organisms when observing purulent drainage at a wound site, the nurse should review the culture and sensitivity results to identify the specific organisms causing the infection and their susceptibility to antibiotics

The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority? A. Assess for vital signs of fluid volume deficit. B. Observe wound drainage characteristics. C. Measure the level of acute pain. D. Determine when the client last ate.

A. Assess for vital signs of fluid volume deficit. a blood glucose level of 720 mg/dL is significantly elevated and may indicate a state of hyperosmolar hyperglycemic state or diabetic ketoacidosis. Both conditions can lead to fluid volume deficit. Assessing for signs of dehydration, such as altered vital signs and dry mucous membranes, is a priority.

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess

A. Bacterial meningitis The client with bacterial meningitis should be assigned the private room because this infection is highly contagious. Airborne precautions are required to prevent the spread of the infection. A private room helps reduce the risk of transmission to other clients.

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A. Body mass index B. Breath sounds C. Self-description of pain D. Level of consciousness

A. Body mass index When determining a client's risk for obstructive sleep apnea syndrome (OSAS), the most important information for the nurse to obtain is the client's body mass index (BMI). Obesity is a significant risk factor for OSAS, and individuals with higher BMIs are more likely to experience obstructive sleep apnea.

the nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. what action should the nurse take next? a. open the roller clamp on the tubing b. label the bag of IV solution c. attach the tubing to the saline lock d. flush the saline lock with saline

A. open the roller clamp on the tubing

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A. Patch one eye B. Evaluate swallow C. Reorient often D. Range of motion

B. Evaluate swallow Osmotic demyelination, also known as central pontine myelinolysis (CPM), can be a complication of rapid correction of hyponatremia, such as in SIADH. This condition can affect the nerves involved in swallowing and lead to dysphagia (difficulty swallowing).

The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurses immediate attention? A. A 16 year-old client diagnosed with major depression who refuses to participate in group B. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack C. An 18 year-old client with antisocial behavior who is being yelled at by other clients D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby

C. An 18-year-old client with antisocial behavior who is being yelled at by other clients This scenario could potentially escalate into a more harmful situation. The immediate verbal conflict suggests a risk of escalation into physical aggression or emotional harm. This situation requires prompt intervention to prevent potential violence or significant stress among the clients

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath bilateral 2+ pedal edema in an oxygen saturation on a room air of 89% which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis

C. Begin supplemental oxygen the client is experiencing signs of fluid overload and respiratory distress, which could be related to the recent hemodialysis

A client is embedded with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every two hours. Which finding should the nurse report immediately to the healthcare provider? A. Anorexia and abdominal distention B. Abdominal pain and vomiting C. Confusion and tremors D. Yellowing and itching of skin

C. Confusion and tremors Confusion and tremors in a client with acute pancreatitis and a history of heavy alcohol consumption may indicate alcohol withdrawal syndrome

The charge nurse of a critical carry unit is informed at the beginning of the shift that lesss than the optical number of registered nurses will be working that shift and planning assignments which client should receive the most care hours by registered nurse (RN)? A. 48 year olds marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. 34 year old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter D. An 82-year-old's client with Alzheimer's disease and newly fractured femur who has a Foley catheter and soft wrist restraint supplied

D. An 82-year-old client with Alzheimer's disease and a newly fractured femur who has a Foley catheter and soft wrist restraints applied This patient presents a complex care situation. The combination of Alzheimer's disease and a new fracture suggests a high risk for confusion, agitation, and potential harm (e.g., attempting to walk and further injuring themselves). The use of restraints also necessitates close and frequent monitoring to prevent complications like skin breakdown or more severe agitation.

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Difficulty locating the uterine fundus B. Excessive lochia C. Saturation of more than one pad per hour D. Hypertension

D. Hypertension If the client develops hypertension, it could be a side effect of methylergonovine maleate, and the medication should be withheld and the healthcare provider notified. Methylergonovine is contraindicated in clients with hypertension due to the risk of exacerbating high blood pressure and potentially causing severe complications.

Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands, and his anterior legs. Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? A. 50% B. 27% C. 9% D. 36%

b. 27% The Rule of Nines is used in burn patients to estimate the total body surface area (TBSA) affected by burns. According to this rule, the body is divided into sections, each representing approximately 9% (or multiples thereof) of the total body surface area. For an adult male with burns on the dorsal surfaces of both arms and hands, and his anterior legs, we can calculate the percentage as follows: - Each entire arm (including the hand) accounts for 9% of the body surface area. Since only the dorsal surfaces (the back sides) are burned, we can estimate this as half of the entire arm. Therefore, each arm would be approximately 4.5%. For both arms, this would be 4.5% x 2 = 9%. - Each entire leg accounts for 18% of the body surface area. Since only the anterior (front) portions of the legs are burned, this can be estimated as half of the entire leg. Therefore, each leg would be approximately 9%. For both legs, this would be 9% x 2 = 18%. Adding these together, the total percentage of burned body surface area would be 9% (arms and hands) + 18% (anterior legs) = 27%.

