HESI 600-800

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.

0.33 mL Rationale: 4mg x 0.5 ml=2/6=0.33 ml

Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) 1. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 2. Place stethoscope in suprasternal area to auscultate from bronchial sounds 3. Document normal breath sounds and location of adventitious breath sounds 4. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds

2. Place stethoscope in suprasternal area to auscultate from bronchial sounds 1. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 4. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 3. Document normal breath sounds and location of adventitious breath sounds

The HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If round is required, round to the nearest tenth.)

2.5

A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only)

3 ml/hour Rationale : 0.01 x 500 x 60 / 100 = 3

A female client reports that she drank a liter of a solution to cleanse her intestines... immediately. How many ml of fluid intake should the nurse document? (Whole number)

760 Rationale: 1L=1000mlSubtract the emesis, 1 cup (8 oz)=240ml1000-240=760 ml

The nurse suspect a patient may be hemorrhaging internally. Which findings of an orthostatic test may indicate signs to the nurse of a major bleed? A) A decrease in the systolic blood pressure of 10 mm Hg with a corresponding increase in heart rate of 20. B) An increase in blood pressure when moving from lying to standing. C) A decrease in heart rate when moving from lying to sitting. D) No significant changes in blood pressure or heart rate.

A) A decrease in the systolic blood pressure of 10 mm Hg with a corresponding increase in heart rate of 20.

A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A) Administer PRN dose of albuterol. B) Initiate mechanical ventilation. C) Administer IV corticosteroids. D) Administer IV aminophylline.

A) Administer PRN dose of albuterol.

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take? A) Advise the UAP to resume positioning the client on schedule. B) Leave the client in their current position. C) Document the UAP's actions and inform the charge nurse. D) Contact the client's family for further instructions.

A) Advise the UAP to resume positioning the client on schedule.

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A) Agitation and threatens to harm the staff. B) Elevated body temperature. C) Elevated blood pressure. D) Increased urine output.

A) Agitation and threatens to harm the staff.

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A) Ask the client about gastrointestinal pain. B) Monitor the client's blood pressure. C) Check the client's urinary output. D) Assess the client's level of consciousness.

A) Ask the client about gastrointestinal pain.

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A) Avoid administration of oxygen at high levels for extended periods. B) Increase the oxygen flow rate to ensure adequate oxygenation. C) Use a mask instead of nasal cannula for better oxygen delivery. D) Encourage the child to breathe deeply to maximize oxygen intake.

A) Avoid administration of oxygen at high levels for extended periods.

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning? A) Cold sensitivity. B) Weight gain. C) Hair loss. D) Increased energy levels.

A) Cold sensitivity.

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? A) Contact the healthcare provider immediately to report the laboratory value regardless of the advice. B) Wait until the healthcare provider makes rounds to report the laboratory value. C) Call the laboratory to verify the accuracy of the potassium level. D) Leave a note for the healthcare provider regarding the potassium level.

A) Contact the healthcare provider immediately to report the laboratory value regardless of the advice.

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A) Elevated blood pressure must be anticipated and identified quickly. B) Frequent blood pressure readings help determine the cause of glomerulonephritis. C) Blood pressure readings are necessary for billing purposes. D) It's a routine practice in all pediatric units.

A) Elevated blood pressure must be anticipated and identified quickly.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? A) Evaluate the oxygen saturation. B) Administer the medications as scheduled. C) Encourage the client to lie flat. D) Notify the healthcare provider.

A) Evaluate the oxygen saturation.

An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A) Have you had any difficulty in starting your urinary stream? B) Have you experienced chest pain recently? C) How many meals do you eat in a day? D) Are you allergic to any medications?

A) Have you had any difficulty in starting your urinary stream?

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? A) Leakage around catheter insertion site. B) Clear, yellow urine in the drainage bag. C) Client reporting a sensation of bladder fullness. D) Hematuria noted in the catheter tubing.

A) Leakage around catheter insertion site.

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? A) Maintain contact transmission precautions. B) Isolate the client in a negative pressure room. C) Administer broad-spectrum antibiotics. D) Allow the client to interact freely with other patients.

A) Maintain contact transmission precautions.

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) A) Notify the healthcare provider. B) Administer a higher dose of thyroid medication. C) Prepare the client for immediate surgery. D) Continue with the current medication regimen.

A) Notify the healthcare provider.

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement? A) Observe for unilateral swelling. B) Elevate the client's leg. C) Apply a warm compress to the calf. D) Administer pain medication.

A) Observe for unilateral swelling

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement? A) Place a portable toilet next to the bed. B) Instruct the client to use a wheelchair. C) Assist the client in performing active range of motion exercises. D) Notify the physical therapist for gait training.

A) Place a portable toilet next to the bed.

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? A) Place the side rails in an up position. B) Assist the UAP in making the bed. C) Correct the way the bed is being made. D) Praise the UAP for their efforts.

A) Place the side rails in an up position.

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A) Plastic tubing located at the chest insertion site. B) Drainage collection chamber. C) Water-seal chamber. D) Suction control chamber.

A) Plastic tubing located at the chest insertion site.

An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats/minute. What action should the nurse take? A) Slow the feeding and monitor the infant's response. B) Continue the feeding at the same rate. C) Increase the rate of the feeding. D) Stop the feeding and notify the healthcare provider.

A) Slow the feeding and monitor the infant's response.

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement? A) Stop the transfusion and start a saline flush. B) Administer an antipyretic medication. C) Monitor the client's vital signs closely. D) Notify the healthcare provider immediately.

A) Stop the transfusion and start a saline flush.

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? A) Suggest the use of alternative sources of protein such as dairy products and nuts. B) Encourage the client to continue eating his favorite foods despite the change in taste. C) Provide the client with appetite stimulants. D) Instruct the client to avoid dairy products due to the bitter taste.

A) Suggest the use of alternative sources of protein such as dairy products and nuts.

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? A) Total calcium 5.0 mg/dl. B) Serum potassium 3.8 mEq/L. C) Sodium level 140 mEq/L. D) Hemoglobin level 12.5 g/dL.

A) Total calcium 5.0 mg/dl.

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next? A) Wait 1 minute and palpate the systolic pressure before auscultating again. B) Record the auscultated blood pressure as the systolic pressure. C) Inflate the cuff to 160 mm Hg and repeat the measurement. D) Discontinue blood pressure measurement and report findings to the healthcare provider.

A) Wait 1 minute and palpate the systolic pressure before auscultating again.

