HESI
The nurses triage and clients in an urgent care clinic. The client with which symptoms should be referred to the healthcare provider immediately? A. High fever, skin rash, and a productive cough. B. Headache, photophobia, and nuchal rigidity. C. Nausea, vomiting, and poor skin turgor. D. Malaise, fever, and stiff, swollen joints.
Answer B. Headache, photophobia, and nuchal rigidity. Rationale Headache, photophobia, and nuchal rigidity (B) are classic signs and symptoms of a meningeal infection, so this client should immediately be referred to the healthcare provider. (A, C, and D) do not have the priority of (B).
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. Fluid retention. B. Hypotension and fever. C. Anxiety and restlessness. D. Increased blood glucose.
Answer B. Hypotension and fever. Rationale Sudden withdrawl from a corticosteroid can cause sudden decreased adrenal function resulting in low serum sodium, high serum potassium, and low blood pressure, which can lead to shock and possible death. Hypotension and fever (B) are the first signs of precipitous withdrawl. Fluid retention (A), anxiety and restlessness (C), and glucose intolerance (D) are common side effects of taking a corticosteroid.
The nurse suspects that a client might be hemorrhaging internally. Which findings of an orthostatic tilt test are the most likely indication of a major bleed (>1,000ml)? A. A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. B. A decrease in the diastolic BP of 10 mm Hg with a corresponding decrease in the HR or 20. C. A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the HR of 10. D. A decrease in the diastolic BP of 20 mm Hg with a corresponding increase in the HR of 10.
Answer A. A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. Rationale The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the heart rate increases by 20% above normal as a compensatory response to the low pressure (A). (B, C, and D) do not correctly characterize the vital sign changes associated with a major bleed.
A client who weighs 75 kg is receiving IV dopamine at 2 mcg/kg/minute. The concentration of the dopamine solution is 200 mg/250 ml of D5NS. How many ml/hour should the nurse program the infusion pump? (Enter the numeric value only. If rounding is required, round to the nearest whole number.)
Answer 11 Rationale Calculate the recommended dose, 2mcg x 75 kg = 150 mcg/minute Next, determine the dose per hour, 150 mcg x 60 minutes = 9000 mcg/hour and converted to 9 mg/hour. Using the formula, D/H x Q, 9 mg/hour / 200 mg x 250 ml = 11.25 = 11 ml/hour
The nurse who working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement? A. Do not allow client to shower until all evidence is obtained. B. Report the incident to the university's security department. C. Listen attentively to the client's description of the event. D. Determine the client's personal reaction to the reported rape.
Answer A. Do not allow client to shower until all evidence is obtained. Rationale It is most important to gather evidence, and a shower distorts such evidence. The client should not be allowed to shower (A) until all evidence is obtained. (B, C, and D) should also be implemented, but these interventions do not have the priority of (A).
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? A. Ensure that the knot can be quickly released. B. Tie the knot with a double turn or square knot. C. Move the ties so the restraints are secured to the side rails. D. Ensure that the restraints are snug against the client's wrist.
Answer A. Ensure that the knot can be quickly released. Rationale The nurse should ensure that the knot can easily be released (A) to maintain client safety. (B) requires more time to release if a rapid response is needed. (C) may cause harm to the client if the side rail is moved without first releasing the restraint. Restraints should fit loosely (two fingers should fit under the restraint) to prevent damage to the client's skin (D).
A client with Type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? (Select all that apply.) A. Fingerstick glucose assessment q6h with meals. B. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose. C. Review with the client proper foot care and prevention of injury. D. Do not contaminate the insulin aspart so that it is available for IV use. E. Coordinate carbohydrate controlled meals at consistent times and intervals. F. Teach subcutaneous injection technique, site rotation and insulin management.
Answer A. Fingerstick glucose assessment q6h with meals. C. Review with the client proper foot care and prevention of injury. E. Coordinate carbohydrate controlled meals at consistent times and intervals. F. Teach subcutaneous injection technique, site rotation and insulin management. Rationale Correct choices are (A, C, E, and F). The nurse should include fingerstick glucose assessments for insulin aspart sliding scale with meals (A), a teaching plan regarding infection risks related to chronic hyperglycemia (C), diet modifications (E), and skills related to insulin management (F). Insulin glargine has a flat peak and should not be mixed with any other insulin (B). Of the very rapid acting insulins, only insulin lispro is recommended for IV use (D).