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty, and the baby is missing. What action should the nurse take first? A. Determine if the newborn is in the nursery B. Activate the lockdown procedure C. Ask the mother if any visitors were expected to arrive D. Match ID bands of all infants and mothers on the unit

b. activate the lockdown procedure In cases of a suspected infant abduction, the immediate priority is to secure the area to prevent anyone from leaving with the infant. Most hospitals have protocols for such situations, often including a facility-wide lockdown. Activating the lockdown procedure ensures that all exits are secured and that the situation is managed according to the hospital's emergency response plan.

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predictable sequence B. The disease is characterized by alternating periods of flare-ups and remissions C. Once an acute attack subsides, the client can expect to feel fine again D. Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness

b. the disease is characterized by alternating periods of flare-ups and remissions Systemic lupus erythematosus is a chronic autoimmune disease that can affect various parts of the body. It is characterized by periods of increased disease activity (flare-ups) followed by periods of reduced activity or remission. Flare-ups can be triggered by various factors such as stress, sun exposure, infections, and certain medications. During remissions, symptoms may subside significantly, but the disease is still present.

The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding? Sound: wheezing A. Chloroquine B. Enalapril C. Albuterol D. Losartan

c. albuterol Albuterol is a bronchodilator commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). It works by relaxing the muscles of the airways, leading to widening (dilation) of the airways, and thereby reducing wheezing and improving airflow.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxiety B. Auscultate the clients bilateral lung sounds and oxygen saturation C. Notify the healthcare provider about the clients distress D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula. Before jumping to other assessments or interventions, the nurse should ensure that the client is receiving an adequate amount of oxygen as prescribed and that there are no issues with the delivery system that could be contributing to the increased shortness of breath.

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client will express acceptance of their newly diagnosed health status. B. The nurse will encourage the client to walk thirty minutes every day C. The client's blood pressure readings will be less than 160/90 mmHg D. The client's skin on the lower legs will be intact at the next clinic visit

d. the client's skin on the lower legs will be intact at the next clinic visit One of the major concerns in clients with peripheral vascular disease is the risk of skin breakdown, especially in the lower extremities, due to reduced blood flow. Ensuring that the skin remains intact and free from ulcers or wounds is a key outcome. Maintaining skin integrity is crucial in the management of PVD to prevent complications such as infections and ulcers.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? A. Administer PRN oral analgesics to a client with a history of chronic pain B. Transport a client who is receiving IV fluids to the radiology department C. Supervise a newly hired graduate nurse during an admission assessment D. Complete ongoing focused assessments of a client with wrist restraints

c. supervise a newly hired graduate nurse during an admission assessment The RN is responsible for more complex tasks that require a higher level of nursing judgment and clinical skills. Supervising a newly hired graduate nurse, particularly during critical tasks like an admission assessment, falls within the scope of responsibilities of an RN. This task requires clinical expertise, assessment skills, and the ability to provide guidance and support to less experienced nursing staff.

An unlicensed assistive personnel (UAP) is a sign to provide personal care for a client whose prescribed activity is bed rest in a bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A. Determine the client's level of mobility and need for assistance B. Instruct the UAP that all clients deserve equal care C. Advise the client to maintain bedrest so that safety can be insured D. Assign another UAP to care for the client

A. Determine the client's level of mobility and need for assistance The nurse should first assess the client's level of mobility and need for assistance to determine the appropriate care plan. This involves considering the client's specific condition, mobility status, and any safety concerns. The nurse can then provide guidance to the unlicensed assistive personnel (UAP) based on the client's individual needs and safety considerations.

An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computer tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Assess clients peoples for their reaction to light B. Request that the CT scan beats immediately C. Review client's history for use of illicit drugs D. Explain the reason for using only non-narcotics

A. assess the client's pupils for their reaction to light Assessing the client's pupils for their reaction to light is an important step in evaluating for potential head injury or increased intracranial pressure, especially after a fall. Changes in pupil size, shape, or reaction to light can be indicative of serious neurological issues that need immediate attention.

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperature D. Erythrocytes, hemoglobin, and hematocrit

B. Serum potassium, calcium, and phosphorus In end-stage renal disease (ESRD), the kidneys are not able to effectively filter and excrete waste products and maintain electrolyte balance. Therefore, monitoring serum electrolyte levels is crucial. Specifically, serum potassium, calcium, and phosphorus are often affected in clients with ESRD. Dysregulation of these electrolytes can lead to various complications, such as hyperkalemia, hyperphosphatemia, and hypocalcemia. Regular monitoring and appropriate interventions are essential to manage these imbalances and prevent complications in clients with ESRD.