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply) A. Close car windows and use air conditioner B. Decrease the raw sugars in the diet. C. Avoid sudden changes in temperature D. Keep away from pets with long hair E. Stay indoors when grass is being cut

A,C,D,E

The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours

A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation

A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? A. Chest physiotherapy should be performed twice a day before a meal. B. Administer a cough suppressant every 6 hours. C. Maintain supplemental oxygen at 4 to 6 L/minute. D. Energy should be conserved by scheduling minimally strenuous activities.

A. Chest physiotherapy should be performed twice a day before a meal. Rationale: Cystic fibrosis causes thick mucus secretions in the respiratory system, so goals of therapy include minimizing respiratory complications. Chest physiotherapy (A) should be performed at least twice a day, early morning and before bedtime, and one hour before meals to minimize appetite suppression caused by expectoration of sputum. (B) should be avoided because they inhibit expectoration, which contribute to developing pulmonary infections. CF is a chronic obstructive pulmonary disease, and oxygen should be administered at no more than 2 L/minute, not (C) to avoid depression of the respiratory drive. Active exercises as tolerated, not (D), should be encouraged to help mobilize secretions.

The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention... A. Determine the availability of two units of packed cells in the blood bank for client B B. Increase the oxygen flow rate to 4 liters/minute per face mask for client A C. Remove any foods, such as banana or orange juice, for the breakfast tray for client C D. Inform client D that surgery is likely to be delayed until the infection responds to antibiotics

A. Determine the availability of two units of packed cells in the blood bank for client B

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex

A. Elevate the head of the bed 60 to 90 degrees

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elev ated blood pressure. Which intervention should the nurse implement first? A. Ensure client takes a diuretic q AM B. Obtain serum creatinine levels daily C. Measure ankle circumference D. Monitor daily sodium intake

A. Ensure client takes a diuretic q AM

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

A. Fresh turkey slices and berries E. raw unsalted almonds and apples

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply.) A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. D. Skin hyperpigmentation. E. Irregular heart beat.

A. Headache and tremors. B. Postural hypotension. C. Pallor and diaphoresis. E. Irregular heart beat. Rationale: (A, B, C, and E) are correct. Addison's crisis results from an acute lack of adrenal cortical hormones. Headache and tremors (A), as well as pallor and diaphoresis (C) may indicate significant hypoglycemia. Hypotension (B) with pale, diaphoretic skin (C) are indicative of progressing signs of life-threatening shock that also require immediate nursing intervention. An irregular heart rate (E) may be the result of hyperkalemia and also requires immediate intervention. (D) is consistent with chronic secondary adrenal insufficiency and does not require immediate nursing intervention.

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg.

A. Hypertension. Rationale: The contraindication for administering clonidine in this scenario is hypertension. Clonidine is an antihypertensive medication and can lower blood pressure. If the client has hypertension, giving clonidine could exacerbate the problem and cause further reduction in blood pressure, potentially leading to complications.

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem? A. Infection B. Ineffective airway clearance C. Altered comfort D. Impaired gas exchange

A. Infection

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?pH 7.50; PaCo2 42; HCO3 33; pO2 92 A. Infuse 0.9 % sodium chloride 500 ml bolus B. Insert nasogastric tube to intermittent suction. C. Maintain head of bed at 45 degrees D. Document strict intake and output A

A. Infuse 0.9 % sodium chloride 500 ml bolus

An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube B. Setup of PCA C. Retraction of the nasogastric tube D. Placement of endotracheal tube

A. Insertion of a left- sided chest tube

A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest? A. Malignancy B. Bacterial infection C. Viral infection D. Lymphangitis

A. Malignancy

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? A. natural whole almonds B. lightly salted potato chips C. Cheddar cheese cubes D. Canned fruits in heavy syrup E. plain, air-popped popcorn

A. Natural whole almonds E. Plain, air-popped popcorn

An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? A. Notify the healthcare provider of the client's refusal B. Administer an oral PRN medication for agitation C. Ask for staff assistance with administering the injection D. explain that oral medications will no longer be required

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

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? A. Place the ID bands on the infant and mother. B. Obtain the infants vital signs. C. Administer vitamin K injection. D. Observe the infant latching onto the breast.

A. Place the ID bands on the infant and mother. Rationale: Prior to leaving the delivery room, the nurse needs to ensure the infant is properly identified (A). (B and C) can be performed when the infant is in the transitional nursery. (D) can be performed prior to the nurse leaving the room, but does not have the priority of (A).

A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC). D. Albumin and protein E. Sodium and potassium

A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC).

The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin? A. Reddened skin areas disappear within 15 minutes of being turned and positioned. B. No complaints of pressure or pain are verbalized by the client after being turned C. Only small areas of redness remain longer than 30 min after the client is turned. D. The client verbalizes feeling better after being turned and positioned

A. Reddened skin areas disappear within 15 minutes of being turned and positioned.

A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? A. Signs a no-self-harm contract. B. Sleep at least 6 hours nightly. C. Attends group therapy every day D. Verbalizes a positive self-image.

A. Signs a no-self-harm contract.

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Talk directly to the adolescent while providing care. B. Monitor vital signs and neuro status every 2 hours. C. Inquire about food allergies and food likes and dislikes. D. Initiate open communication with the teen's parents.

A. Talk directly to the adolescent while providing care. Rationale: Talking directly to the adolescent (A) who is in a sustained vegetative state provides environmental stimulation and includes him in an interpersonal relationship because he may still be able to hear and process verbal communication. (B) is not warranted for a non-acute comatose client. (C) is not warranted for a comatose client or a client who is in a vegetative state. Open communication that is compassionate and honest (D) provides support to the family, but verbal stimulation is an important aspect of caring for comatose clients and offers hope for the possibility of a response.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache

A. Watery diarrhea

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) A.) Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B.) T3 and T4 hormone levels are increased C.) Large protruding eyeballs are a sign of hyperthyroid function D.) Weight gain is a common complaint in hyperthyroidism E.) Early treatment includes levothyroxine (Synthroid).

A.) Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B.) T3 and T4 hormone levels are increased C.) Large protruding eyeballs are a sign of hyperthyroid function

A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The client is unable to complete the procedure because of early morning stiffness. What intervention should the nurse implement?

Assign a UAP to assist the client with a warm shower early in the morning

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A) Proceed with medication administration as scheduled. B) Discontinue the painful IV after a new IV is inserted. C) Assess the IV site without flushing. D) Administer pain medication and reevaluate the IV site later.

B) Discontinue the painful IV after a new IV is inserted.