After an elderly female client receives treatment for drug toxicity, the healthcare provider prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the healthcare provider of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.
Answer A. Initiate the urine collection as prescribed. Rationale The nurse should implement the urine collection (A) even though the serum creatinine is low. Elderly clients may develop drug toxicity due to impaired renal function (best evaluated by completing a 24-hour creatinine clearance), because decreased muscle mass often results in a lower serum creatinine. (B) is not necessary. (C) is a less specific indicator of renal function than the serum creatinine or creatinine clearance tests. If renal function is impaired, an increase in serum potassium is more likely than hypokalemia (D).
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) A. Monitor abdominal girth. B. Increase oral fluid intake to 1,500 ml daily. C. Report serum albumin and globulin levels. D. Provide diet low in phosphorous. E. Note signs of swelling and edema.
Answer A. Monitor abdominal girth. C. Report serum albumin and globulin levels. E. Note signs of swelling and edema. Rationale (A, C, and E) should be implemented. Monitoring for increasing abdominal girth (A) and generalized tissue edema and swelling (E) are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin (C) and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.
A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse include when responding to this client? (Select all that apply.) A. One of the medications is used to anesthetize the corneal surface. B. The iris must be paralyzed during surgery to prevent it from reacting to light. C. A medication is used to induce sleep during the procedure. D. Pupillary dilation is necessary to access the eye chamber for lens removal. E. These medications assist in obstructing client's vision during the surgery.
Answer A. One of the medications is used to anesthetize the corneal surface. B. The iris must be paralyzed during surgery to prevent it from reacting to light. D. Pupillary dilation is necessary to access the eye chamber for lens removal. Rationale Correct items are (A, B, and D). Cataract surgery is accessed through the cornea, using eyelid retractors, while the client is awake. It is necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and provide pupil dilation (D) (mydriasis) to facilitate access to the lens which lies behind the iris (the posterior chamber of the anterior cavity). A sedative may be administered to reduce anxiety but is not used to induce sleep (C). Cloudy vision may be a side effect of these agents, but the client will still be able to see during the surgery (E).
The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding(s)? (Select all that apply.) A. Restlessness. B. Clenched fists. C. Increased pulse rate. D. Increased temperature. E. Peripheral pallor of the skin. F. Increased respiratory rate.
Answer A. Restlessness. B. Clenched fists. C. Increased pulse rate. F. Increased respiratory rate. Rationale Correct selections are (A, B, C, and F). Physiologic responses to pain include restlessness (A), increased muscle tone, such as clenching fists (B), and increased pulse rate (C) and respiratory rate (F), all of which occur as the result of stimulation of the sympathetic nervous system. (D) postoperatively is usually a sign of infection, not pain. (E) is more consistent with vasoconstriction related to exposure to cold, anemia, or decreased circulation.
Following a motor vehicle collision (MVC), an unrestrained female client is admitted to the intensive care unit with altered mental status. She has multiple rib fractures and bruising across her lower abdomen. Which assessment finding warrants immediate intervention by the nurse? (Please scroll and view each tab's information in the client's medical record before selecting the answer.) A. Several apnea episodes lasting ten seconds. B. A large amount of gross hematuria. C. Delayed peripheral capillary refill. D. Numbness of the left lower extremity.
Answer A. Several apnea episodes lasting ten seconds. Rationale Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 22 to 26 mEq/L (mmol/L), and pO2 80 to 100 mmHg. The ABG results reveal partially compensated respiratory acidosis as evidenced by a low pH, high PaCO2, and a high HCO3, due to the kidneys attempting to compensate by retaining HCO3 to normalize the pH. Increasing PaCO2 decreases the clients desire to breathe, as evidenced by periods of apnea (A) that can progress to respiratory arrest, so this is the priority assessment finding. Hematuria (B) is an obvious sign of bleeding. Delayed capillary refill (C) indicates poor perfusion. Numbness (D) of an extremity may indicate compression of the spinal cord or a spinal injury. The clients telemetry reveals normal sinus rhythm at 90 beats/minute.