Well caring for a toddler receiving oxygen via facemask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A. Use a topical lidocaine analgesic for cracked lips B. Use a water soluble lubricant on affected oral and nasal mucosa C. Ask the mother what she usually uses on the child's lips and nose D. Apply a petroleum jelly to the child's nose

B. Use a water soluble lubricant on affected oral and nasal mucosa To address dry and cracked lips and nares in a toddler receiving oxygen via a facemask, the nurse should use a water-soluble lubricant on the affected oral and nasal mucosa. This helps prevent further dryness and discomfort.

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Regional relocation center for earthquake victims B. Vitamin supplements for high-risk pregnant women C. Lead screening for children in low income housing D. Case management and screening for clients with HIV

B. Vitamin supplements for high-risk pregnant women Primary prevention aims to prevent disease or injury before it ever occurs. This is done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to disease or injury, and increasing resistance to disease or injury should exposure occur. Providing vitamin supplements to high-risk pregnant women is a primary prevention strategy, as it aims to prevent potential health problems in both the mother and the developing fetus before they occur.

A 12 year-old client who had an appendectomy two days ago was receiving 0.9% normal saline at 50 mL/ hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A. Assess bowel sounds in all quadrants B. Encourage popsicles and fluids of choice C. Evaluate postural blood pressure measurements D. Obtain a specimen for your analysis

B. encourage popsicles and fluids of choice encouraging the intake of fluids, such as popsicles or the client's preferred fluids, can help to increase hydration and subsequently lower the urine specific gravity to a more normal range (typically 1.005-1.030). hydration is important postoperatively and offering fluids in a variety that is appealing to a child can encourage better fluid intake

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcomes indicate the program is effective? A. At risk clients received an increase number of routine health screenings B. Clients reported having new confidence in making healthy food choices C. Clients who incurred disease complications promptly received rehabilitation D. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign

C. Clients who incurred disease complications promptly received rehabilitation tertiary prevention focuses on minimizing the impact of a disease by preventing complications, restoring function, and improving the quality of life for individuals with existing conditions; in the context of cardiovascular disease, clients who incur complications and promptly receive rehabilitation represent a successful outcome of tertiary prevention efforts

In caring for a client with Cushing's syndrome which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin

C. Glucose Cushing's syndrome is characterized by an excess of cortisol in the body, which can significantly impact glucose metabolism. This excess cortisol can lead to hyperglycemia (high blood sugar levels), making it crucial to regularly monitor the client's glucose levels. Managing blood sugar is an important aspect of caring for a client with Cushing's syndrome to prevent complications associated with hyperglycemia.

A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should the nurse implement first? A. Document as specifically as possible the client's behavior in the nurse's note B. Discuss with a client why he is making sexual advances toward the nurse C. Tell the client in a matter-of-fact manner to stop the sexual advances D. Request an immediate team meeting to discuss the inappropriate behavior

C. Tell the client in a matter-of-fact manner to stop the sexual advances The first action the nurse should take is to establish clear and firm boundaries by directly addressing the inappropriate behavior. This helps convey that such behavior is not acceptable and sets the tone for professional and therapeutic interaction. Subsequently, documentation and further discussions or team meetings can be initiated as needed.

The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO B. Confirm monitor reading in synchronous mode C. Notify the rapid response team of the transfer D. Secure cardioversion pads on the client's chest

a. document that the client has remained NPO Before a procedure like cardioversion, it's important to ensure that the client has been NPO (nothing by mouth) for the appropriate amount of time. This is to reduce the risk of aspiration during the procedure, which can occur if the client has a full stomach. Documenting the NPO status is essential for procedural safety.

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? A. Decrease in intracranial pressure and cerebral edema B. Increased time of ambulation between periods of rest C. Normal electroencephalogram after drug administration D. Absence of seizure activity for the duration of treatment

d. absence of seizure activity for the duration of treatment Seizures can be a complication of bacterial meningitis due to inflammation of the brain tissue. The primary therapeutic goal of phenytoin in this context is to control or prevent seizure activity. Therefore, the absence of seizures during treatment would indicate that the medication is effectively achieving its intended purpose.

The nurse is caring for client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Increasing the client's fluid intake D. Administering narcotics for pain relief

d. administering narcotics for pain relief Narcotic pain medications can suppress respiratory function, which is a significant concern in clients with COPD. COPD already compromises respiratory status, and narcotics can further decrease respiratory drive and lead to hypoventilation, especially in higher doses or if the client is not closely monitored. It is important to assess the client's respiratory status frequently when administering narcotics and to use the lowest effective dose for pain control.