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? A) How would you describe the location of your pain? B) Does your pain occur when walking short distances? C) Can you tell me about your family history of heart disease? D) What do you typically eat for breakfast?

B) Does your pain occur when walking short distances?

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? A) Administer bronchodilators to improve lung function. B) Evaluate daily blood clotting factors. C) Provide pain relief medications as needed. D) Encourage deep breathing and coughing exercises.

B) Evaluate daily blood clotting factors.

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? A) Reports intermittent low back pain. B) Fetal heart rate of 200 beats/minutes C) Complains of early morning heartburn D) Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI)

B) Fetal heart rate of 200 beats/minutes

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture? A) Administer a local anesthetic to the site. B) Lower the left arm below the level of the heart. C) Apply a warm compress to the affected area. D) Assess the client's blood glucose level.

B) Lower the left arm below the level of the heart.

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan? A) Crush the tablet and mix it with food. B) Take on an empty stomach with a full glass of water. C) Take it at bedtime with a snack. D) Take it with a calcium supplement.

B) Take on an empty stomach with a full glass of water.

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? A. "You have become dehydrated from the nausea. You will need to rest and increase fluid intake" B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms" C. A urine specimen will be needed to determine what kind of infection you have developed" D. use insulin per sliding scale until the nausea resolves, and then resume your oral medication"

B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms"

Which class of drugs is the only source of a cure for septic shock? A. Antihypertensives. B. Antiinfectives. C. Antihistamines. D. Anticholestermics.

B. Antiinfectives. Rationale: Anti-infective agents (B), such as antibiotics, are the only drugs that eliminate bacteria. The only way to halt the destruction to organ systems in septic shock is to eliminate the production of endotoxins by bacterial invaders. (A) is contraindicated due to the low cardiac output which results in low blood pressure and occurs in late septic shock. While (C) may reduce some of the destructive effects of massed cell release occurring with the inflammatory response that may occur, endotoxin release would not be stopped. (D) has no therapeutic effect relevant to septic shock.

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding

B. Appearance of wound

While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement? A. Encourage the client to continue verbalize his anxiety B. Attempt to distract the client with general conversation C. Explain the procedure in detail while removing the staples D. Reassure the client that this is a simple nursing procedure.

B. Attempt to distract the client with general conversation

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist? A. Administer PRN dose of lorazepam B. Auscultate bilateral breath sounds C. Check urinary catheter for obstruction D. Review the heart rhythms on cardiac monitor.

B. Auscultate bilateral breath sounds

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? A. Call respiratory therapy. B. Begin manual ventilation immediately. C. Monitor oxygen saturation levels q5 minutes. D. Silence the alarm and call the technician.

B. Begin manual ventilation immediately. Rationale: The first action that must be taken is to begin manual ventilation. Remember the ABC's — airway, breathing and circulation! The nurse's highest priority is to ensure that the client is receiving oxygen. Also, remember Maslow — safety is a primary human need and breathing is fundamental to safety. (A, C, and D) do not have the priority of initiating manual ventilation.

The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take? A. Complete and file an incident (variance) report B. Call the healthcare provider who wrote the prescription C. Contact the healthcare provider review board for instructions D. Report the situation to the house supervisor

B. Call the healthcare provider who wrote the prescription

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? A. Remain on clear liquids until the vomiting subsides B. Come to the clinic to be seen by a healthcare provider C. Make an appointment at the clinic if a fever occurs D. Take nothing by mouth until there is no more nausea

B. Come to the clinic to be seen by a healthcare provider

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? (Select All that Apply) A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site

B. Confirm that the nurse has gathered the necessary supplies D. Instruct the nurse to use a transparent dressing over the site

AssessWhich assessment is most important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of motion. B. Distal pulse intensity. C. Extremity sensation. D. Presence of exudate.

B. Distal pulse intensity. Rationale: Distal pulse intensity, assesses the blood flow through the extremity and is the most important assessment for a client with a burn extremity because it provides information about adequate circulation to that extremity.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? A. Genetically inherited disorders of family members. B. Frequency of laxative use for chronic constipation. C. Length and frequency of the client's tobacco use. D. Ingestion of shellfish or fish oil capsules daily.

B. Frequency of laxative use for chronic constipation Rationale: Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B. Furosemide Rationale: Furosemide is given to help treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. It works by acting on the kidneys to increase the flow of urine. Furosemide

A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain? A. Use of sleeping medications. B. History of alcohol use C. Use of anti-anxiety medications D. History of this behavior.

B. History of alcohol use

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad-spectrum antibiotic D. Potassium chloride

B. Hydrocortisone Rationale: Hydrocortisone tablets work as a hormone replacement for a natural hormone called cortisol. You may take hydrocortisone tablets if your body does not make enough cortisol - for example if you have Addison's disease or if you've had your adrenal glands taken out.

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement? A. Administer second dose of nitroglycerin. B. Infuse a rapid IV normal saline bolus. C. Begin external chest compressions. D. Give a PRN antiemetic medication.

B. Infuse a rapid IV normal saline bolus. Rationale: When chest pain is treated with a vasodilator, such as nitroglycerin, and the blood pressure falls to a critical level, a right ventricular infarction may have occurred which requires immediate infusion of IV fluid (B). (A and D) may worsen the condition if implemented prior to rapid infusion of fluids. Chest compressions (C) are not indicated when the client has a pulse.

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local support HIV support groups D. Observe for adverse drug reactions

B. Monitor for secondary infections

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply.) A. Administer low molecular weight heparin as prescribed B. Teach client to use incentive spirometer every 2 hours while awake C. Remove urinary catheter as soon as possible and encourage voiding D. Maintain sequential compression devices while in bed E. Assess pain level and medicate PRN as prescribed

B. Teach client to use incentive spirometer q2 hours while awake. C. Remove urinary catheter as soon as possible and encourage voiding.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A peripheral IV is saline-locked. B. The client is lying supine in bed. C. Oxygen is flowing at 5 L/minute via mask. D. A prescribed diet that is low in sodium. E. A pitcher of water is on the bedside table. F. A bedside commode is located near the bed.

B. The client is lying supine in bed. C. Oxygen is flowing at 5 L/minute via mask. E. A pitcher of water is on the bedside table. Rationale: (B, C, and D) are the correct answers and represent hazards to this client. The client's head of the bed should be elevated to promote lung expansion, not supine (B). Oxygen flow rate (C) is too high for a client with COPD, whose respirations are dependent upon a hypoxic drive due to pCO2 levels. The pitcher of water (E) should not be readily assessable to the client with intravascular volume overload associated with an exacerbation of HF. (A, D, and F) are expected interventions in observations that provide for the client's safety during the treatment of HF and COPD.

