HESI with Rationale
An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Answer 0.4 Rationale Calculate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml
A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Answer 1.6 Rationale Using the formula D/H x Q 200mg/250 mg x 2ml = 200/250 = 1.6 ml
The healthcare provider prescribes heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)
Answer 12 Rationale 144/2.2= 65kg 18units/kg/hr 65 kg x 18units/kg/hr= 1170 units/hr 25000 units heparin/250 ml of D5W = 100 units heparin per ml of solution Formula D/H x A = X
The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)
Answer 12.5 Rationale Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
Answer 12160 Rationale 4ml x 67kg x 40 (bsa) =12,160 ml
A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only.)
Answer 3 Rationale 0.01 x 500 x 60 / 100 = 3
A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? (Enter numeric value only.)
Answer 7 Rationale Convert the client's weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour
A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only.)
Answer 700 Rationale D/H x Q = 25000 / 500 x 14 = 700
The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only.)
Answer 8 Rationale Calculate the client's weigh in kg: 220 pounds divide by 2.2 pounds/kg ꞊100 kg Calculate the client's dose, 80 units x 100 kg ꞊ 8,000 units Use the formula, D / H X Q ꞊ 8,000 units / 1,000 units x 1ml ꞊ 8
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. Evaluate closet proximal pulse. B. Asses skin elasticity of the stump. C. Observe for swelling around the stump. D. Note amount color of wound drainage.
Answer A. Evaluate closet proximal pulse. Rationale A primary focus of care for a client with an AKA is monitoring for signs of adequate tissue perfusion, which include evaluating skin color and ongoing assessment of pulse strength.
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. What is the best response by the nurse? A. Explain that the client will start to lose consciousness and his body system will slow down. B. Reassure the spouse that the healthcare provider will let her know when to call the children C. Offer to discuss the client's health status with each of the adult children D. Gather information regarding how long it will take for the children to arrive
Answer A. Explain that the client will start to lose consciousness and his body system will slow down. Rationale Expected signs of approaching death include noticeable changes in the client's level of consciousness and a slowing down of body systems. The nurse should answer the spouse's questions about the signs of imminent death rather than offering reassurance that may or may not be true. Other options listed may be implemented but the nurse should first answer the spouse's question directly.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A. Hypokalemia B. Ketonuria. C. Peripheral edema D. Elevated blood pressure
Answer A. Hypokalemia Rationale Pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias.
A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? A. Level of consciousness. B. Percussion of abdomen C. Serum electrolytes D. Blood glucose.
Answer A. Level of consciousness. Rationale Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and metal status.
When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply.) A. Pasta, noodles, rice. B. Egg, tofu, ground meat. C. Mashed, potatoes, pudding, milk. D. Brussel sprouts, blackberries, seeds. E. Corn bran, whole wheat bread, whole grains.
Answer A. Pasta, noodles, rice. B. Egg, tofu, ground meat. C. Mashed, potatoes, pudding, milk. Rationale A client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits with skin, grains and seeds are omitted.
Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? A. Transfuse Type A negative blood until type AB negative is available. B. Recheck the client's hemoglobin, blood type and Rh factor. C. Administer normal saline solution until type AB negative is available D. Obtain additional consent for administration of type A negative blood
Answer A. Transfuse Type A negative blood until type AB negative is available. Rationale Those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client's hemoglobin is critically low and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation.
A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement? A. Schedule a home visit in the afternoon to assess the son and client role as caregiver. B. Acknowledge the client's stress and suggest that she consider respite care. C. Provide feedback to the client about her atonement for guilt about her son's impairment. D. Teach the client to problem-solve for herself and establish her own priorities.
Answer B. Acknowledge the client's stress and suggest that she consider respite care. Rationale When this amount of disclosure is offered, the client is usually seeking information focuses on the client's expression of worry, concern and stress and addresses the client's need to initiate a request for assistance with respite care.
An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? A. Examine the client's room for hidden food. B. Assign staff to monitor what the client eats. C. Ask the client if the food provided is being eaten or discarded. E. Provide the client with a high calorie diet.
Answer B. Assign staff to monitor what the client eats. Rationale Clients with an eating disorder have an unhealthy obsession with food. The client's continued weight loss, despites indication that the client has consumed 100% of the diet, should raise questions about the client's intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary.
A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? A. Call poison control emergency number. B. Determine type of chemical exposure. C. Obtain equipment for gastric lavage. D. Assess child for altered sensorium.
Answer B. Determine type of chemical exposure. Rationale Once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested.