While attempting to establish risk reduction strategies in a community, the nurse notes that the regional studies indicate a high number of persons with growth stunting and irreversible mental deficiencies (cretinism) due to hypothyroidism. The nurse should seek funding to implement which screening measure? A. T4 levels in newborns. B. TSH levels in women over 45. C. T3 levels in school-aged children. D. Iodine levels in all persons over 60.
Answer A. T4 levels in newborns. Rationale Screening for low T4 levels in newborns (A) with follow-up treatment can reduce the risk for irreversible growth stunting and metal deficiencies (cretinism) caused by congenital hypothyroidism. (B, C, and D) do not reduce the risk for congenital hypothyroidism, which is often the result of low iodine intake in women of child-bearing age.
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.
Answer 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.
A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply.) A. Topical corticosteroid. B. Topical scabicide. C. Topical alcohol rub. D. Transdermal analgesic. E. Oral antihistamine.
Answer A. Topical corticosteroid. E. Oral antihistamine. Rationale Anti-inflammatory actions of topical corticosteroids (A) and oral antihistamines (E) provide relief from severe pruritus (itching). Other options are not indicated.
A male client with HIV, who is receiving saquinavir PO in combination with other anti-retroviral therapy, tells the home health nurse that he is always hungry and thirsty but seems to be losing weight. What action should the nurse implement? A. Use a glucometer to determine the client's capillary glucose level. B. Reassure the client that he will gain weight as his viral load decreases. C. Explain to the client that he may require an increased dose of his medication. D. Teach the client strategies to ensure that he measures his weight accurately.
Answer A. Use a glucometer to determine the client's capillary glucose level. Rationale The nurse should determine the clients blood glucose (A) before taking further action. Protease inhibitors such as may saquinavir may increase blood glucose, producing symptoms such as polyphagia, polydipsia, polyuria, and weight loss. (B) is inaccurate if the client has developed diabetes melitus. (C) is not indicated if the client has developed adverse effects from the medication. Daily weight measurement is important (D), but of less concern than the symptoms reflecting hyperglycemia that the client is manifesting.
The charge nurse is observing the care provided for a client with acquired immune deficiency syndrome (AIDS) who was admitted yesterday with Pneumocystis carinii pneumonia. Which observation is an indication that staff education is needed? A. An environmental service technician wears gloves to use a bleach solution to wipe up blood. B. A nursing student is wearing a mask while taking the clients blood pressure. C. A laboratory technician is wearing gloves while performing a venipuncture. D. The staff nurse is allowing visitors to enter the clients room without donning personal protection.
Answer B. A nursing student is wearing a mask while taking the clients blood pressure. Rationale Mask and gloves are only necessary when there is the possibility of direct contact with the clients blood and body fluids, which is not likely to occur while taking a blood pressure (B). Wearing gloves while using a bleach solution (A) is needed to kill the virus associated with AIDS. Gloves (C) are required when performing venipuncture because of the possibility of coming in contact with blood. Personal protection equipment (PPE), such as gloves, are nor required for visitors (D) because there is a low probability.
A client presents at the emergency department complaining of a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A. Assess for presence of non-pitting edema. B. Administer prescribed dose of levothyroxine. C. Offer additional blankets and a warm drink. D. Note client's most recent hemoglobin level.
Answer B. Administer prescribed dose of levothyroxine. Rational In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid gland does not respond with adequate production of thyroid hormones (T3 and T4) to regulate basal metabolic rate. These serum hormone levels indicate the need to administer supplemental thyroid hormone, such as levothyroxine (B), as soon as possible to avert possible myxedema coma. Non-pitting edema is seen in chronic hyperthyroidism and assessment of the presence and location of the edema (A) is not a top priority. Providing warmth (C) is beneficial but of less priority than (B). Anemia is common in hypothyroidism but (D) is of lower priority than initiating treatment to prevent myxedema coma.
After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client? A. An older adult who is unable to communicate elimination needs. B. An older man whose sheets are damp each time he is turned. C. A woman with osteoporosis who is unable to bear weight. D. A poorly nourished client who requires liquid supplements.
