Med Surg HESI 2023

A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using? a.) Sublimation. b.) Suppression. c.) Regression. d.) Compensation.

a.) Sublimation.

A client is admitted to a medical unit and diagnosed with gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? a. Lorazepam (Ativan) b. Famotidine (Pepcid) c. Thiamine (Vitamin B1) d. Atenolol (Tenormin)

c. Thiamine (Vitamin B1)

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? ● Low-grade fever, headache, and malaise for the past 72 hours ● Unable to bear weight on the left foot, with the swelling and bruising ● Chest discomfort one hour after consuming a large, spicy meal ● One-inch bleeding laceration on the chain of the crying five-year-old

● Chest discomfort one hour after consuming a large, spicy meal

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 the abdomen c. Serum electrolytes d. Blood glucose.

a. Level of consciousness

A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first?

- instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 900 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero

(900/25,000)x250 mL STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 900 units/hr STEP 3: What is the dose available? Dose available = Have 25,000 units STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 250 mL STEP 6: Set up an equation and solve for X.Desired x Quantity/Have = X mL 900 units x 250 mL/25,000 units = X mL X = 9 mL / hr

A primary health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

16 gtt/min

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take? A Notify the client's healthcare provider of the vomiting. B Remove the transdermal patch until the vomiting subsides. C Reposition the transdermal patch to the client's trunk. D Explain that this is a side effect of the medication in the patch.

A Notify the client's healthcare provider of the vomiting.

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)] A. Assess urine and stool for occult blood. B. Obtain client's temperature every 4 hours. C. Monitor for signs of activity intolerance D. Require visitors to wear respiratory masks.

A. Assess urine and stool for occult blood.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A. Intravenous administration of benztropine. B. Oral administration of divalproex. C. Intravenous administration of isotonic crystalloid fluid. D. Oral administration of lorazepam.

A. Intravenous administration of benztropine.

The RN implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective? A. Average client scores improved on specific risk factor knowledge tests. B. More than 50% of at-risk clients were diagnosed early in their disease process. C. Condoms were provided in all health clinics in the community. D. Healthcare providers prescribed 40% more HPV vaccines.

A. Average client scores improved on specific risk factor knowledge tests. An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.

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

A. Have the client vocalize the instructions provided

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called tor another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take? A Call for an assistant. B Finish the procedure C Respond to the code. D Close the room door.

B Finish the procedure

An older client is admitted with pneumonia, and the healthcare provider prescribes penicillin G potassium IV. Which assessment finding increases the risk of adverse reactions in this client? A. Previous treatment with penicillin for pneumonia. B. Daily use of spironolactone for hypertension. C. Documented allergy to sulfa drugs. D. Sputum culture results of streptococcus pneumoniae.

B. Daily use of spironolactone for hypertension.

The nurse identifies several problems for an older client with diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority? A. Impaid bed mobility B. Fluid volume deficit C. Caregiver role strain D. Bowel incontinence

B. Fluid volume deficit

121. A client is undergoing peritoneal dialysis. After several fluid exchanges the abdomen is distended and blood pressure is elevated and 6500ml were infused while 5500ml were drained, in response to this finding what action should the nurse take? A. Turn the client from side to side B. Irrigate the drainage tube with normal saline C. Lower the head of the bed D. instruct the client to cough

B. Irrigate the drainage tube with normal saline

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse? A. O2 is being administered via NC @ 4L w/out humidification B. Low intermittent suction prescribed for NG tube is turned off C. Urinary catheter drainage bag is almost completely full D. Hemovac drain is partially full of serous drainage and not compressed

B. Low intermittent suction prescribed for NG tube is turned off

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse? A, initiate teaching for client care after discharge B. Validate intravenous flow rate C. Begin initial sterile wound care for surgical clients D. Evaluate and update plans of care for clients

B. Validate intravenous flow rate

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.) A. Use standard precautions and wear a mask. B. Monitor the client's white blood cell count. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Explain the purpose of a low-bacteria diet.

