D1 301-350 Hesi

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)

0.4 Rationale: Calsulate 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

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.)

12.5 Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) Administer a daily dose of lisinopril as scheduled. Assess the client for postural hypotension. Notify the healthcare provider immediately Provide a PRN dose of acetaminophen for headache Withhold the next scheduled daily dose of warfarin.

Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache

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

Administer a nebulizer Treatment Rationale: The client needs an immediate medicated nebulizer treatment. Sitting in an upright position with head and arms resting on the over-bed table is an ideal position to promote breathing because it promotes lung expansion. Other actions me be accurate but not yet indicated.

When should intimate partner violence (IPV) screening occur? As soon as the clinician suspects a problem Only when a client presents with an unexplained injury As a routine part of each healthcare encounter Once the clinician confirms a history of abuse

As a routine part of each healthcare encounter Rationale: Universal screening for IPV is a vital means to identify victims of abuse in relationship. The suspicious of different clinicians vary greatly, so screening would not be implemented consistently. The client should be screened regardless of the presence of injury. Although history of abuse is difficult to confirm, screening should occur regardless, and this incident may know may be initial case of abuse.

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? Arrange transport for admission to the hospital. Insert saline lock for IV diuretic therapy. Assess compliance with routine prescriptions. Instruct the client to monitor daily caloric intake.

Assess compliance with routine prescriptions. Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction range is 50 to 75%)

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? Examine the client's room for hidden food. Assign staff to monitor what the client eats. Ask the client if the food provided is being eaten or discarded. Provide the client with a high calorie diet.

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.

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today? Assist client in identifying goals for the day. Encourage client to participate for one hour in a team sport. Schedule client for a group that focuses on self-esteem. Help client to develop a list of daily affirmations.

Assist client in identifying goals for the day. Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participate in care by identifying goals for the day is the most important intervention for the client's first day at the unit. Other options can be implemented over time, as the depression decreases.

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? Limit intake fatty foods for one month after surgery. Notify the healthcare provider if edema occurs. Increase activity and exercise gradually, as tolerated. Avoid crowds for first two months after surgery.

Avoid crowds for first two months after surgery. Rationale: Cyclosporine immunosuppression therapy is vital in the success of liver transplantation and can increase the risk for infection, which is critical in the first two months after surgery. Fever is often.

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? Do not read without direct lighting for 6 weeks. Avoid straining at stool, bending, or lifting heavy objects. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

Avoid straining at stool, bending, or lifting heavy objects. Rationale: after cataract surgery, the client should avoid activities which increase pressure and place strain on the suture line.

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? Confusion and tremors Yellowing and itching of skin. Abdominal pain and vomiting Anorexia and abdominal distention

Confusion and tremors Rationale: daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action.

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.)

Correct : ODCP 1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to 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 Rationale: First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients' meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle.

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? Total calcium 9 mg/dl (2.25 mmol/L SI) Creatinine 4 mg/dl (354 micromol/L SI) Phosphate 4 mg/dl (1.293 mmol/L SI) Fasting glucose 95 mg/dl (5.3 mmol/L SI)

Creatinine 4 mg/dl (354 micromol/L SI)

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? Conversion of the client's PPD test from negative to positive. Length of time of the exposure to tuberculosis. Current diagnosis of hepatitis B. History of intravenous drug abuse.

Current diagnosis of hepatitis B. Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment.

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? Report the incident to the local child protective services. Find a home health agency that specializes in brain injuries. Determine the mother's basic skill level in providing care. Consult the ethics committee to determine how to proceed.

Determine the mother's basic skill level in providing care. Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother's skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions.

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? Determine when the client last had an influenza vaccination. Discuss the concerns expressed by the client about the vaccination. Ask about any recent exposure to persons with the flu or other viruses. Review the informed consent form for the vaccination with the client.

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.

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? Evaluate closet proximal pulse. Asses skin elasticity of the stump. Observe for swelling around the stump. Note amount color of wound drainage.

