mid term hesi

nurse is caring for a client with diabetes insipidus (DI). which data warrants the most immediate interventions by the nurse? A. serum sodium of 185 mEq/L (185mmol/L) B. Dry skin with inelastic turgor C. apical rate of 110 beats per minute D. polyuria and excessive thirst

A. serum sodium of 185 mEq/L (185mmol/L)

A client with chronic kidney disease is started to hemodialysis. during the first dialysis treatment the client blood pressure drops from 150/90 mmHg to 80/30. which action should the nurse take first. A. stop the dialysis treatment B. Administer 5% albumin IV C. monitor blood pressure q45 mins D. lower the head of the chair and elevate the feet

A. stop the dialysis treatment

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. the client is anxious and is complaining of a dry mouth. which intervention should the nurse implement A. Assist client to an upright position B. Administer a prescribed sedative c. Apply a high flow venturi mask D. Encourage client to drink water

A. Assist client to an upright position

a client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider A. Distended, hard, and rigid abdomen B. Clay-colored stool C. Radiating, sharp pain in right shoulder D. Bile -stained emesis

A. Distended, hard, and rigid abdomen

The nurse is obtaining a health history from a new client who has a history stones. which statement by the client indicates an increased risk for renal calculi? A. Eats a vegetarian diet with cheese 2 to 3 times a day B. Experiences additional stress since adopting a child C. Jogs more frequently than usual daily routine D. Drinks several bottles of carbonated water daily

A. Eats a vegetarian diet with cheese 2 to 3 times a day

A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the clients hemoglobin is 12 g/dL (120 g/L) and the hematocrit is 35% (0.35). which action should the nurse prepare to take? A. continue to monitor for blood loss B. Administer 1000 (1L) normal saline C. Transfuse 2 units of platelets D. Prepare the client for emergency surgery

.B Administer 1000 (1L) normal saline

The healthcare provider prescribes penicillin 200,000 units intramuscularly for client with pneumonia. the available vial is labeled penicillin 500,000 units/mL. how many mL should the nurse administer to this client

0.4

The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, as seen in the video, which instruction should the nurse provide. watch the video A. Select a different injection site B. continue with the insulin injection C. Keep the skin flat rather than bunched D. lie down flat for better skin exposure

B. continue with the insulin injection

A client receives a prescription for 1 liter of lactated Ringer's intravenously to be infused over 6 hours . how many mL/hr should the nurse program the infusion pump to deliver

167

The nurse is providing discharge instruction to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison Ivy . which symptoms should the nurse tell the client to report to the health care provider A. rapid weight gain B. Abdominal striae C. Moon facies D. Gastric irritation

A. rapid weight gain

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 SI) the client describe to the nurse of not understanding why the blood glucose level continues to be out of control. which interventions should the nurse implement. select all A. Have the client describe a typical day at work, home and social activities B. Determine if the client is using a new insulin needle each administration C. Evaluate the client's asthma medications that can elevate the blood glucose D. Ask the client if they want a different manufacturer's glucose monitoring device E. Have the client demonstrate techniques used to monitor blood glucose levels

A. Have the client describe a typical day at work, home and social activities E. Have the client demonstrate techniques used to monitor blood glucose levels

During spring break, a young adult presents to the urgent care clinic and reports stiff neck, a fever for the past 6 hours and a headache. What intervention is most important for the nurse to implement first A. Initiate isolation precautions B. Administer an antipyretic C. Draw blood cultures D. prepare for a lumbar puncture

A. Initiate isolation precautions

An adult who was recently diagnosed with glaucoma tells the nurse, it fells like i am driving through the tunnel". the client expressed great concern about going blind, which nursing instruction is most important A. Maintain prescribed eye drop regimen B. Avoid frequent eye pressure measurement C. wear prescription glasses D. eat a diet high in carotene

A. Maintain prescribed eye drop regimen

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement A. Perform chest physiotherapy B. teach the client breathing exercises C. Initiate passive range of motion excercises D. Establish a regular bladder routine E. Encourage use of incentive spirometer

A. Perform chest physiotherapy B. teach the client breathing exercises E. Encourage use of incentive spirometer

A healthcare provider prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia, which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? A. Sputum culture and sensitivity B. Blood cultures C. Arterial blood gasses (ABG) D. computerized tomography (CT) of the chest