BCD A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

A client with a history of COPD is admitted with pneumonia. Vital signs include HR 122, RR 28, and BP 170/90. Which assessment finding warrants the most immediate intervention by the nurse? A. Bilateral diffuse wheezing B. Temperature of 100.5 C. Yellow expectorated sputum D. Shortness of breath on exertion

C.

When assessing a client with an ionized calcium level of 17mg/dL. Which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm

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

C. Brings a heavy can close to body before lifting. E. Widens stance while working near the sink.

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information stated by the client indicates understanding? Reference Range Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L] A. Do not take take diabetes medication when feeling sick B. Obtain an A1C blood test every year to monitor glucose control. C. Have some form of rapid acting glucose easily accessible D. Using salt, herbs, and spices will improve the flavor of foods.

C. Have some form of rapid acting glucose easily accessible. Rationale: Having a source of rapid acting glucose on hand is important for treating hypoglycemia which can be a side effect of diabetes mellitus.

An older adult client asks the nurse about the best foods to help prevent osteoporosis. Which type of foods should the nurse recommend? A. Water and herbal teas B. Low fat dairy products C. Iron-rich meals D. Fresh fruit and vegetables

C. Iron-rich meals

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

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action?

Check the neurovascular status of the toes on the casted leg.

39-A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider? a. Electromyography b. Allergy test c. Complete blood count d. Skin biopsy.

Complete Blood Count RATIONALE: Zidovudine is used to treat HIV

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which flindhy thould the murne document in the student's screening record? A Rounded spine from head to hips without concave curves. B Posterior curvature that is convex in the thoracic area. C Lateral curvature that creates asymmetry of the shoulders. D Excessive concave curvature of the lumbar spine.

D Excessive concave curvature of the lumbar spine.

The nurse assesses a client who has bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. What action should the nurse implement? A. Monitor the client's current WBC B. Withhold next scheduled dose of low molecular weight heparin C. Confirm that the continuous passive motion device is intact D. Determine if the wound drainage device is functioning correctly

D. Determine if the wound drainage device is functioning correctly

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A. Restrained and restless with a low volume alarm sounding B. An audible voice when clients is trying to communicate. C. High pressure alarm sounds when clients is coughing D. Diminished breath sounds in the right posterior base.

D. Diminished breath sounds in the right posterior base.

Client is transferred from the operating room to the post anesthesia care unit (PACU) with vial signs of T 99.8, HR 62, RR 8, BP 95/54, and O2 94% on 2L. Which medication should the nurse administer? A. Acetaminophen B. Morphine C. Milrinone D. Naloxone

D. Naloxone Rationale: The client's vital signs indicate that they are experiencing respiratory depression, as evidenced by the low respiratory rate of 8 breaths/minute. The normal respiratory rate for an adult is typically between 12 and 20 breaths per minute.

While completing an admission assessment for a client with unstable angina , which closed ended questions should the nurse ask about the client's chest pain?

Does your pain occur when walking a short distance?

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

Encouraging the client to consume 2 to 3 quarts of clear fluids daily

A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a peripheral line. The UAP reports to the nurse that the client's HR is 90 BPM, and BP is 110/50. Which intervention should the nurse implement? 1. tell the uap to turn off the amiodarone 2. restart the IV infusion in another site 3. Determine the regularity of the peripheral pulses 4. Evaluate the rhythm of the heart rate

Evaluate the rhythm of the heart rate

The nurse is preparing an adult with Addison's disease for self-management. Which Information should the nurse include in the client's instruction?

Events requiring steroid dose adjustments

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain? A. Physical soothing. B. Verbal reassurance. C. Simultaneous injections. D. Supine positioning.

Simultaneous injections

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

Neutrophil Count RATIONALE: An infection may be present if the leg ulcer site develops a red, painful, and swollen lesion. White blood cells called neutrophils are essential for the body's immunological response to bacterial infections. An infection or inflammation may be indicated by a high neutrophil count, commonly referred to as neutrophilia. As a result, assessing the client's neutrophil count can assist the practical nurse in determining whether an infection is present and in prescribing the right course of action.

A client is receiving a continuous infusion of the anticoagulant, heparin, for treatment of a deep vein thrombosis of the right calf. Which goal should the nurse include in this client's plan of care?