During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first? A. Determine when the client last had an influenza vaccination. B. Discuss the concerns expressed by the client about the vaccination. C. Ask about any recent exposure to persons with the flu or other viruses. D. Review the informed consent form for the vaccination with the client.
Answer B. Discuss the concerns expressed by the client about the vaccination. Rationale The nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form.
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A. Erythrocyte Sedimentation Rate (ESR). B. Hemoglobin. C. Calcium. D. Osmolality.
Answer B. Hemoglobin. Rationale Naproxen can cause gastric bleeding, so the nurse should monitor the client's hemoglobin to assess for possible bleeding. Other options are not likely to be affected by the used of naproxen and are not related to the client's current symptoms.
The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? A. Initiation of the impulses from a location outside the SA node. B. Inability of the SA node to initiate an impulse at the normal rate. C. Increased conduction time from the SA node to the AV junction. D. Interference with the conduction through one or both ventricles.
Answer B. Inability of the SA node to initiate an impulse at the normal rate. Rationale A prolonged PRI reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first degree heart block.
The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client? A. Put his behavior on extinction and continue talking with the newly admitted. B. Inform him that the nurse is busy admitting a new client and will talk to him later. C. Encourage him to go to the nurse's station and talk with another nurse. D. Introduce him to the newly admitted client and ask him to him to join in the conversation.
Answer B. Inform him that the nurse is busy admitting a new client and will talk to him later. Rationale The psychiatric nurse must set limits with antisocial behavior so that appropriate behavior is demonstrated. Interrupting a conversation is rude and inappropriate, so telling the client that they can talk later is the best course of action. Other options may cause the client to become angry and they do not address the client's behavior. The nurse should not involve this client with newly admitted client's admission procedure.
A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply.) A. Check urine for ketones. B. Measure blood glucose. C. Monitor vital signs. D. Assessed level of consciousness. E. Obtain culture of wound.
Answer B. Measure blood glucose. C. Monitor vital signs. D. Assessed level of consciousness. Rationale Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS.
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? A. Insomnia. B. Muscle cramping. C. Increase appetite. D. Anxiety.
Answer B. Muscle cramping. Rationale SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.
A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? A. Determine client's level current blood alcohol level. B. Observe for changes in level of consciousness. C. Involve the client's family in healthcare decisions. D. Provide grief counseling for client and his family.
Answer B. Observe for changes in level of consciousness. Rationale Based on the client's history of drinking, he may be exhibiting sing of hepatic involvement and encephalopathy. Changes in the client's level of consciousness should be monitored to determine if he able to maintain consciousness, so neurological assessment has the highest priority.
The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? A. White blood count of 19,000 mm3. B. Oral temperature of 100.6° F. C. Fundus deviated to the right side. D. Breasts are firm when palpated.
Answer B. Oral temperature of 100.6° F. Rationale A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.
A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? A. Chew food slowly and thoroughly before attempting to swallow. B. Plan volume-controlled evenly-space meal thorough the day. C. Sip fluid slowly with each meal and between meals D. Eliminate or reduce intake fatty and gas forming food.
Answer B. Plan volume-controlled evenly-space meal thorough the day. Rationale It is most important for the client to learn how to eat without damaging the surgical site and to keep the digestive system from dumping the food instead of digesting it. Eating volume-control and evenly-space meals thorough the day allows the client to fill full, avoid binging, and eliminate the possibility of eating too much one time. Chewing slowly and thoroughly helps prevent over eating by allowing a filling of fullness to occur. Taking sips, rather than large amounts of fluids keeps the stomach from overfilling and allow for adequate calories to be consumed. Gas forming foods and fatty foods should be avoiding to decrease risk of dumping syndrome and flatulence.
One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care? A. Encourage Progressive active range of motion B. Teach need for dietary and supplementary vitamin D3. C. Explain the need for skin exposure to sunlight without sunscreen D. Instruct the client to use of muscle strengthening exercises
Answer B. Teach need for dietary and supplementary vitamin D3. Rationale Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normal-appearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided.
Based on principles of asepsis, the nurse should consider which circumstance to be sterile? A. One inch- border around the edge of the sterile field set up in the operating room. B. A wrapped unopened, sterile 4x4 gauze placed on a damp table top. C. An open sterile Foley catheter kit set up on a table at the nurse waist level. D. Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
Answer C. An open sterile Foley catheter kit set up on a table at the nurse waist level. Rationale A sterile package at or above the waist level is considered sterile (C). The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface.