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother? A. Give another dose. B. Withhold this dose. C. Administer a half dose now. D. Mix the next dose with food.

B. Withhold this dose. Rationale: This dose should be withheld (B) because the amount absorbed by the infant is unknown. (A and C) pose safety concerns due to the unknown absorption. (D) is not recommended because all of the mixture (food and medicine) may not be eaten.

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

Bone marrow transplantation

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? A) Chronic rejection is usually reversible with the right treatment. B) Chronic rejection doesn't occur in kidney transplant recipients. C) Dialysis would need to be resumed if chronic rejection becomes a reality. D) Chronic rejection only affects the transplanted kidney, not the overall health.

C) Dialysis would need to be resumed if chronic rejection becomes a reality.

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? A) Apply ice to the fracture site. B) Notify the healthcare provider. C) Document the extent of the bruising in the medical record. D) Elevate the affected limb.

C) Document the extent of the bruising in the medical record.

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? A) Administer a sedative medication. B) Call the client's family to discuss discharge plans. C) Explore the client's reasons for wanting to be discharged. D) Inform the client that she needs to remain in the unit.

C) Explore the client's reasons for wanting to be discharged.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? A- Encourage the client to go immediately to the ED for treatment B- Tell the client to alter his eating habits because he eats too much food, too fast C- Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer D- Tell the client that eating a large dinner closer to bedtime will help relieve the symptoms

C- Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

An adolescent, whose mother recently died, comes to the school nurse complaining of a headache. Which statement made by the students should warrant further explanation by the nurse? A. "I've had dreams about Mon since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mom and would like to go see her'". D. " it's hard to concentrate on my homework"

C. "I miss Mom and would like to go see her'".

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies" on preoperative checklist B. Assess client's allergies to non-drug substances C. Assess client's knowledge of an allergy response D. Flag "no known drug allergies" on the front of the chart

C. Assess client's knowledge of an allergy response

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures

C. Clarify end of life desires

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer? A. Pickle relish. B. Steak sauce. C. Fresh horseradish. D. Tomato ketchup.

C. Fresh horseradish. Rationale: A cardiac diet restrict sodium intake. Horseradish (C) should be recommended because it is low in sodium. (A, B, and D) are high in salt content and should not be offered.

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply) A. Ask the client to bear down as if voiding to relax the sphincter B. Complete perianal care with soap and water C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Record pain evaluation B. Assess blood glucose C. Identify pills in the bag D. Obtain a medical history

C. Identify pills in the bag

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Give the infant 5% dextrose in water orally B. Insert a nasogastric tube for feeding C. Initiate a prescribed IV for parental fluid D. Feed the infant 3 ounces of Isomil

C. Initiate a prescribed IV for parental fluid

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan? A. Hire a caregiver for eight hours daily. B. Develop a walking exercise routine. C. Keep room temperature 80. D. Wear TED stockings at night.

C. Keep room temperature 80 Rationale: Keeping the environment warm (C) may minimize vasoconstriction which decreases blood flow and causes the pain associated with Raynaud's disease. The client is not helpless and does not require a caregiver (A). Exercise (B) may increase pain. TED stockings (D) have no therapeutic value for those with Raynaud's disease.

An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? A. Bacterial infection B. Lymphangitis C. Malignancy D. Viral infection

C. Malignancy

A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding? A. Phobias and panic attacks when confronted by authority figures. B. Suicidal ideations and multiple attempts C. Multiple convictions for misdemeanors and class B felonies. D. Delusions of grandiosity and persecution

C. Multiple convictions for misdemeanors and class B felonies.

When checking a third grader's height and weight, the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? A. Report findings to the parents. B. Document findings in the child's school file. C. Refer child to the family healthcare provider. D. Encourage child to get more sleep.

C. Refer child to the family healthcare provider. Rationale: ADHD is most commonly managed with methylphenidate, which causes insomnia due to CNS stimulation and growth suppression secondary to appetite suppression. The child should be referred to the healthcare provider (C) because a change in the administration schedule of methylphenidate or discontinuing the drug is indicated until the child's growth increases. (A and B) may not ensure referral for a valuation of the medication's impact on the child's growth pattern. (D) is ineffective.

When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.) A. Turn off the water faucet. B. Interlace the fingers. C. Rub hands palm to palm. D. Dry hands with paper towel.

C. Rub hands palm to palm. B. Interlace the fingers. D. Dry hands with paper towel. A. Turn off the water faucet.

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3(12 x 109/L SI)

C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) Rationale: The typical range for serum creatinine is: For adult men, 0.74 to 1.35 mg/dL. For adult women, 0.59 to 1.04 mg/dL.

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise

C. Space activities to allow for rest periods E. Take warm baths before starting exercise

The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom) A. Aspirate the desired volume from vial A B. Inject the volume of air to be aspirated from each vial C. Verify the drug and dose with the label on the vial D. Aspirate the desired volume from vial B

C. Verify the drug and dose with the label on the vial B. Inject the volume of air to be aspirated from each vial A. Aspirate the desired volume from vial A D. Aspirate the desired volume from vial B

After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? A. CIWA-Ar for alcohol withdrawal score of 30 B. Acute onset of unrelenting chest pain C. Widening QRS complexes and flat waves D. Intense tremor and involuntary muscle activity

C. Widening QRS complexes and flat waves

A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? A. soft pretzels B. fruit-flavored yogurt C. oatmeal cookies D. low fat cheese sticks

C. oatmeal cookies

A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports...which action should the nurse implement to reduce the client's risk for falls? Select all that apply. (SATA) A.)Assign the client a wheel chair B.)The utilization of crutches C.)Schedule frequent rest periods D.)Provide assistance to bedside commode E.)Teach to patch one eye when ambulating

C.) Schedule frequent rest periods D.) Provide assistance to bedside commode E.) Teach to patch one eye when ambulating

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Complain of headaches and stiff neck

A client is complaining of intermittent, left, lower abdominal pain that began two days ago...in what order would the nurse implement the following interventions?Correct order: (DPIA) 1. Auscultate all four abdominal quadrants 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Determine when the client had last bowel movement

Correct order: (DPIA) 4. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 1. Auscultate all four abdominal quadrants

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next? A) Witness the client's signature on the consent form. B) Document the conversation with the interpreter. C) Notify the healthcare provider of the client's consent. D) Ask for a full explanation from the interpreter of the witnessed discussion.