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. The leg of a client who is receiving hospice

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? Determine the client's level of emotional functioning' Assess functional ability of the primary support system. Evaluate the client's mood, cognition and orientation. Review the client's pattern of adaptive coping skill

Evaluate the client's mood, cognition and orientation. Review the client's pattern of adaptive coping skill 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.

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? Explain that the client will start to lose consciousness and his body system will slow down Reassure the spouse that the healthcare provider will let her know when to call the children Offer to discuss the client's health status with each of the adult children Gather information regarding how long it will take for the children to arrive

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

Explore the client's decision to refuse treatment and offer support Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client's decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings

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) Seeds, spices, lettuce Consomme, celery, carrot Oranges, orange juice, bananas Fortified whole wheat cereals, whole-grain pasta, brown rice Spinach, kale, dried raisins and apricots

Fortified whole wheat cereals, whole-grain pasta, brown rice 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

In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? Elevated thyroid hormone level. Hematocrit of 28%. Heart rate of 92 beats per minute. Systolic murmur.

Hematocrit of 28%. Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28% is below pregnant norms and could signify iron-deficiency anemia. Other options are normal finding pregnancy

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings? Squeeze the nipple base to introduce milk into the mouth Position the baby in the left lateral position after feeding Alternate milk with water during feeding Hold the newborn in an upright position

Hold the newborn in an upright position Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated by the use of special feeding appliances and nipples such as the haberman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce a volume that is greater than the neonate can coordinate swallowing. The preferred positon of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate's intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate's stomach.

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? Clean up the spilled blood to reduce infection transmission. Notify the healthcare provider that the client appears to be bleeding. Apply direct pressure to the client's IV site. Identify the source and amount of bleeding.

Identify the source and amount of bleeding. Rationale: the nursed should first assess the client to determine the action that should be taken. Patient safety is the priority; other options are not priority.

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? Hygiene-self-care deficit Imbalance nutrition Disturbed sleep pattern Self-neglect

Imbalance nutrition Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition. Other options are nursing problems that should also be addresses with the client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) Decrease laxative use to every other day, and use oil retention enemas as needed. Include oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation. Report constipation to healthcare provider related to cardiac medication side effects.

Include oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation. Rational: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas.

What action should the school nurse implement to provide secondary prevention to a school-age children? Collaborate with a science teacher to prepare a health lesson Prepare a presentation on how to prevent the spread of lice Initiate a hearing and vision screening program for first-graders Observe a person with type 1 diabetes self-administer a dose of insulin

Initiate a hearing and vision screening program for first-graders Rationale: Community care occurs at primary, secondary, and tertiary levels of prevention. Primary prevention involves interventions to reduce the incidence of disease. Secondary prevention includes screening programs to detect disease. Tertiary prevention provides treatment directed toward clinically apparent disease. Secondary prevention focuses on screaming children for a specific disease processes such as hearing and vision screening. The other options are not examples of secondary prevention.

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? The intravenous fluid replacement contains a hypertonic solution of sodium chloride Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained by hem concentration.

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

Instructions about how much fluid the child should drink daily information about non-pharmaceutical pain reliever measures

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) Check urine for ketones Measure blood glucose Monitor vital signs Assessed level of consciousness Obtain culture of wound

Measure blood glucose Monitor vital signs 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.

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? Obtain a urine sample from the bed pan Remove dressing and assess surgical site Insert an indwelling urinary catheter Measure the client's oral temperature

Measure the client's oral temperature Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client's temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation at this time. An indwelling catheter should be avoided if possible because it increases the risk of infection Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client's temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation at this time. An indwelling catheter should be avoided if possible because it increases the risk of infection

After receiving report, the nurse can most safely plan to assess which client last? The client with... A rectal tube draining clear, pale red liquid drainage A distended abdomen and no drainage from the nasogastric tube No postoperative drainage in the Jackson-Pratt drain with the bulb compressed Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.

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.