A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? A. Prepare the client for an emergency cesarean birth B. Encourage the client to move to a hands-and-knees position. C. Assist the client to sharply flex her thighs up against the abdomen. D. Lower the head of the bed an apply suprapubic pressure.
Answer C. Assist the client to sharply flex her thighs up against the abdomen. Rationale Flexing the client's thighs against the abdomen (Mc Robert's maneuver) changes the angle of the pelvis and increases the pelvic diameter, making more room for the shoulders to emerge. (A, B, and D) are implemented after (C).
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. Serum albumin B. Creatinine level C. Culture for sensitive organisms. D. Serum blood glucose (BG) level
Answer C. Culture for sensitive organisms. Rationale A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client's laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time.
A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take? A. Provide the client with information about treatment options for breast cancer. B. Reassure the client that the final diagnosis has not been made. C. Encourage the client to continue express her fears and concerns. D. Suggest to the client that she seek a second opinion.
Answer C. Encourage the client to continue express her fears and concerns. Rationale The nurse should show support for the client by encouraging her to continue expressing her concerns. A diagnosis has not yet been made, so it is too early to discuss treatment options. Other options dismiss the client's feelings or are premature given that the diagnosis is not yet made.
The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? A. Determine the client's level of emotional functioning. B. Assess functional ability of the primary support system. C. Evaluate the client's mood, cognition and orientation. D. Review the client's pattern of adaptive coping skill.
Answer C. Evaluate the client's mood, cognition and orientation. Rational The mental status exam assesses the client for abnormalities in cognitive functioning; potential thought processes, mood and reasoning, the other options listed are all components of the client's psychosocial assessment.
A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A. Collect a clean catch urine specimen. B. Instruct the client to empty the bladder. C. Obtain vital signs and breath sounds. D. No specific nursing action is required
Answer C. Obtain vital signs and breath sounds. Rationale The client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication.
In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? A. High urinary PH. B. Abdominal Ascites. C. Orthopnea. D. Fever.
Answer C. Orthopnea. Rationale If the client is orthopneic, the nurse needs to adapt the insertion position that does not place the client in a supine position (the head of the bed should be elevated as much as possible).
A Native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? A. Identifies his ethnocentric values and behaviors. B. States an understanding of the medical treatment. C. Participated actively in all treatments regimens. D. Expresses a desire for cultural assimilation.
Answer C. Participated actively in all treatments regimens. Rationale Indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural clash between the two forms of treatment. The client has already identify he's cultural values (A). (B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural values with the prescribed medical treatment (D).
A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Allow the client to use a bedpan. B. Assist the client to the bathroom. C. Perform a sterile vaginal exam. D. Explain the fetal head is descending.
Answer C. Perform a sterile vaginal exam. Rationale When a client in active labor suddenly expresses the urge to have a bowel movement, a sterile vaginal exam should be performed to determine if the fetus is descending.
The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? A. Hold the client at arm's length while transferring to better distribute the body weight. B. Apply the gait belt around the client's waits once standing position has been assumed. C. Place a client's locked wheelchair on the client's strong side next to the bed. D. Pull the client into position by reaching from the opposite side of the bed.
Answer C. Place a client's locked wheelchair on the client's strong side next to the bed. Rationale Placing the wheelchair on the client's strong side offers the greatest stability for the transfer. Holding the client arm's length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client, but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position.
During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)? A. Encourage the woman at risk for cancer to obtain colonoscopy. B. Present a class of breast-self examination. C. Prepare a woman for a bone density screening. D. Explain the follow-up need it for a client with prehypertension.
Answer C. Prepare a woman for a bone density screening. Rationale A bone density screening is a fast, noninvasive screening test for osteoporosis that can be explained by the PN. There is no additional preparation needed (A) required a high level of communication skill to provide teaching and address the client's fear. (B) Requires a higher level of client teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to provide needed teaching regarding this complex topic.
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm. B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level. D. Administer PRN antianxiety medication.
Answer C. Review the client's serum calcium level. Rationale Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? A. Wash hands frequently. B. Avoid drinking lake water. C. Wear long sleeves and pants. D. Do not share personal products.
Answer C. Wear long sleeves and pants. Rationale Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites.
After receiving report, the nurse can most safely plan to assess which client last? The client with... A. a rectal tube draining clear, pale red liquid drainage. B. a distended abdomen and no drainage from the nasogastric tube. C. no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. D. dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.
Answer C. no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. Rationale The most stable client is the one with a functioning drainage device and no drainage. This client can most safely be assesses last. Other clients are either actively bleeding, have an obstruction in the nasogastric tube which may result in vomiting, or may be bleeding and / or may have a malfunction in the Hemovac® drain.