D) Ask for a full explanation from the interpreter of the witnessed discussion.

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? A) Muscle strain. B) Ligament injury. C) Bursitis. D) Destruction of joint cartilage.

D) Destruction of joint cartilage.

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? . A) Administer epinephrine. B) Initiate synchronized cardioversion. C) Continue chest compressions. D) Give IV dose of adenosine rapidly over 1-2 seconds

D) Give IV dose of adenosine rapidly over 1-2 seconds

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? A) Loss of appetite B) Serum K+ 4.0 mEq/L or mmol/L (SI) C) Loose, runny stools. D) Tented skin turgor.

D) Tented skin turgor. Rationale: Indicates dehydration, a serious complication following prolonged diarrhea that requires further intervention by the nurse.

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A. "I think I am qualified to teach this group." B. "How old do you think I am?" C. "Do you think you can teach it any better?" D. "We need to stay focused on the topic."

D. "We need to stay focused on the topic." Rationale: (D) is the best response since the nurse should keep the students focused and avoid entering into an argument with them. (A) is defensive; there is no need for the nurse to defend her/his position. (B) is irrelevant; it does not matter how old the student thinks the nurse is. (C) is sarcastic; the nurse should avoid this kind of exchange and remain professional.

To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take? A. Establish a trusting nurse-client relationship. B. Complete an incident report following a client injury. C. Maintain current professional malpractice insurance D. Adhere consistently to standards of care.

D. Adhere consistently to standards of care.

The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse? A. Tall peak T waves on the cardiac monitor B. Peripheral pitting edema at 2 + indentation C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl D. Anuria for the last 12 hours.

D. Anuria for the last 12 hours. Rationale: Anuria is nonpassage of urine, in practice is defined as passage of less than 100 milliliters of urine in a day. Anuria is often caused by failure in the function of kidneys. It may also occur because of some severe obstruction like kidney stones or tumours. It may occur with end stage kidney disease.

A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse? A. Hypotension and fever B. Increased blood glucose. C. Fluid retention D. Anxiety and restlessness.

D. Anxiety and restlessness.

A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A. Instruct the client to use the call button when a bedpan is needed B. Apply adult diapers after each attempt to void C. Check residual urine volume using an indwelling urinary catheter D. Assist the client's to a bedside commode every two hours

D. Assist the client's to a bedside commode every two hours

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Do not take any over the counter meds. B. Eat a high carb, low fat, low protein diet. C. Call the crisis hotline if feeling lonely. D. Avoid exposure to large crowds.

D. Avoid exposure to large crowds.

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? A. Massage the uterus to decrease atony B. Review the hemoglobin to determine hemorrhage C. Increase intravenous infusion D. Check for a distended bladder

D. Check for a distended bladder

A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? A. Inquire about recent sexual activity. B. Instruct to wipe from front to back. C. Palpate the suprapubic region. D. Collect a clean-catch specimen.

D. Collect a clean-catch specimen. RationaleThis client is exhibiting symptoms of a urinary tract infection (UTI), so the nurse should collect a clean-catch urine specimen (D) for urine analysis, and culture and sensitivity. (A) may provide additional data about the etiology of these symptoms, but a urine analysis is the best method for determining the existence of a urinary tract infection (UTI). (B) is a basic hygiene instruction to help prevent UTI. (C) may elicit tenderness but is not necessary.

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Knows that insulin must be given 30 min before eating B. Frequently eats fruits and vegetables at meals and between meals C. Has someone available who can prepare and oversee the diet D. Demonstrates willingness to adhere to the diet consistently

D. Demonstrates willingness to adhere to the diet consistently

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? A. Decreasing gastrointestinal (GI) cramping and nausea. B. Chest pain and dysrhythmia. C. Vasodilation of the extremities. D. Hypotension and tachycardia.

D. Hypotension and tachycardia. Rationale: When a client with bleeding esophageal varices receives vasopressin intravenously (IV), the nurse should monitor for the adverse effects of hypotension and tachycardia (Choice D). Vasopressin is a vasoconstrictor medication that can cause a rapid increase in blood pressure (hypertension) and reflexive bradycardia. To counteract these effects, the client may also experience tachycardia and hypotension. Monitoring for these adverse effects is essential to ensure the client's safety during the infusion.

A client who has a suspected brain tumor is scheduled for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client's neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client's food allergy history

D. Obtain the client's food allergy history

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

D. Outline the area with ink and check it every 15 minutes to see if the area has increased

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

D. Oxygen saturation

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors

D. Play a board game with the client and begin taking about stressors

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Continue the insertion since this is a typical response B. pause and monitor for a continues drop of the heart rate C. Insert the feeding tube into the infant's nasal passage D. Postpone the feeding until the infant's vital signs and stable

D. Postpone the feeding until the infant's vital signs and stable

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first? A. Provide the client with a PRN antianxiety medication and allow privacy for her to grieve. B. Instruct the UAP to notify the client's spiritual advisor of her need for counseling. C. Ask another nurse to finish giving medications and attend to the client immediately. D. Tell the client that the nurse will be back to talk to her after medications are given.

D. Tell the client that the nurse will be back to talk to her after medications are given. Rationale: The nurse should first acknowledge the client's grief and arrange with the client a time to provide support, then complete the administration of medications (D). During that time, the nurse should assess the client to determine what intervention is best to offer the grieving client (A). The nurse, not the UAP (B), should talk with the client to determine if the client needs her spiritual advisor's counsel and support. The client's grief is not an emergency situation, so after acknowledging it and informing her that the nurse will return to talk with her, the nurse should finish administering the medications (C) and then spend time supporting the grieving client.

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

D. Three year history of taking oral contraceptives

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Onset of mild confusion B. Pain score 8 out of 10 C. Pale, diaphoretic skin D. Weak palpable distal pulses

D. Weak palpable distal pulses

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? A."Antacids decrease the production of gastric secretions." B."It will improve the emptying of food through your stomach." C."This medication will coat the lining of your esophagus." D."Antacids will neutralize the acid in your stomach."

D."Antacids will neutralize the acid in your stomach."

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A.) Ask the mother what she usually uses on the child's lips and nose B.) Apply a petroleum jelly (Vaseline) to the child's nose and lips C.) Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips D.) Use a water soluble lubricant on affected oral and nasal mucosa

D.) Use a water soluble lubricant on affected oral and nasal mucosa

During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond?

Give me specific examples to support your statements.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

Leave the room and close the door quietly

The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

Medication Port

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client?

