Foundations and Practice of Mental Health Nursing HESI EXIT 5

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place.

0.6

A client who has a hemoglobin of 6 gm/dL is refusing blood because of religious reasons. What is the most appropriate action by the nurse?

Notify the primary health care provider of the client's refusal of blood products.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of:

Hypokalemia

A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in:

A plastic liquid detergent bottle with a screw-top lid

A nurse addresses the needs of a client who is hyperventilating to prevent what complication?

Carbonic acid deficit

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication?

Cardiac arrest

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem (Cardizem)?

Change positions slowly

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration?

Failure to secure the catheter adequately

A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure?

Monitoring the extremity distal to the insertion site

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for:

Myocardial depression

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?

Notify the health care provider.

A client is admitted to the hospital with complaints of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. The nurse concludes that the probable cause of the client's presenting adaptations is:

Systemic responses of the body to a localized inflammatory process

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? Select all that apply.

1/Clients have a right to refuse treatment. 2/Nurses are required to answer clients truthfully. 3/The health care provider should have been notified.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply.

1/Pain history, including location, intensity, and quality of pain 2/Pain pattern, including precipitating and alleviating factors

A client is scheduled to receive an IV infusion of potassium chloride (KCl) 40 mEq in 100 mL of 5% dextrose and water to be infused over 2 hours. Before administering this IV medication, it is a priority for the nurse to assess which of the following? (Select all that apply.)

1/Urinary output 2/Last serum potassium level 3/Patency of the intravenous access

The nurse is preparing to administer a subcutaneous dose of 15 units of lispro insulin (Humalog) to a client. Choose the proper syringe for this injection.

15 unit 100 unit syringe

A nurse who is observing a sleeping newborn identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL. The nurse concludes that these findings are indicative of:

Expected adaptations

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received from the pharmacy. What is the most appropriate action for the nurse to take?

Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing?

Hyponatremia

A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe:

Hypotension

The nurse provides discharge teaching to a client who has received prescriptions for digoxin (Lanoxin), furosemide (Lasix), and a 2-gram sodium diet. The nurse evaluates that further teaching is needed when the client states:

I can use a little table salt on my food as long as I do not use it when cooking."

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

Respiratory and urinary

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness

A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The health care provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)?

S-T segment

When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is:

Sodium

A client is admitted to the hospital for a total hip replacement. Included in the health care provider's prescriptions is a prescription for digoxin (Lanoxin) 2.5 mg by mouth daily. The nurse knows that digoxin is supplied in 0.125 mg tablets. What should the nurse do?

Verify the prescription with the health care provider.

What factors are most important for the nurse to consider when delegating responsibilities?

Staff member's level of education and expertise

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond?

"It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

The client is diagnosed with peripheral arterial disease (PAD) and the nurse is discussing lifestyle modifications. Which of these is the most beneficial lifestyle modification the nurse should teach this client?

Stop smoking

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?

"My incision will probably be painful."

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to:

Stop the transfusion

During a blood transfusion a client develops chills and a headache. What should be the nurse's first response?

Stop the transfusion

The health care provider prescribes a progressive exercise program that includes walking for a client with a history of diminished arterial perfusion to the lower extremities. The nurse explains to the client that if leg cramps occur while walking, the client should:

Stop to rest until the pain resolves

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will:

Take clients' vital signs after their procedures are over."

Which nutrient-related problem is common to a newborn infant, a client after a cholecystectomy, and a client receiving anticoagulant therapy after a myocardial infarction?

Blood-clotting function of vitamin K

The nurse has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 and 164/98. What is the appropriate nursing action in response to these readings?

Take the client's blood pressure in the other arm and then schedule a health care practitioner's appointment for as soon as possible.

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

Take vital signs and notify the health care provider.

Knee-length elastic support stockings are prescribed for a client with varicose veins. What should the nurse teach the client about the elastic stockings?

The stockings should be applied before getting out of bed.

A client is admitted with the diagnosis of possible myocardial infarction, and a series of diagnostic tests are prescribed. Which blood level should the nurse expect will increase first if this client has had a myocardial infarction?

Troponin T (cTnT),,

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Verifying oxygen saturation frequently to adjust flow on the basis of need

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Encourage the client to express feelings

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period?

Turning frequently

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1 mg scored tablets. How many tablets should the nurse administer? Record the numeric answer, using one decimal place. _____ tablet(s)

2.5

A client is seen in the clinic with sickle cell anemia. A brief explanation for this condition is:

Abnormally shaped red blood cells.

A male client receiving hemodialysis undergoes surgery to create an arteriovenous fistula. Before discharge, the nurse discusses care at home with the client and his wife. Which statement by the client's wife indicates that further teaching is required?

"I have to take his blood pressure every day in the arm with the fistula."

Furosemide (Lasix) has been prescribed as part of the medical regimen for a client with hypertension, and the nurse has provided related teaching. The nurse concludes that the client needs additional teaching when the client states,

"I plan to eat a food high in vitamin K every day."

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction?

"I should obtain a pneumococcal vaccination each year."

A client asks a nurse why captopril (Capoten) was prescribed. What specific drug classification should the nurse include in the explanation to the client?

Antihypertensive

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?