A. Sputum culture and sensitivity

which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet A. fortified milk and cereals B. Citrus fruits and juices C. Green leafy vegetable D. Red meats and eggs

A. fortified milk and cereals

The nurse is caring for a client in post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. the nurse observes the following vital signs. HR 140 bpm, R 26, bp 140/90 which intervention is most important for the nurse to implement? A. medicate for pain and monitor vital signs according to protocol b. administer intravenous fluids bolus as prescribed by the healthcare provider c. apply oxygen at 10L via non-rebreather mask and monitor pulse oximeter d. encourage the client to splint the incision with a pillow to cough and deep breathe

A. medicate for pain and monitor vital signs according to protocol

A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with a normal saline is infusing and the nurse observers dark, pink-tinged outflow with blood clots in the tubing and collection bad. which action would the nurse take? A. monitor catheter drainage B. decreasing the flow rate C. Irrigating the catheter manually D. Discontinuing infusing solution

A. monitor catheter drainage

The nurse is caring for a client who is postoperative for a femoral head fracture repair . Which interventions should the nurse plan to administer for deep vein thrombosis prophylaxis. Select all that apply A. pneumatic compression devices B. Incentive spirometer C. assist with ambulation D. patient- controlled analgesia E. Calf-pump exercises F. Prescribed anticoagulant therapy

A. pneumatic compression devices E. Calf-pump exercises F. Prescribed anticoagulant therapy

A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF) . The nurse determines that the client distal pulses are diminished in the left foot. which interventions should the nurse implement? (select all that apply) A. verify pedal pulses using a doppler pulse device B. Evaluate the application of the splint to the left leg C. Offer ice chips and oral clear liquids D. Monitor left leg for pain, pallor, paraesthesia, paralysis, pressure E. Administer oral antispasmodics and narcotic anaglesics.

A. verify pedal pulses using a doppler pulse device B. Evaluate the application of the splint to the left leg D. Monitor left leg for pain, pallor, paraesthesia, paralysis, pressure

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. the nurse observe the area of inflammation extends above the ankle area. the client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? A. Eat high protein food to achieve ideal body weight B. Drink at least 8 cups of water per day C. Use electric pad when pain is at its worse D. Encourage active range of motion of limit stiffness

B. Drink at least 8 cups of water per day

An obese client with emphysema who smokes at least a pack of cigarettes daily after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan. A. methods for weight loss B. Guideline for oxygen use C. Approaches to conserve energy D. Strategies for smoking cessation

B. Guideline for oxygen use

A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. which action should the nurse implement A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Identify all sexual partners in the last four days

B. Obtain a specimen of urethral drainage for culture

A client with Herpes zoster (shingles) on the thorax the nurse having difficulty sleeping. Which is the probable etiology of this problem A. Frequent cough B. Pain C. Nocturia D. Dyspnea

B. Pain

A client is hospitalized with heart failure (HF). which intervention should the nurse implementation to improve ventilation and reduce venous return A. Perform passive range of motion exercises B. Place the client in high Fowler position C. Administer oxygen per nasal cannula D. Increase the client's activity level.

B. Place the client in high Fowler position

the nurse assesses a client with petechiae (bleeding into the skin) and ecchymosis (Large bruise area) scattered across the arms and legs. Which laboratory result should the nurse review A. red blood cell B. Platelet count C. Hemoglobin levels D . White blood cell count

B. Platelet count

A client with acute renal injury (AKI) weighs 50kg and potassium level of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. which prescribed medication should the nurse administer first? A. Calcium acetate one tablet by mouth B. Sodium polystyrene sulfonate 15 grams by mouth C. Epoetin alfa, recombinant 2500 units subcutaneously D. sevelamer one tablet by mouth

B. Sodium polystyrene sulfonate 15 grams by mouth

which client has highest risk for developing skin cancer A. a 70 yr old fair skinned client who works as a secretary B. a 65 yr old fair skinned client who is a construction worker C. a 16 yr old dark skin client who tans in tanning beds once a week D. a 25 yr old dark skinned client whose mother had skin cancer