Answer B. An older man whose sheets are damp each time he is turned. Rationale A Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture (B) places the client at a high risk for skin breakdown, and interventions should be implemented to pull moisture away from the client's skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture.
An adult male is admitted to a rehabilitation center after 3 weeks in an acute care hospital. The client suffered a right-sided brain injury that occurred as the result of a fall from a ladder. Which intervention should the nurse include in this client's plan of care? A. Maintain elastic stockings continuously. B. Apply a hand splint for finger extension. C. Monitor blood pressure every 4 hours. D. Give antithrombolytic injections daily.
Answer B. Apply a hand splint for finger extension. Rationale The client suffered a right-sided brain injury, so his left hand is likely to experience some degree of paralysis. The use of a hand splint (B) keeps the fingers in extension and prevents contractures that can impede any rehabilitation efforts to reestablish some degree of dexterous function. (A, C, and D) are interventions that should be included in the clients plan of care, especially during the acute phase of treatment, but may not be necessary during rehabilitation.
A client who has a tracheostoma is complaining of mouth pain. While performing oral care, the nurse determines that the client has mouth ulcers and that the oral mucosa is irritated. The client also has halitosis. Which intervention should the nurse implement? A. Encourage frequent use of a mouthwash. B. Apply viscous gel to ulcers during mouth care. C. Provide flavored oral swabs to use q2 hours. D. Rinse out mouth with a liquid germicide daily.
Answer B. Apply viscous gel to ulcers during mouth care. Rationale Mouth ulcers and irritation of the lining of the mucous membranes are very painful. An oral viscous gel (B), such as lidocaine anesthetic, can be used to temporarily relieve the pain (B). Routine mouth care is necessary, but should not be done too frequently (A) because it may cause further irritation of the mucous membrane. Oral swabs (C) and liquid germicide (D), such as peroxide, may be beneficial but do not relieve the discomfort or facilitate healing.
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. Clarify end of life desires. C. Initiate comfort measures. D. Offer sips of favorite beverages.
Answer B. Clarify end of life desires. Rationale Clarifying end-of-life desires for this client who is terminally ill is the most important intervention and should be done first before any further interventions are implemented. Other measures can then be implemented as indicated.
An adult male is admitted to the psychiatric unit from the emergency department because he is in the maniac stage of bipolar disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and is "too busy to eat". He is alert and oriented to time, place, and person, but not situation. Which nursing problem has the greatest priority? A. Hygiene self care deficit. B. Imbalanced nutrition. C. Disturbed sleep pattern. D. Self neglect.
Answer B. Imbalanced nutrition. Rationale The client's nutritional status (B) has the highest priority at this time, and finger foods are often provided so that clients who are in the maniac phase of bipolar disease can receive adequate nutrition. (A, C, and D) are nursing problems that should also be addressed in this client's plan of care, but at this stage in the client's treatment, adequate nutrition is a priority.
A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? A. Slow-onset of facial drooping associated with headaches. B. Inability to close the affected eye, raise brow, or smile. C. A flat nasolabial fold on the right resulting in facial asymmetry. D. Drooling is present on right side of the mouth, but not on the left.
Answer B. Inability to close the affected eye, raise brow, or smile. Rationale Because the motor functions controlling eye closure, brow movement, and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell's palsy has occurred (B). (A) is more indicative of stroke. (C and D) can occur with both Bell's palsy and stroke, so (B) is the definitive choice.
A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? A. Implements decisions about future hospices services within the next 3 months. B. Maintains pain level below 4 when implementing outpatient pain clinic strategies. C. Request home health care if independence become compromised for 5 days. D. Arranges for short term counseling if stressors impact work schedule for 2 weeks.
Answer B. Maintains pain level below 4 when implementing outpatient pain clinic strategies. Rationale An outpatient pain clinic (B) provides the interdisciplinary services needed to manage chronic pain. Although the client has a terminal disease and is being discharged home, hospice (A) and home health care (C) are not indicated at this time. Short term counseling (D) may help the client cope with terminal cancer, but pain management is most important so that the client can continue to participate in his normal life activities as long as possible.