No further thrombus will form.

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) Open the sterile catheter kit close to the client's perineum. Don sterile gloves and prepare to sterile field. Cleanse the urinary meatus using the solution, swabs, and forceps provided. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus.

Open the sterile catheter kit close to the client's perineum. Don sterile gloves and prepare to sterile field. Cleanse the urinary meatus using the solution, swabs, and forceps provided. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

During discharge teaching, an overweight client 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?

Plain, air-popped popcorn Natural whole almonds

On admission, a client with an acute myocardial infarction receives a thrombolytic, aspirin, and IV heparin. Which finding indicates to the practical nurse (PN) that the client is having a therapeutic response to the medication? a. Activated partial thromboplastin time (APTT) results 2 times the control. b. Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex. c. Guaiac test of the stools is positive. d. S3 heart sounds are present with auscultation.

RATIONALE: The correct answer is a. Activated partial thromboplastin time (APTT) results 2 times the control. This indicates that the heparin is working to prevent further clotting, which is a desired therapeutic response in the treatment of myocardial infarction. Acute Coronary Syndrome (ACS) protocol includes the administration of thrombolytics, aspirin, and IV heparin, which prolongs the activated partial thromboplastin time at the therapeutic range that is two times the control value (C). This protocol of medications has no therapeutic effect on lungs sounds (A), heart rate or peripheral edema (B), or platelet count (normal platelet count is 100,000 to 400,000/mm3) (D).

The family of an older adult client who received a lung transplant asks if the 2 year old grandkid can visit. Which response should nurse offer? A. Yes grandchildren offer emotional support and positive diversion B. No protective precautions are required after a lung transplant C. No small children are often carriers of infectious organisms D. Yes if the child is not ill or has not recently received a live vaccine

(WE CHOSE COULDN'T FIND) D. Yes if the child is not ill or has not recently received a live vaccine

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning an preparing the client, rank the actions in the sequence they should be implemented. (Place the first action at the top with the last action at the bottom.) a. Cleanse the urinary meatus using the solution, swabs, and forceps provided. b. Open the sterile catheter kit close to the client's perineum. c. Done sterile gloves and prepare the sterile field. d. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus.

1.) Open the sterile catheter kit close to the client's perineum. 2.) Done sterile gloves and prepare the sterile field. 3.) Cleanse the urinary meatus using the solution, swabs, and forceps provided. 4.) Place distal end of the catheter in sterile specimen cup and insert catheter into meatus.

n evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

A. Palpate all peripheral pulse points for volume and strength.

Which is the best approach for the nurse to use when interviewing a client about intimate partner violence? A. Ask questions in a vague, non-specific format. B. Begin with questions that are less sensitive in nature. C. Get the most difficult questions over with first. D. Share personal values to put the client at ease.

B. Begin with questions that are less sensitive in nature.

PHOTO: child in skeletal traction - where should RN assess for signs of compartment syndrome?

(I think you click on the top of the feet - to assess pedal pulses)

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take? A. Move the client to a private room, keep the door closed, and initiate droplet precautions B. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results. C. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. D. Assist the client to recall everyone possibly exposed since onset of symptoms.

A. Move the client to a private room, keep the door closed, and initiate droplet precautions

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include the client's postoperative discharge teaching? A. Monitor urinary stream for decreased output. B. Report when hematuria becomes pink tinged. C. restrict all physical activities. D. use the incentive spirometer.

A. Monitor urinary stream for decreased output.

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV dextrose infusion of dextrose 5% in LR infusing at a rate of 100 mL/hr. What assessment is MOST important for the nurse to monitor? A.) Peristomal skin integrity B.) serum electrolytes C.) Urinary output D.) Skin Turgor

A. Serum Electrolytes Rationale: The client is losing large amounts of fluids and electrolytes in the liquid feces from the ileum, so monitoring of the client's serum electrolytes to evaluate the effectiveness of replacement by the present infusion of Dextrose 5% in Lactated Ringer's is most important.