B. a 65 yr old fair skinned client who is a construction worker

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action A. monitor hemoglobin and hematocrit B. Encourage turning and deep breathing C. Administer IV antibiotics as prescribe D. Auscultate for presence of bowel sounds

C. Administer IV antibiotics as prescribe

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? A. elevate extremities on pillows B. Evaluate edema for pitting C. Assess pulses with a vascular Doppler D. Wrap the feet with warmed blankets

C. Assess pulses with a vascular Doppler

The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. the client has expressive aphasia and often become frustrated with the nursing staff. which intervention should the nurse implement A. Teach the client use of basic sign language B. Speak slowly to the client C. Encourage client's use of picture charts D. ask the client simple questions

C. Encourage client's use of picture charts

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) What is the best initial nursing action A. Provide additional oral fluid intake B. Measure the client's intake and output C. Increase the flow of the bladder irrigation D. Administer a PRN dose of an antispasmodic agent

C. Increase the flow of the bladder irrigation

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations of 16 beats/ min oxygen saturation 96%, and blood pressure 116/70 mmHg. The nurse obtains a 12 leads ECG. which assessment finding is most critical. A. Irregular pulse rate B. Blue colored emesis C. ST elevation in three leads D. Complaint of radiating jaw pain

C. ST elevation in three leads

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include A. Have small frequent meals and sit up for at least two hours after meals B. Eat a bland diet and avoid spicy foods C. eat a high-fiber and increase fluids intake D. Eat a soft diet with increased intake of milk and milk products

C. eat a high-fiber and increase fluids intake Because high fiver help soften the stools and prevent constipation that can irritate the colon and prevent flare up

the nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain A. presence and activity of bowel sounds B. color and consistency of feces C. eating patterns and dietary intake D. level and amount of physical activity

C. eating patterns and dietary intake

the nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client's plan of care? A. Assess for signs of increased intracranial pressure B. Prepare to administer intravenous levothyroxine C. Review the client's serum electrolyte values D. Obtain a prescription for artificial tear drops

D. Obtain a prescription for artificial tear drops

A client who had C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to full bladder. Which assessment finding should the nurse expect this client to exhibit A. Complaints of chest pain and shortness of breath B. Hypotension and venous pooling in the extremities C. Profuse diaphoresis and severe, pounding headache D. Pain and a burning sensation upon urination and hematuria

D. Pain and a burning sensation upon urination and hematuria

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath , productive cough with, thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self care? A. Call the clinic if undesirable side effects of medications occur B. Avoid crowed enclosed areas to reduce pathogen exposure C. Increase the daily intake of oral fluids to liquefy secretions D. Teach anxiety reduction methods for feeling of suffocation

Increase the daily intake of oral fluids to liquefy secretions

An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. the healthcare provider prescribes ferrous sulfate 325mg PO daily. which laboratory values should the nurse monitor. A. platelet count and hematocrit b. serum electrolytes c. serum iron and ferritin d. neutrophils and eosinophils

c. serum iron and ferritin (because it is the most consistent finding risk factor to RLS is iron insufficiency)

A client with orthopnea (discomfort when breathing when lying down) expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based? a. a thoracentesis is a brief procedure that has minimal discomfort b. orthopnea is frequently caused by a client's uncontrolled anxiety c. the procedure is performed with the client in an upright position d. extra pillows can be used if needed to elevate the client's head

c. the procedure is performed with the client in an upright position

the nurse is obtaining the admission history of a client with suspended peptic ulcer disease (PUD). which subjective data reported by the client supports this medical diagnosis. A. Frequent use of chewable and liquids antacids for indigestion B. severe abdominal cramps and diarrhea after eating spicy food. C. upper mid-abdominal pain described as gnawing and burning D. marked loss of weight and appetite over the last 2 or 4 months

c. upper mid-abdominal pain described as gnawing and burning

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. which mechanism contributes to edema and ascites in client with cirrhosis A. hyperaldosteronism causing an increase sodium reabsorption in renal tubules B. Decreased portacaval pressure with greater collateral circulation c. decreased rein-angiotensin response related to an increased renal blood flow d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure