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. Lymphangitis. B. Malignancy. C. Bacterial infection. D. Viral infection.
Answer B. Malignancy. Rationale Rapid enlargement of a lymph node, particularly the subclavian node with no tenderness or inflammation is suggestive of malignancy (B). Lymphangitis (A) is characterized by pain and inflammation. In infectious processes (C and D) the involved nodes become warm and tender to the touch.
The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A. A listing of African-American women so live in the community. B. Participation of community leaders in planning the program. C. Morbidity data for breast cancer in women of all races. D. Technical assistance to produce a video on breast self-examination.
Answer B. Participation of community leaders in planning the program. Rationale When developing a culturally-competent health promotion project, the participation of stakeholders and community leaders (B) is most important. (A and C) might be useful background information, but first the program should be developed. Technical assistance in developing educational tools (D) may be useful fulfilling the plan developed by the health care team and the community leaders if funding for this assistance is included in the budget.
An older adult male is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident (CVA). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A. Suction oral cavity q4 hours. B. Place a bedside commode next to the bed. C. Play classical music in room while client is awake. D. Measure neurological vital signs q4 hours. E. Encourage family to participate in the client's care.
Answer B. Place a bedside commode next to the bed. D. Measure neurological vital signs q4 hours. E. Encourage family to participate in the client's care. Rationale (B, D, and E) are correct. A bedside commode promote safety (B). To evaluate the client's continued convalescence and rehabilitation, monitoring neurological status (D) guides care, monitors client's progress, and identifies early signs of complications. Encouraging the family to participate in the client's care (E) helps prepare for home care and demonstrates the value of family members providing participative care for the client. The client's oral cavity should be suctioned as needed, not on a scheduled basis (A). Although providing sensory input may stimulate cognitive recovery, this measure is a continuous background stimulation (C) and should be based on the client's preferences.
The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? A. Encouraging the client to join a support group. B. Shaking the clients hand during the introduction. C. Wearing gloves when interviewing the client. D. Allowing the client to ventilate feelings.
Answer B. Shaking the clients hand during the introduction. Rationale Touch, more than any other gesture, communicates acceptance of the client with a skin problem such as psoriasis (B). (A and D) are worthwhile nursing interventions, but do not address this client's need for acceptance. (C), when not touching the affected area, shows rejection, not acceptance of the skin problem.
The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? A. High salt can damage the lining of the blood vessels. B. Too much salt can cause the kidneys to retain fluid. C. Excessive salt can cause blood vessels to constrict. D. Salt can cause information inside the blood vessels.
Answer B. Too much salt can cause the kidneys to retain fluid. Rationale Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.
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. Oxygen saturations 90%. B. Upper airway stridor. C. Expiratory wheezing. D. Blood tinged sputum.
Answer B. Upper airway stridor. Rationale Mucosal trauma related to extubation can cause airway swelling. Stridor (B) is consistent with airway swelling and obstruction, that if not resolved is life-threatening and should be reported to the healthcare provider immediately. Oxygen (A) should be titrated to achieve an oxygen saturation of 94%. Expiratory wheezing (C) should also be reported to the healthcare provider, but it is not a life-threatening finding. Blood tinged sputum (D) is common following extubation and results from mucosal trauma.
A female client is taking to the urgent care clinic after a fainting while exercising at the gym. She is weak, pale, and diaphoretic. Which intervention should the nurse implement first? A. Offer in oral hydration drink. B. Auscultate heart sounds. C. Check blood glucose level. D. Perform a 12-lead electrocardiogram.
Answer C. Check blood glucose level. Rationale Assessing for hypoglycemia can be done quickly and the effects easily reversed, which justifies checking the blood glucose level (C) first. Offering an oral hydration drink (A), such as Gatorade, may quench the client's thirst but may alter glucose results, which should be determined first. Abnormal heart sound (B) may indicate a serious underlying condition, and a 12 lead electrocardiogram (D) may provide additional information about the heart, but both these interventions can be done after the glucose level is obtained.
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? A. Low-grade fever, headache, and malaise for the past 72 hours. B. Unable to bear weight on the left foot, with the swelling and bruising. C. Chest discomfort one hour after consuming a large, spicy meal. D. One-inch bleeding laceration on the chain of the crying five-year-old.