Decreased blood pressure

A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The mother shares that she is four weeks pregnant and questions as to whether this pregnancy will result in a child with hemophilia. The best response is:

With each pregnancy, there is a 50% chance of a carrier transmitting the condition or being a carrier, depending on the sex of the child.

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best response?

You were in a work-related accident this morning."

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000 mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ___ mL

950

An electrocardiogram (ECG) is performed before a client is to have a cardiac catheterization, and hypokalemia is suspected. To confirm the presence of hypokalemia, the nurse expects the primary health care provider to prescribe:

A serum electrolyte level

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications?

Angiotensin-converting enzyme (ACE) inhibitors

An emergency department nurse is admitting a client after an automobile collision. The health care provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment finding should the nurse expect this client to exhibit?

Apical heart rate of 142 beats/min

A health care provider prescribes epoetin (Epogen) subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first?

Assess the client's readiness to learn.

A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia?

Avoid traumatic injuries and exposure to infection

A client admitted for uncontrolled hypertension and chest pain was prescribed a low sodium diet and started on furosemide (Lasix). The nurse should instruct the client to include which foods in the diet?

Bananas

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy?

Behavioral changes

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood clotting.

A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit the client's vital signs remained stable for one hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?

Check the dressing on the incision

A Foley catheter was placed with an urimeter for an 85-year-old client with a history of congestive heart failure. The output is 45 mL/hour, cloudy, and has sediment. These findings indicate:

Cloudy urine may be indicative of infection.

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?

Complete the entire course of antibiotic therapy.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution?

Cover the infected site with a dressing.

The nurse is caring for a client that is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear what lung sounds?

Crackles

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client?

Demonstrate correct use of the insulin pump."

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will:

Determine adequate dosage levels of the drug."

A client who is receiving multiple medications for a myocardial infarction complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of:

Digoxin (Lanoxin)

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion?

Diuretic therapy

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching?

Do not change positions suddenly

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take?

Don an N95 respirator mask before entering the room.

A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings?

Don the stockings before getting out of bed in the morning

For which common complication of myocardial infarction (MI) should the nurse monitor the client that has been admitted to the coronary care unit for two days?

Dysrhythmia

A nurse is caring for a postoperative client that has a nasogastric tube set to low intermittent suction. The nurse recalls that the primary reason that an IV of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent:

Electrolyte imbalance

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to:

Elevate the circulating blood volume.

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture?

Eliminates surface bacteria that may contaminate the culture

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?

Encourage early mobility.

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results?

Excessive mechanical ventilation

Several individuals who sustained urgent but nonemergent injuries are seated in the emergency department when an ambulance arrives with a client suspected of having a myocardial infarction. The nurse must explain to the waiting clients that they will have to wait longer for care. Which is the best explanation for the nurse to give?

I know you have been waiting, but a client's life depends on immediate treatment. You will receive the same attention when you are seen."

A client is admitted with a higher than expected red blood cell (RBC) count. What physiological alteration does the nurse expect will result from this clinical finding?

Increased blood viscosity

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse explain increases the risk of these thromboses?

Increased blood viscosity

A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take?

Initiate an agency incident report.

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). What clinical finding confirms this complication?

Jaundice that develops in the first 12 to 24 hours

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do?

Keep a record of the day's activities

A client is diagnosed with hypertension that is related to atherosclerosis. The nurse recalls that with atherosclerosis:

Lipid plaque formation occurs within the arterial vessels

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication?

Medication is not adequately effective.

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? Select all that apply.

Melena Tachycardia

An 85-year-old client has a serum potassium level of 6.7 mEq/L. Which nursing action is a priority at this time?

Monitor for cardiovascular irregularities

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take?

Notify the primary healthcare provider of the result that is critically low.

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective?

Pain subsides as a result of arteriole and venous dilation

The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. The response that demonstrates emotional readiness for the surgery is when the client:

Participates in learning perioperative care

A client develops heart failure. Which response should the nurse expect when assessing the client?

Peripheral edema

A client who has a history of several myocardial infarctions is admitted to the hospital for an unrelated medical condition. Because of the client's history, the nurse is concerned about the possibility of the client experiencing right ventricular failure. For what early common indication of right ventricular failure should the nurse monitor the client?

Peripheral edema

After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing?

Place the dressing in a red bag/hazardous materials bag.

What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open heart surgery?

Plan for maximum periods of rest.

A nurse weighs a neonate who is born at 29 weeks' gestation. The weight is 1619 g (3 lb 9 oz). In light of this weight and gestational age, how should this infant be classified?

Preterm

A client diagnosed with multiple myeloma has been given a poor prognosis. After discharge, the client plans to travel on an airplane and attend sporting events with friends and family. The nurse prepares a discharge teaching plan for this client and includes:

Preventing infection; the client is at risk for leukopenia

A client is admitted to the coronary care unit complaining of "viselike" chest pain radiating to the neck. Assessment reveals a blood pressure of 124/64, an irregular apical pulse of 64 beats per minute, and diaphoresis. Cardiac monitoring is instituted and morphine sulfate 4 mg intravenous (IV) push stat is prescribed. The priority nursing care for this client is directed toward:

Relief of pain

A nurse who is caring for a client experiencing anginal pain expects that the pain will be:

Relieved by sublingual nitroglycerin