d. Hypoalbuminemia that results in a decreased colloidal oncotic pressure

while completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. the client reports joint pain and trouble twisting a door knob due to weakness. which action should the nurse take in response to these findings a. explain that relief of the migraine pain will reduce related symptoms b. gather additional assessment data about the pain and weakness c. implement fall precautions to reduce the client risk for injuries' d. consult with the occupational therapist for a functional assessment

d. consult with the occupational therapist for a functional assessment

while caring for a client with a full thickness burns covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client lab a. WBC b. platelet count c. blood pH level d. hematocrit (volume of red blood cell)

a. WBC (because burn cause inflammation, the bigger the burn the higher level of WBC)

a client receives prescriptions for multidrug regimen for the treatment of TB. which information should the nurse prioritize a. adherence to the regimen is imperative b. medication should be taken with food c. serum liver panels are collected regularly d. enhanced sun protection measures will be needed.

a. adherence to the regimen is imperative

the nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. which information should the nurse provide a. family members can help with regular foot exams b. heating pads are useful if on the lowest setting c. aching feet may be soaked in lukewarm water for one hour or more d. shoes should be worn outside the house , but it is fine to be barefoot inside

a. family members can help with regular foot exams

The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. the client has an open femur and is bleeding moderately from the bone protrusion site. during the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously. what is the priority nursing action a. notify the provider of the client health history b. observes the heparin injections sites for signs of bruising c. have the client sign the surgical and transfusion permits d. ensure that the potential for bleeding is explained to the client

a. notify the provider of the client health history

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. which instruction regarding skin care of the portal site should the nurse provide. a. protect the skin of the radiation portal site from sunlight exposure b. apply moisture lotions daily to the radiation portal site c. avoid washing the skin inside the radiation portal site d. remove the ink mark of the portal after each radiation treatment

a. protect the skin of the radiation portal site from sunlight exposure

the family suspects that acquired immune deficiency syndrome AIDS dementia is occurring in their son who is human immunodeficiency virus (HIV)positive. which symptoms confirms their suspicious a. he has begun to sleep 18 out of 24 hrs b. a change has recently occurred in his hand writing c. he refused to see any of his friends or return their phone calls d. he exhibits angry outburst when the subject of dying is approached

b. a change has recently occurred in his hand writing

a client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. when performing a head to toe assessment, the nurse discovers four analgesic patches on the client body. which intervention should the nurse implement first a. remove all the morphine patches b. administer a narcotic antagonist c. apply oxygen per face mask d. measure the client BP

b. administer a narcotic antagonist

a hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. which statement by the client indicated to the nurse that learning as occurred a. whenever i am sitting in a chair i will keep my legs up to reduce swelling b. i can use a mirror to check the bottoms of my feet for any signs of breakdown c. i will try to keep moving if leg pain occurs to help promote good circulation .d. i will use my swimming pool early in the day while the water is still very cool

b. i can use a mirror to check the bottoms of my feet for any signs of breakdown

a client with Cushing's syndrome (when the body makes too much cortisol (stress hormone) hormone) is recovering from an elective laparoscopic procedure. which assessment finding warrants immediate intervention by the nurse a. purple marks on skin of the abdomen b. irregular apical pulse c. quarter size blood spot on the dressing d. pitting ankle edema

b. irregular apical pulse

A client in the operating room received succinylcholine (skeletal muscle relaxation during intubation). The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? a. hold a prescription for dantrolene until the fever is reduced b. prepare ice packs for placement in the client's axillary area c. call the PACU nurse to prepare prolonged ventilatory support d. determine if prescribed antibiotics were administered preoperatively

b. prepare ice packs for placement in the client's axillary area

An older client with a long term type 2 diabetes mellitus is seen in the clinic for a routine health assessment . which assessment would the nurse complete to determine if a patient with type 2 diabetes mellitus is experiencing long-term complications? select all A. signs of respiratory tract infection b. sensation in feet and legs c. skin condition of lower extremities d. serum creatinine and blood urea nitrogen E. visual acuity

b. sensation in feet and legs c. skin condition of lower extremities E. visual acuity

the nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. which outcome should the nurse indicate in the plan of care for this patient? a. the nurse will encourage the client to walk b. the client's family will state signs and symptoms about the disease c. the client's daily blood pressure will be less than 140/80 this month d. the client's blood pressure readings will be less than 160/90 mmHg

the client's daily blood pressure will be less than 140/80 this month