A nurse is performing routine assessment of an IV site in a patient receiving both IV fluids and medications through the line. Which of the following would indicate the need for discontinuation of the IV line as the next nursing action? A. The patient complains of pain on movement. B. The area proximal to the insertion site is reddened, warm, and painful. C. The IV solution is infusing too slowly, particularly when the limb is elevated. D. A hematoma is visible in the area of the IV insertion site.

A. The patient complains of pain on movement. B. The area proximal to the insertion site is reddened, warm, and painful.

A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention(s) should the nurse implement? (Select all that apply.) A. Have the client demonstrate technique used to monitor blood glucose levels. B. Evaluate the client's asthma medications that can elevate the blood glucose. C. Ask the client if they want a different manufacturer's glucose monitoring device. D. Understand the client's daily routine E. Ensuring the client uses a new insulin needle for each administration

ABDE A. Have the client demonstrate technique used to monitor blood glucose levels. B. Evaluate the client's asthma medications that can elevate the blood glucose. D. Understand the client's daily routine. |E. Ensuring the client uses a new insulin needle for each administration.

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action(s) should the nurse take? Select all that apply. A. Determine if the mother has recently experienced a fall. B. Review the client's current food and medication allergies. C. Encourage increased intake of high-protein foods. D. Instruct the daughter to check her mother's temperature. E. Ask if the mother is experiencing any pain with urination.

ADE RATIONALE: Choice A reason: This is a correct answer because determining if the mother has recently experienced a fall is important to rule out any head injury or concussion that could cause confusion. Parkinson's disease can increase the risk of falls due to impaired balance, coordination, and mobility. Choice B reason: This is not a correct answer because reviewing the client's current food and medication allergies is not relevant to the mother's confusion. However, it may be important to review the client's current medications and dosages to check for any adverse effects or interactions that could affect cognition. Choice C reason: This is not a correct answer because encouraging increased intake of high protein foods is not helpful for the mother's confusion. In fact, high protein foods may interfere with the absorption of levodopa, a medication used to treat Parkinson's disease symptoms. The nurse should advise the daughter to consult with a dietitian about the optimal timing and amount of protein intake for her mother. Choice D reason: This is a correct answer because instructing the daughter to check her mother's temperature is important to detect any fever or infection that could cause confusion. Older adults are more susceptible to infections such as urinary tract infections (UTIs), pneumonia, or sepsis, whih can affect mental status. Choice E reason: This is a correct answer because asking if the mother is experiencing any pain with urination is important to screen for any UTI that could cause confusion. UTIs are common in older adults due to reduced bladder function, incomplete emptying, and decreased immunity. UTIs can cause symptoms such as dysuria, frequency, urgency, hematuria, and delirium.

A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/Ml VIAL. How many mL should the nurse administer? (enter numerical value only. If rounding is required, round to the nearest tenth.)

ANSWER: 1.4 mL. RATIONALE: Calculate the total dosage required: 44 mcg/kg * 65 kg = 2860 mcg. Convert mcg to mg: 2860 mcg / 1000 = 2.86 mg. Divid by concentration: 2.86 mg / 2 mg/ mL = 1.43 mL or 1.4 mL.

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which intervention is most important for the nurse to implement? A Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B Verify troponin level assessments are scheduled every 3-6 hours for a series of three. C Count and record the number of premature ventricular contractions per minute. D Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%.

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Ask the client to describe the pain

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begins to show improvement in affect RATIONALE: When a depressed client begins to show signs of improvement, it can be because the client has "figured out" how to be successful in committing suicide. Depressed clients, particularly those who have shown signs of potentially becoming suicidal, should be watched with care for an impending suicide attempt might be greater when the client appear suddenly happy, begin to give away possessions, or becomes more relaxed and talkative.

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-lerm nurang facility. The clem lis anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care? A Initiate toileting schedule. B Monitor for signs of anemia. C Encourage intake of high potassium foods. D Provide perineal skin barrier cream.

B Monitor for signs of anemia.

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? A Place an indwelling urinary catheter and institute strict intake and output measurements. B Record pain score and administer sublingual nitroglycerine every 5 minutes up to 3 doses. C Verify troponin level assessments are scheduled every 3-6 hours for a series of three. D Count and record the number of premature ventricular contractions per minute.