The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A. A 64 year old client who had a total hip replacement the previous day. B. A 75 year old client with renal calculi who requires urine straining. C. An adolescent with multiple contusions due to a fall that occurred 2 days ago. D. A 30 year old depressed client who admits to suicide ideation.
Answer D. A 30 year old depressed client who admits to suicide ideation. Rationale A client who is suicidal requires psychological assessment, therapeutic communication and knowledge beyond the educational level of a practical nurse (RN). Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse.
The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? A. Stroke the inner thigh below the perineum to initiate urinary flow. B. Contract, hold, and then relax the pubococcygeal muscle. C. Pour warm water over the external sphincter at the distal glans. D. Apply downward manual pressure at the suprapubic regions.
Answer D. Apply downward manual pressure at the suprapubic regions. Rationale The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic are.
When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? A. Rectus femenis. B. Ventrogluteous. C. Vastus lateralis. D. Deltoid.
Answer D. Deltoid. Rationale The acromion process is a parameter identified for the deltoid site.
The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take? A. Ask the client if the stocking feel comfortable. B. Supervise the UAP in the removal of the stockings. C. Place a cover over the client's toes to keep them warm. D. Discuss effective use of the stockings with the client on UAP.
Answer D. Discuss effective use of the stockings with the client on UAP. Rationale Antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings.
The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A. Encourage the client's family to visit more often. B. Schedule a daily conference with the social worker. C. Encourage the client to participate in group activities. D. Engage the client in a non-threatening conversation.
Answer D. Engage the client in a non-threatening conversation. Rationale Consistent attempts to draw the client into conversations which focus on non-threatening subjects can be an effective means of eliciting a response, thereby decreasing isolation behaviors. There is not sufficient data to support the effectiveness of A as an intervention for this client. Although B may be indicated, nursing interventions can also be used to treat this client. C is too threatening to this client.
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. Reorient often. C. Range of motion. D. Evaluate swallow.
Answer D. Evaluate swallow. Rationale Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH. Difficulty swallowing due to brainstem nerve damage should be care, but determining the client's risk for aspiration is most important.
When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Seeds, spices, lettuce. B. Consomme, celery, carrot. C. Oranges, orange juice, bananas. D. Fortified whole wheat cereals, whole-grain pasta, brown rice. E. Spinach, kale, dried raisins and apricots.
Answer D. Fortified whole wheat cereals, whole-grain pasta, brown rice. E. Spinach, kale, dried raisins and apricots. Rationale Nutritional anemia in pregnancy should be supplemented with additional iron in the diet. Foods that are high in iron content are often protein based, whole grains (D), green leafy vegetables and dried fruits (E). (A, B, and C) are not iron rich sources
The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? A. Administer the Tropol immediately and monitor the client until the heart rate increases. B. Provide the dose of Tropol as scheduled and assign a UAP to monitor the client's BP q30 minutes. C. Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. D. Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.
Answer D. Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Rationale Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.
The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? A. Low bioavailability. B. Rapid onset of action. C. Short half life. D. Narrow therapeutic index.
Answer D. Narrow therapeutic index. Rationale A drug with a narrow therapeutic index has a high risk for toxicity because there is a narrow range between the therapeutic dose and the toxic dose.
A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A. Check the visual difficulties. B. Note most recent hemoglobin level. C. Assessed for he and Hand joint pain. D. Observe rhythm on telemetry monitor.
Answer D. Observe rhythm on telemetry monitor. Rationale If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels.
At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A. Encourage the client to turn on her left side. B. Place a pillow under the client's head and knees. C. Explain to the client that her position is not safe. D. Place a wedge under the client's right hip.
Answer D. Place a wedge under the client's right hip. Rationale Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure on the vena cava or would not allow the client the remaining her position of choice.
When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond? A. Replace the dressing and remove the drainage device. B. Reposition the drainage device and keep the plug open. C. Notify the healthcare provider that the drain is not working. D. Recompress the wound suction device and secure to plug.
Answer D. Recompress the wound suction device and secure to plug. Rationale The plug of a wound suction device, such as a Hemovac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated.
A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? A. Irrigate the indwelling urinary catheter. B. Prepare the client for external pacing. C. Obtain capillary blood glucose measurement. D. Titrate the dopamine infusion to raise the BP.
Answer D. Titrate the dopamine infusion to raise the BP. Rationale The client is experiencing cardiogenic shock and requires titration per protocol of the vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the client's capillary blood glucose should be monitored, but is not directly indicated at this time.