Answer C. Chest discomfort one hour after consuming a large, spicy meal. Rationale Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain (C), respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.
A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? A. Increased Glasgow coma scale score. B. Nuchal rigidity and papilledema. C. Confusion and papilledema D. Periorbital ecchymosis.
Answer C. Confusion and papilledema Rationale Papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP (C). (A) indicated an improvement in neurologic status. (B and D) may be responses to the injury, but do not necessarily reflect increased ICP.
A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? A. Evaluate postural blood pressure measurements. B. Obtain specimen for uranalysis. C. Encourage popsicles and fluids of choice. D. Assess bowel sounds in all quadrants.
Answer C. Encourage popsicles and fluids of choice. Rationale Specific gravity (Sp Gr) of urine is a measurement of hydration status (normal range of 1.010 to 1.025) which is indicative of fluid volume deficit when Sp Gr increases as urine becomes more concentrated. The nurse should continue the prescribed IV fluid and increase PO fluid intake (C). (A, B, and D) may be implemented, but do not address the child's need for additional hydration.
A client with C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? A. Loud hallway noise. B. Fever C. Full bladder D. Frequent cough.
Answer C. Full bladder Rationale A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder (C). (A, B, and D) are unlikely to produce the manifestation of autonomic hyperreflexia.
An adult male who fell from a roof and fractured 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. Pale, diaphoretic skin. B. Pain score 8 out of 10. C. Onset of mild confusion. D. Weak palpable distal pulses.
Answer C. Onset of mild confusion. Rationale Onset of any confusion (C) or change in level of consciousness may indicate a life-threatening situation, such as massive loss of blood that often occurs with femur fractures or a head injury resulting from the fall. Pale, diaphoretic skin (A) can result from pain or blood loss and warrants further investigation. Pain (B) and weak distal pulses (D) are normal findings for a fractured femur and should be treated, but are not life-threatening.
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.
Answer D. Tented skin turgor. Rationale Tented skin turgor (D) indicates dehydration, a serious complication following prolonged diarrhea that requires further intervention by the nurse. (A and C) are expected findings with infectious gastroenteritis. Serum potassium (normal value 3.5 to 5.0 mEq/L or mmol/L) is normal (B) and monitoring should be continued.
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. Insert the feeding tube into the infant's nasal passage. C. Pause and monitor for a continued drop of the heart rate. D. Postpone the feeding until the infant's vital signs and stable.
Answer C. Pause and monitor for a continued drop of the heart rate. Rationale Insertion of an orogastric tube for gavage feedings often triggers vagus stimulation, which can result in bradycardia. Pausing during insertion and monitoring (C) the infant's heart rate and color may be all that is necessary for the heart rate to return to normal. (A) may precipitate further bradycardia. (B) traumatizes the nasal mucosal, which can cause edema that obstructs nasal breathing. The feeding should be given (D) since a heart rate drop alone does not indicate instability.
In assessing an infant 10 hours after birth, the nurse notes that the infant is slightly cyanotic and has a large amount of mucus. Which intervention should the nurse implement first? A. Begin oxygen at 2 L/minute. B. Insert a nasogastric tube. C. Suction the infant as needed. D. Assess the heart rate.
Answer C. Suction the infant as needed. Rationale To clear the airway, the nurse should first suction the mucus (C) which is likely to resolve the cyanosis. (A) is premature until the infant has a patent airway. (B) will not clear the airway. (D) does not treat the immediate problem of an inadequate airway.
Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions? A. Pizza. B. Chocolate milkshake. C. Sugar cookies. D. Tacos.
Answer C. Sugar cookies. Rationale The child with gastroesophageal reflux should adhere to a low-fat diet, and restrict intake of chocolate (B), caffeine, and spicy (D) and acidic foods (A). (C) is the best snack selection considering these guidelines.
When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Canned fruit cocktail. B. Creamy peanut butter. C. Vegetable juice. D. Vanilla frozen yogurt. E. Clear beef broth.
Answer C. Vegetable juice. D. Vanilla frozen yogurt. E. Clear beef broth. Rationale A full liquid diet includes all liquids that are not clear, such as vegetable juice and frozen yogurt, as well as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids.