Neurologically stable without indications of an increased IC

A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first?

Observe the perineum

Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

One with a clamp.

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

Place a mask on the client's face.

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take?

Pull up a chair and sit beside the client's bed

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?

Vomiting

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? a- An older client who fell yesterday and is now complaining of diplopia b- An adult newly diagnosed with type 1 diabetes and high cholesterol c- A client with pancreatic cancer who is experience intractable pain. d- An older client post-stroke who is aphasic with right-sided hemiplegia

a- An older client who fell yesterday and is now complaining of diplopia

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a- Explain that memory loss and confusion are common with vitamin B12 deficiency. b- Ask if the client is experiencing any changes in bowel habits c- Determine if the client is taking iron and folic acid supplements d- Encourage the husband to bring the client to the clinic for a complete blood count.

a- Explain that memory loss and confusion are common with vitamin B12 deficiency Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate? a- Ineffective coping related to denial b- Anxiety related to treatment of choice c- Decisional conflict related to stress d- Deficient knowledge related to lifestyle changes

a- Ineffective coping related to denial

The nurse is preparing to discharge an older adult female client who is at risk for hyPOCALCEMIA nurse include with this client's discharge teaching? (SATA) a- Report any muscle twitching or seizures b- Take vitamin D with calcium daily c- Avoid seafood, particularly shellfish d- Low fat yogurt is a good source of calcium e- Keep a diet record to monitor calcium intake

a- Report any muscle twitching or seizures b- Take vitamin D with calcium daily d- Low fat yogurt is a good source of calcium e- Keep a diet record to monitor calcium intake Rationale: Twitching and seizure are signs of low calcium. (A) Vit D supplement with calcium to enhance calcium absorption, especially in older adults. Dairy product should be included in the diet. Keeping a food record is a good healthcare practice. Foods high in calcium are recommended to maintain normal calcium level and it is important to verify if the client has allergy to shellfish.

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information? (Select all that apply) a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthcare provider c- Counseling should be sought to resolve the husband's desire to control his wife d- The healthcare team will formulate a plan of care to keep the client comfortable e- The client should seek a second medical opinion before deciding to stop treatment.

a- The husband cannot sign the consent for the client, her signature is required b- The client's specific wishes should be discussed with her healthcare provider d- The healthcare team will formulate a plan of care to keep the client comfortable Rationale: An adult client who is mentally competent has the autonomy and the client's right to make her own decision regarding her treatment.

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse? a- Uncontrollable drooling b- Inability to raise voice c- Tingling of extremities d- Eyelid drooling

a- Uncontrollable drooling

When organizing home visits for the day, which older client should the home health nurse plan to visit first? a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools. b. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level c. A man with emphysema who smokes and is complaining of white patches in his mouth d. A frail woman with heart failure who reported a 2 pounds' weight gain in the last week.

a. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? a. Avoid exposure to respiratory infections. b. Use relaxation exercise when anxious c. Continue physical therapy at home d. Plan short, frequent rest periods.

a. Avoid exposure to respiratory infections.

A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. An unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement? a. Determine how the client is cared for when caregiver is not present. b. Develop a client needs assessment and review with the caregiver c. Evaluate the caregiver's ability to care for the client's needs. d. Review with the care giver the interventions provided each day.

a. Determine how the client is cared for when caregiver is not present.

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) a. Ease the client to the floor b. Loosen restrictive clothing c. Note duration of the seizure d. Place pillows around surrounding

a. Ease the client to the floor b. Loosen restrictive clothing c. Note duration of the seizure

A male client with cancer, who is receiving antineoplastic drugs, is admitted to the... what findings is most often manifest this condition? a. Ecchymosis and hematemesis b. Weight loss and alopecia c. Weakness and activity intolerance d. Sore throat and fever

a. Ecchymosis and hematemesis

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform? a. Hold the thermometer in place. b. Place the disposable pad under buttocks c. Instruct the client to breathe deeply d. Return the probe to the charger.

a. Hold the thermometer in place.

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a- Hypernatremia b- Excessive thirst c- Elevated heart rate d- Poor skin turgor

a. Hypernatremia Rationale: Hypernatremia can lead to neurological symptoms, such as overactivity in the brain and nerve muscles, confusion, seizures, or even coma. Without treatment, central diabetes inspidus can lead to permanent kidney damage.

The health care provider prescribes atenolol 50 mg daily for a client with angina pectoris...to the health care provider before administering this medication? a. Irregular pulse b. Tachycardia c. Chest pain d. Urinary frequency

a. Irregular pulse

An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client? a. Magnesium hydroxide (Maalox). b. Birth control pills c. Cough syrup containing codeine d. Cold medication containing alcohol

a. Magnesium hydroxide (Maalox) Rationale: Some aluminum containing antacids (Maalox, for example) may cause Acute Kidney Failure if used over long periods of time. Antacids can also disrupt the electrolyte balance of people with CKD.

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? a. Nausea and indigestion. b. Hyper salivation c. Eyelid and facial twitching d. Increased appetite

a. Nausea and indigestion.

The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding? a. Pupils reactive to accommodation b. Nystagmus present with pupillary focus. c. Peripheral vision intact d. Consensual pupillary constriction present

a. Pupils reactive to accommodation

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a. Recommend weigh bearing physical activity b. Reduce intake of foods high in vitamin D c. Decrease intake of foods high in fat d. Minimize heavy lifting and bending.

a. Recommend weigh bearing physical activity

The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? a. Remind the client to hold his breath after inhaling the medication b. Confirm that the client has correctly shaken the inhaler c. Affirm that the client has correctly positioned the inhaler d. Ask the client if he has a spacer to use for this medication

a. Remind the client to hold his breath after inhaling the medication

When administering ceftriaxone sodium (Rocephin) intravenously to a client before... most immediate intervention by the nurse? a. Stridor b. Nausea c. Headache d. Pruritus

a. Stridor Rationale: Stridor, a crowing respiration, indicates the client is experiencing bronchospasm, as a reaction to Rocephin, and antibiotic. The finding requires immediate action by the nurse. B and C are side effects that are not life-threatening. Pruritus may be the result as... and need nursing intervention but is of less immediacy than stridor.

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood cells b. Obtain blood and sputum cultures. c. Infuse 1000 ml normal saline d. Titrate oxygen to keep o2 saturation 90%

a. Transfuse packed red blood cells Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical.