B Record pain score and administer sublingual nitroglycerine every 5 minutes up to 3 doses.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours. B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection. C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery. D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide? A. Discuss that partners without similar symptoms may not be infected. B. Answer questions directly and correct any misinformation. C. Provide counseling that most contraceptives protect against infection. D. Notify that persons with STIs are reported to local health departments.

B. Answer questions directly and correct any misinformation.

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review? A. Liver enzymes. B. Complete blood count. C. Serum electrolytes. D. Platelet count.

B. Complete blood count.

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching? A. Eat high protein foods to achieve ideal body weight. B. Report experiencing right upper quadrant discomfort. C. Use electric heating pad when pain is at its worse. D. Replace dietary table salt with salt substitutes.

B. Report experiencing right upper quadrant discomfort.

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)? A. Call the pharmacy to obtain a client's next antibiotic dose. B. Observe a client's gait to determine the need for assistance. C. Bring a sterile chest drainage unit from central supply to the unit. D. Evaluate a client's urinary catheter for proper drainage.

C. Bring a sterile chest drainage unit from central supply to the unit.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? A. Center attention on positive upbeat music. B. Find outlets for more social interaction. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

C. Practice using muscle relaxation techniques.

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement? A. Clarify reality with the client about delusional thoughts. B. Reduce the client's interaction with others during day. C. Use distraction and therapeutic communication skills. D. Awaken the client for reality checks every 4 hours at night.

C. Use distraction and therapeutic communication skills.

The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 ml. remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report? A. Peripheral pulses present with full range of motion of both legs. B. History of vomiting at home for 3 days prior to surgery. C. Soft abdomen, absent bowel sounds, no bleeding on dressing. D. Declining to take ice chips for complaints of dry mouth.

C. Soft abdomen, absent bowel sounds, no bleeding on dressing.

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective? A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

D. A tuna fish sandwich with chips and ice cream.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention? A. Initiate bilateral intermittent sequential pneumatic compression devices B. Administer aspirin to prevent further clot formation and platelet clumping C. Place indwelling catheter and measure strict I/O D. Obtain focused history to determine recent bleeding and use of anticoagulants

D. Obtain focused history to determine recent bleeding and use of anticoagulants

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? A. Document that an accurate oxygen saturation reading cannot be obtained B. Elevate to client's hands for five minutes prior to obtaining a reading from the finger C. Increase the oxygen based on the clients breathing patterns and lung sounds D. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

D. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

NGN CASE STUDY: 24YO F presents to ED w/abdominal pain. The client reports that she was vacuuming in her home approximately 1 hours prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. The client has a prior medical history of anxiety and constipation. The stool soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 weeks ago. She is not currently sexually active. Her partner was two years ago. a. SELECT 4 ASSESSMENT FINDINGS THAT REQUIRE IMMEDIATE FOLLOW UP: i. Respirations 28 breaths/minute with shallow breathing. ii. Feels anxious. iii. Radial and Pedal pulses +2 iv. Blood Pressure 115/76 mm Hg v. Heart Rate 121 beats/ minute vi. Capillary refill 2 seconds. vii. Severe abdominal pain in right lower quadrant viii. Temperature 100.8 F ix. Vomiting small amounts of green bile

The four assessment findings that require immediate follow-up are: 1. Respirations 28 breaths/minute with shallow breathing - This is above the normal range of 12-20 breaths per minute for adults and indicates that the patient may be experiencing respiratory distress. 2. Heart Rate 121 beats/ minute - This is also above the normal range of 60-100 beats per minute for adults and could indicate a response to pain, anxiety, or other underlying conditions. 3. Severe abdominal pain in right lower quadrant - This could indicate a number of serious conditions such as appendicitis, especially when combined with the patient's other symptoms. 4. Vomiting small amounts of green bile - This could indicate a blockage in the digestive tract or other serious gastrointestinal issues.