The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? A. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. B. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. C. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container. D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.
Answer D. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale The client with an abdominal- perineal resection (D) is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. (A, B, and C) do not indicate acute life-threatening conditions.
The nurse brings an oral medication prescribed to be given daily to a male client who tells the nurse that he will take his medications later. What action should the nurse implement? A. Inform the client that his medication is scheduled to be taken now. B. Leave the medication on the bedside table with a fresh glass of water. C. Note the client's noncompliance with medications in the nurse's notes. D. Agree upon a time to return to the clients room with the medication.
Answer D. Agree upon a time to return to the clients room with the medication. Rationale Direct observation of a client ingesting medications is a safe practice of medication administration that validates administration time and client compliance, so the nurse should return with the medications later, preferably at a time agreed upon by the nurse and the client (D). (A) may encourage the client's cooperation with hospital routine, but does not consider the client's sense of control or participation in planning care. (B) does not verify medication administration and increases the risk that the client does not take the medication or that and inaccurate dosing schedule results. The client has the right to refuse medication (C), and further assessment is necessary before identifying the client's behavior as noncompliant.
An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? A. Request that the CT scan be done immediately. B. Review the client's history for use of illicit drugs. C. Assess client's pupils for their reaction to light. D. Explain the reason for using only non-narcotics.
Answer D. Explain the reason for using only non-narcotics. Rationale The client needs to understand that any pain medication they can mask declining neurological symptoms, such as narcotics (D), should be avoided. There is not an indication that the CT scan needs to be done immediately (A). In the absence of additional information, (B) is presumptive. Regular neurological assessments (C) are necessary but they do not address the client's pain.
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. Blood cultures. B. Oxygen saturation. C. White blood cell count. D. Mean arterial pressure (MAP).
Answer D. Mean arterial pressure (MAP). Rationale The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then maintain mean arterial pressure (D) of at least 65 mmHg. (A, B, and C) are also important parameters to monitor in the overall management of septic shock, but (D) is the most direct measure of the effectiveness of fluid volume resuscitation.
When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. A sluggish blood return. B. Client uses the arm cautiously. C. Spot of dried blood at insertion site. D. Red streak tracking of the vein.
Answer D. Red streak tracking of the vein. Rationale A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present site. A sluggish blood return (A), cautious use of the arm (B), and dried blood at the insertion site (C) are not indications for relocating the IV site or other immediate intervention.
Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? A. Have partners screened for human immunodeficiency virus. B. Report a sudden onset arthralgia to the healthcare provider. C. Decrease intake of high-fat foods, caffeine, and alcohol. D. Use two forms of contraception while taking this drug.
Answer D. Use two forms of contraception while taking this drug. Rationale Antibiotics, especially broad spectrum drugs like azithromycin, decrease the affectiveness of oral contraceptives and some spermicides, so the adolescent should be encouraged to use at least two forms of contraception to prevent pregnancy. (A, B, and C) provide important information but do not address the possibility of becoming pregnant, which can be an unintended outcome if additional or secondary methods are not use while taking azithromycin.
Which assessment finding is most important when planning to provide a complete bed bath to a bed fast client? A. 2+ pitting edema of the feet. B. Right-sided paralysis. C. Orthopnea. D. Pallor.
Answer C. Orthopnea. Rationale Orthopnea (C), the inability to breathe effectively while lying flat, has the greatest implication for the nurse when planning to provide a bed bath to a bedfast client. (A, B, and D) are also important assessment findings that may impact client care measures, but they are of less priority than ensuring adequate oxygenation.
The community health nurse is planning how to address the issue of child abuse in a large metropolitan area. Which primary prevention program should the nurse develop? A. Form weekly support group meetings for abused children. B. Start home visits for families identified at risk for violence. C. Develop an anger management class for abusive parents. D. Create a child development class for high school students.
Answer D. Create a child development class for high school students. Rationale Primary levels of prevention are aimed at preventing a health problem or disease before it occurs. Providing a child development class to high school students (D) before they have children that teaching the attendees what to expect from children which helps minimize risk for child abuse. (A, B, and C) are examples of secondary intervention.