A client who is at 36 weeks gestation is admitted with severe preeclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse? A. Urine output 20 ml/hour B. Blood pressure 138/88 C. Respiratory rate 18 breaths/min D. Temperature of 99.8

a. Urine output 20 ml/hour Rationale: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement? a- Support the client by telling her what wonderful progress she is making. b- Ask the client if she has had any recent thoughts of harming herself. c- Reassure the client that the antidepressant drugs are apparently effective d- Tell the client to keep her belongings because she will need hem at discharge.

b- Ask the client if she has had any recent thoughts of harming herself.

In caring for a client receiving the aminoglycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test? a- Urinalysis b- Serum creatinine c- Serum osmolarity d- Liver enzymes.

b- Serum creatinine Rationale: Aminoglycosides can cause nephrotoxicity, so it is important for the nurse to monitor the serum creatinine level which can monitor the renal function.

After removing a left femoral arterial sheath, which assessment findings warrant immediate interventions by the nurse? (Select all that applied.) a- Tenderness over insertion b- Unrelieved back and flank pain. c- Cool and pale left leg and foot. d- Left groin egg-size hematoma. e- Quarter size red drainage at site.

b- Unrelieved back and flank pain. c- Cool and pale left leg and foot. d- Left groin egg-size hematoma.

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a- Your baby is gaining weight right on schedule b- What food does your baby usually eat in a normal day? c- The baby is below the normal percentile for weight gain d. What was the baby's weight at the last well-baby clinic visit

b- What food does your baby usually eat in a normal day? Rationale: The normal weight gain in the first year of life is approx. twice the birth weight

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide? a. Does your child seem mentally slower than his peers also? b. "His smaller size is probably due to the heart disease" c. Haven't you been feeding him according to recommended daily allowances for children? d. You should not worry about the growth tables. They are only averages for children

b. "His smaller size is probably due to the heart disease" Rationale: Poor growth patterns are associated with heart disease.

After checking the fingerstick glucose at 1630, what action should the nurse implement? a. Notify the healthcare provider b. Administer 8 units of insulin aspart SubQ c. Gives an IV bolus of Dextrose 50% 50 ml d. Perform quality control on the glucometer.

b. Administer 8 units of insulin aspart SubQ

The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain? a- Cognitive b- Affective c- Comprehension d- Psychomotor

b. Affective Rationale: The affective domain involves our feelings, emotions, and attitudes, and includes the manner in which we deal with things emotionally (feelings, values, appreciation, enthusiasm, motivations, and attitudes).

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a- Obtain the results for STAT serum cardiac biomarkers b- Assess for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI)

b. Assess for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI

Which nursing intervention has the highest priority for a multigravida who delivered? a. Maintain cold packs to the perineum for 24 hrs. b. Assess the client pain level frequently c. Observe for appropriate interaction with the infants. d. Assess fundal tone and lochia flow

b. Assess fundal tone and lochia flow Rationale: D is the priority intervention because is a multigravida and this pregnancy predisposes the client to uterine atony which could result in hemorrhage.

The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply) a. Maintain current caloric intake b. Avoid use of alcohol as a sleep aide at bedtime c. Reduce intake of dairy products d. Start a weight loss program e. Set a goal of increasing BMI (Body Mass Index)

b. Avoid use of alcohol as a sleep aide at bedtime d. Start a weight loss program

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and... Which nursing intervention has the highest priority? a. Offer to notify the client's minister of his condition. b. Determine if the client has an executed living will c. Provide the family with information about palliative care d. Explore the possibility of organ donation with the family.

b. Determine if the client has an executed living will Rationale: Once the client is intubated and ventilated, emergency intervention should continue until patient t be stable check if the client has an executed living will.

A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours? a. Maintain the client NPO during the diuresis phase b. Evaluate daily serial renal laboratory studies for progressive elevations. c. Observe the urine character for sedimentation and cloudy appearance. d. Monitor for onset of polyuria greater than 150ml/hr.

b. Evaluate daily serial renal laboratory studies for progressive elevations.

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care ...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take? a. Encourage the UAP to remain in the client's room, until completed b. Explain that the hand rub can be completed in less than 2 minutes. c. Inform the UAP that handwashing helps to promote better asepsis. d. Determine why the UAP was not wearing gloves in the client's room

b. Explain that the hand rub can be completed in less than 2 minutes.

An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority? a. Advise the mother to withhold all medications by mouth. b. Instruct the mother to take the teen to the emergency room c. Recommend that the teen withhold food and fluids for 2 hours d. Suggest that the adolescent breath slowly and deeply.

b. Instruct the mother to take the teen to the emergency room

The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost... hypothyroidism, what question is most important for the nurse to ask the mother? a. Has your son had any immunizations yet? b. Is your son sleepy and difficult to feed? c. Are you breastfeeding or bottle feeding your son? d. Were any relatives born with birth defects?

b. Is your son sleepy and difficult to feed? Rationale: Like adults with hypothyroidism, excess fatigue is common and a "good" baby is of.... occurs with hypothyroidism and can result in poor sucking.

The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter? a. Home hospice agency b. Long-term care facility c. Rehabilitation facility d. Independent senior apartment e. Home health agency

b. Long-term care facility e. Home health agency Rationale: Long term care facilities and home health agencies performs ADLs. Hospice provides empathetic, attentive care for dying. C provide physical therapy to strengthen a part of the body.

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)... which breakfast selection by the client indicates effective learning? a. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam. b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces' coffee. c. Banana pancake with maple syrup, sausage links, half grapefruit, and low -fat milk d. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.

b. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces' coffee.

A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement? a. Initiate contact isolation b. Obtain a wound swab for culture and sensitivity c. Assess temperature q4 hours d. Use alcohol-based solutions for hand hygiene.

b. Obtain a wound swab for culture and sensitivity

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? a. Hypoactive bowel sounds in the lower quadrant. b. Rebound tenderness in the upper quadrants. c. Tympani with percussion of the abdomen. d. Light colors gastric aspirate via the nasogastric tube.

b. Rebound tenderness in the upper quadrants Rationale: Rebound tenderness in the upper quadrant may be indicative of peritonitis. A is a clinical finding associated with bowel obstruction and does not need to be reported D may be something characteristic of the client's condition.

The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client... a. Avoid strenuous activity for 6 weeks b. Report fresh blood in the urine. c. Take acetaminophen for fever 101 d. Consume 6 to 8 glasses of water daily.

b. Report fresh blood in the urine.