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Apply intermittent pneumatic compression devices. b. Maintain intervascular infusion rate. c. Obtain frequent pain level assessments. d. Progress diet slowly from ice chips to clear liquids.

a. Apply intermittent pneumatic compression devices. (This action is important to prevent deep vein thrombosis (DVT) in immobile patients. It helps to improve blood circulation in the legs.) RATIONALE: The most important action for the nurse to take to prevent postoperative complications in an immobile client after spinal surgery is to apply intermittent pneumatic compression devices.

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Apply intermittent pneumatic compression devices. b. Maintain intervascular infusion rate. c. Obtain frequent pain level assessments. d. Progress diet slowly from ice chips to clear liquids.

a. Apply pneumatic compression devices RATIONALE: The most important action for the nurse to take to prevent postoperative complications in an immobile client after spinal surgery is to apply intermittent pneumatic compression devices.

After receiving report on an inpatient acute care unit, which client should the nurse assess first? a. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. b. The client who has surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. c. The client with an obstruction of the large intestine who is experiencing abdominal distention. d. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. RATIONALE: A small bowel obstruction is a potentially serious condition, and the drainage of green fluid through the nasogastric tube may indicate a possible bowel perforation or compromised blood supply. This situation requires immediate assessment and intervention to prevent further complications or deterioration of the client's condition.

a. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. RATIONALE: A small bowel obstruction is a potentially serious condition, and the drainage of green fluid through the nasogastric tube may indicate a possible bowel perforation or compromised blood supply. This situation requires immediate assessment and intervention to prevent further complications or deterioration of the client's condition.

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18 (16?) gauge needle. What action should the charge nurse take? a. Suggest starting a secondary infusion at the IV tubing port. b. Direct the nurse to remove the needle before the procedure. c. Send an unlicensed assistive personnel (UAP) to gather equipment. d. Propose that the nurse use the antecubital site for IV access.

b. Direct the nurse to remove the needle before the procedure. (This is the correct action. Needles are not used to irrigate intravenous catheters. Instead, a syringe is attached directly to the catheter or extension tubing to flush the line.)

A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Blood alcohol level of 0.09% b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) c. Six hours of sleep in the past three days. d. Weight loss of 10 pounds (4.5 kg) in past month.

b. Serum lithium level of 1.6 mEq/L or mmol/l (SI)

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists. b) Move the ties so the restraints are secured to the side rails. c) Ensure that the knot can be quickly released. d) Tie the knot with a double turn or square knot.

c) Ensure that the knot can be quickly released.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a- Conversion of the client's PPD test from negative to positive. b- Length of time of the exposure to tuberculosis. c-Current diagnosis of hepatitis B. d- History of intravenous drug abuse.

c-Current diagnosis of hepatitis B.

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach

c. Use cold and allergy medications only as directed by a health care provider

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include heart rate of 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmhg. Which assessment finding warrants the most immediate intervention by the nurse? a. Bilateral diffuse wheezing. b. Temperature of 100.5. c. Yellow expectorated sputum. d. Shortness of breath on exertion.

c. Yellow expectorated sputum.

A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? a.Administer epinephrine IV b.Give an IV bolus of amiodarone c.Provide immediate defibrillation d.Prepare for synchronized cardioversion

c.Provide immediate defibrillation

The nurse assesses a client who has bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. What action should the nurse implement? a. Monitor the client's current WBC. b. Withhold next scheduled dose of low molecular weight heparin. c. Confirm that the continuous passive motion device is intact. d. Determine if the wound drainage device is functioning correctly.

d. Determine if the wound drainage device is functioning correctly. (This is the correct action. If the dressing is saturated with drainage, the nurse should first check to see if the wound drainage device is functioning properly. If it's not, this could explain the excessive drainage.) RATIONALE: The immediate concern is the excessive drainage from the surgical site.

A client underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? a. Count and record the number of premature ventricular contractions per minute. b. Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three. c. Place an indwelling urinary catheter and institute strict intake and output measurements. d. Record pain score and administer sublingual nitroglycerin every 5 minutes up to 3 doses.

d. Record pain score and administer sublingual nitroglycerin every 5 minutes up to 3 doses. (This is the correct action to take. The patient's symptoms indicate a possible cardiac emergency. Nitroglycerin can help to relieve chest pain by relaxing and widening blood vessels, allowing more blood to flow to the heart.)