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

Notify the healthcare provider of the client's lack of understanding. Rational: the nurse is only witnessing the signature, and is not responsible for the client's understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider's legal responsibility. The other options are not indicated.

A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? Offer to provide the influenza vaccination to the student while she is at the clinic Encourage the student to obtain a vaccination prior to the next influenza season. Confirm that a history of asthma can increase risks associated with the vaccine. Advise the student that the nasal spray vaccine reduces side effects for people with asthma.

Offer to provide the influenza vaccination to the student while she is at the clinic Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma but the nasal spray may result in increased wheezing after receiving that form of the vaccination.

When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk. Brussel sprouts, blackberries, seeds. Corn bran, whole wheat bread, whole grains.

Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk. Rational: 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.

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? Encourage the client to turn on her left side. Place a pillow under the client's head and knees. Explain to the client that her position is not safe. Place a wedge under the client's right hip.

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.

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? Chew food slowly and thoroughly before attempting to swallow Plan volume-controlled evenly-space meal thorough the day Sip fluid slowly with each meal and between meals Eliminate or reduce intake fatty and gas forming food

Plan volume-controlled evenly-space meal thorough the day

A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action? Postpone discharge instructions at this time and offer to contact the client by phone in a few days Invite the client to return to the unit for discharge teaching in a few days, when there is less anxiety Provide only necessary information in short, simple explanations with written instructions to take home Give detailed instructions speaking slowly and clearly while looking directly at the client when speaking

Provide only necessary information in short, simple explanations with written instructions to take home Rationale: Simple, short explanations should be provided. Information is not retained when the recipient is anxious, and too much information can increase worry. Ethically, discharge instructions may not be postponed.

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) Encourage the woman at risk for cancer to obtain colonoscopy. Present a class of breast-self examination Prepare a woman for a bone density screening Explain the follow-up need it for a client with prehypertension.

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.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? Remove the heating pads and place a soft blanket over the client's leg and feet. Advise the UAP to observe the client's skin while the heating pads are in place. Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently. Instruct the UAP to reposition the heating pads to the sides of the legs and feet.

Remove the heating pads and place a soft blanket over the client's leg and feet.

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

Report mental status change to the healthcare provider Assess the client's breath sounds and oxygen saturation Review the client's most recent serum electrolyte values Rationale: The healthcare provider should be informed of changes in the client's condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP (D).

The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Reposition the infant every 2 hours. Perform diaper changes under the light. Feed the infant every 4 hours. Cover with a receiving blanket.

Reposition the infant every 2 hours. Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy.

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take? Ask family member to wear gloves when touching the patient Send family to the waiting area while the client's history is taking Obtain a blood sample to determine is the client is HIV positive Complete the head to toes assessment to identify other sign of HIV

Send family to the waiting area while the client's history is taking Rationale: To protect the client privacy, the family member should be asked to wait outside while the client's history is take. Gloves should be worn when touching the client's body fluids if the client is HIV positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without the client explicit permission. A further assessment can be implemented after the family left the room.

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

Thiamine Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is Two days postoperative bladder surgery with continuous bladder irrigation infusing. One day postoperative laparoscopic cholecystectomy requesting pain medication. Three days postoperative colon resection receiving transfusion of packed RBCs. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

Three days postoperative colon resection receiving transfusion of packed RBCs.

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? Irrigate the indwelling urinary catheter. Prepare the client for external pacing. Obtain capillary blood glucose measurement. Titrate the dopamine infusion to raise the BP.

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.

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) Topical corticosteroid. Topical scabicide. Topical alcohol rub. Transdermal analgesic. Oral antihistamine

Topical corticosteroid. Oral antihistamine

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? Transfuse Type A negative blood until type AB negative is available. Recheck the client's hemoglobin, blood type and Rh factor. Administer normal saline solution until type AB negative is available Obtain additional consent for administration of type A negative blood

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.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake. Initiate IV fluid replacement. Administer antiemetic as needed. Evaluate intake and output ratio. Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

clubbing