A client with hypertension receives a prescription for enalapril, an angiotensin... instruction should the nurse include in the medication teaching plan? a. Increase intake of potassium-rich foods b. Report increased bruising of bleeding c. Stop medication if a cough develops d. Limit intake of leafy green vegetables

b. Report increased bruising of bleeding Rationale: ACEIs can cause thrombocytopenia and increased risk for bruising and bleeding. A is not necessary because is a potassium-sparing

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? a. Confirm that all the staff nurses are assigned to an equal number of clients. b. Review the staff nurse job description to ensure it is clear, accurate, and recurrent. c. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. d. Analyze the amount of overtime needed by the nursing staff to complete assignments

b. Review the staff nurse job description to ensure it is clear, accurate, and recurrent.

A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement? a. Teach a client amount the use of a home pregnancy test. b. Schedule a weekly home visit to draw hCG values. c. Make a 5 week follow- up with healthcare provider d. Begin chemotherapy administration during the first home visit

b. Schedule a weekly home visit to draw hCG values Rationale: To monitor for development of choriocarcinoma, a complication TD, level of hCG should be monitor for negative results.

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete? a. Client's lungs are clear bilaterally and oxygen saturation is 97% b. Surgeon needs to see client immediately to evaluate the situation c. Left peripheral pulses were present

b. Surgeon needs to see client immediately to evaluate the situation

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? a. Blood tinged sputum b. Upper airway stridor c. Expiratory wheezing d. Oxygen saturations 90%

b. Upper airway stridor

A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take? a) Tell the mother to stop speaking for the client b) Notify the charge nurse of the situation c) Request that the mother leave the room d) Request security to remove her from the room

c) Request that the mother leave the room

A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action? a- Ask social services to dins a Korean interpreter b- Establish direct eye contact with the client. c- Allow several minutes for the client to respond. d- Repeat the question slowly and distinctly.

c- Allow several minutes for the client to respond.

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? a- Obtain a second IV access. b- Decrease the room temperature. c- Give the prescribed antiemetic. d- Insert an indwelling catheter

c- Give the prescribed antiemetic. Rationale: carboprost is used to treat severe bleeding after childbirth (postpartum).two-thirds experienced vomiting and diarrhea, approximately one third had nausea, one-eighth had a temperature increase greater than 2° F, and one-fourteenth experienced flushing

What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure... a- Stop the seizure activity b- Decrease the temperature c- Manage the airway d- Protect the body from injury

c- Manage the airway

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? a. A 12-year old reporting neck, arm and lower back discomfort b. An 8 year old with a full leg air splint for a possible broken tibia c. An 11 year old with a headache nausea and projectile vomiting d. A6 year old with multiple superficial lacerations of all extremities

c. An 11 year old with a headache nausea and projectile vomiting

A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next? a. Perform an otoscopic examination b. Measure the child's abdominal girth c. Collect a urine specimen for routine urinalysis d. Obtain a blood specimen for serum electrolytes.

c. Collect a urine specimen for routine urinalysis Rationale: Acute glomerulonephritis is an auto-immune reaction to a precursory streptococcus. Manifestation of AGN include oliguria, edema, hypertension.

An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? a. Addiction b. Phobia c. Compulsion d. Obsession

c. Compulsion

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results? a. Instructor client to prevent a paper bag b. Initiate oxygen administration at 2 to 3/L per nasal cannula c. Institute coughing and deep breathing protocols d. Prepared to administer sodium chloride fluids

c. Institute coughing and deep breathing protocols

The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide? a. Secure the mouthpiece under the tongue. b. Press down on the device after breathing in fully c. Move the device one to two inches away from the mouth d. Breathe out slowly and deeply while compressing the device

c. Move the device one to two inches away from the mouth Rationale: Optimal position of a metered dose inhaler includes placing the inhaler one two inches away from the mouth.

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication? a- Dilute the Dextrose in one liter of 0.9% Normal Saline solution. b- Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. c- Push the undiluted Dextrose slowly through the currently infusion IV. d- Ask the pharmacist to add the Dextrose to a TPN solution.

c. Push the undiluted Dextrose slowly through the currently infusion IV Rationale: To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose infusing IV.

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? a- Diabetic ketoacidosis whose Glasgow coma Scale score changed from 10 to 7 b- Myxedema coma whose blood pressure changed from 80/50 to 70/40 c- Viral meningitis whose temperature changed from 101 F to 102 F. d- Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

c. Viral meningitis whose temperature changed from 101 F to 102 F. Rationale: The most stable patient should be assigned to the PN, changes in the Glasgow coma Scale indicated the client's neurological status is worsening. The client decreasing BP is physiologically unstable. An increasing systolic blood pressure and widening pulse pressure is indicative of increasing intracranial pressure.

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a- 0800, 1200, 1600, 2000 b- Administer with meals and a bedtime snack c- Five in equally divided doses during waking hours d- 1000, 1600, 2200, 0400

d- 1000, 1600, 2200, 0400 Rationale: D is the best schedule because the antibiotic should be administered around the clock to keep the blood level of the antibiotic constant.

An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse? a- Explain that this is an expected occurrence with aging. b- Observe the lower extremity for signs of muscle atrophy c- Review the medical record for recent diagnosis test results. d- Ask the client to describe the changes that have occurred

d- Ask the client to describe the changes that have occurred

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse? a. Extremity muscle weakness b. Bilateral eyelid drooping c. Inability to swallow pills d. Evidence of hypoventilation

d. Evidence of hypoventilation Rationale: Hypoventilation indicates respiratory muscle weakness, and if the client is unable to breath... respiratory distress and life-threatening.

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide? a. I have to call the supervisor to get someone else to transfer to this unit to care for him. b. I know you are good nurse and can handle this client in a professional manner. c. I'll talked to the client about his sexual harassment and I'll insist that he stop it immediately. d. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

d. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client is lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? a. Note the appearance and patency of the client's peripheral IV site. b. Palpate the volume of the client's right radial pulse c. Auscultate the client's breath sounds bilaterally. d. Observe the amount and dose of morphine in the PCA pump syringe.

d. Observe the amount and dose of morphine in the PCA pump syringe.

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? a- Maintain adequate cardiac output b- Promote adequate tissue perfusion c- Promote rest and sleep d- Reduce the risk for injury

d. Reduce the risk for injury Rationale: Paget's is a metabolic bone disorder which place the client at high risk for injury. Once the client is symptom free the next goal is reducing risk for injury

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis? a. Begin a weight-bearing exercise plan b. Increase intake of foods rich in calcium c. Schedule a bone density tests every year. d. Remain upright after taking the medication.

d. Remain upright after taking the medication Rationale: Risendronate, causes reflux and esophageal erosion.