HESI attempt 1

The nurse is caring for a client with acute renal failure. Which assessment finding warrants immediate intervention? A. Dyspnea and sinus tachycardia B. Low, concentrated urine output C. Productive cough and fever D. Complaint of bad taste in mouth

A

... what pathophysiologic condition should the nurse identify as primary responsible for the declining PaO2 (refractory hypoxemia) which is PaO2 below 50 at FiO2 of 60%

ARDS

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness and drainage around the catheter site on the abdominal wall. In planning care, the nurse is most concerned about preventing which complication related to these findings? A. Exit site infection B. Peritonitis C. Outflow obstruction D. Atelectasis

B

A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic.... What assessment data should the nurse obtain next? A. Capillary glucose B. BP C. Body temp D. O2 sat

B

A male client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped at this time. What action is most important for the nurse to take? A. Administer an anti-anxiety medication B. Encourage the client to express his anxieties. C. Explain the importance of regular dressing changes. D. Proceed with the scheduled dressing change.

B

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis.

B) Nocturia. Rationale: As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure.

A client diagnose with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg

D

The nurse positions a male client for a lumbar puncture by placing him in the side-lying position with his knees flexed and pulled toward his trunk. What action should the nurse implement next? A. Call another nurse to assist the healthcare provider B. Provide a small pillow for the client to curl around C. Instruct the client to perform a Valsalva maneuver D. Support the client's head bent forward to the chest

D

The chest x-ray for a pt who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe? a. low pitched, sonorous rhonchi b. diminished breath sounds c. pleural friction rub d. crackles or course rales

Pic said D

What are plate guards?

Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit.

A nurse is caring for a client with acute respiratory distress syndrome. What should the nurse expect to note in the client? 1. Pallor 2. Low arterial Pao2 3. Elevated arterial Pao2 4. Decreased respiratory rate

The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg.

A hospitalized pt with chemo-induced stomatitis complains of mouth pain. What the a. cleanse the tongue and mouth with glycerin swabs b. admin a topical analgesic per prn protocol c. obtain a soft diet for the pt d. encourage frequent mouth care

b

Which food is most important for the nurse to encourage a male pt with osteomalacia to include in his daily diet? a. red meats and eggs b. fortified milk and cereals c. citrus fruits and juices d. green leafy vegetables

mayb B pic says B

A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? A. Encourage family members to cook meals outdoors and bring the cooked food inside B. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting C. Assess the client's mucous membranes and report the findings to the HCP D. Advice the client to replace cooked foods with a variety of different nutritional supplements

A

A female pt with ALL finished a chemo tx course two weeks ago and her ... WBC's: 1,100, neutrophils 5% and bands 4%. Which instructions is most important for the nurse to... result of this lab data? a. take precautions to avoid all known sources of infection b. assess temp if feeling hot, and report any fever c. do not take any medications that contain aspirin d. no instructions are needed as counts are expected postchemotherapy

A

A male client with cirrhosis is experiencing symptoms of peripheral neuropathy. Which nursing intervention has the highest priority? A. Teach the client to protect his feet from injury B. Assess the client's intake of Vitamin B-rich foods C. Observe the client's skin for signs for jaundice D. Refer the client for alcohol abuse counseling

A

A male pt who reports feeling chronically fatigued has a hgb of 11, hct of 34% and microcytic and hypochromic RBC's. Based on these finding, which dinner selection should the nurse suggest? a. beef steak with steamed broccoli and orange slices b. cheese pasta and lettuce and tomato salad c. broiled white fish with a baked sweet potato d. grilled shrimp and seasoned rice with asparagus salad

A

After confirming this rhythm in another lead, CPR is started. What should the nurse prepare to implement? A. Epinephrine (Adrenaline) IVP B. Transcutaneous pacemaker C. Atropine IVP D. Defibrillate

A

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to pro... what information should the nurse provide this client? A. The xenograft is taken from nonhuman sources B. Grafting increases the risk of bacterial infections C. As the burn heals. the graft permanently attaches D. Grafts are later removed by debriding procedure

A

Which instruction should the nurse include in the teaching plan of a client with portal hypertension and esoph A. Use stool softeners to avoid straining at stool. B. Eat several small meals throughout the day. C. Eat high potassium foods like bananas to help prevent bleeding. D. Take prescribed anticoagulants at the same time every day.

A

A client has an absolute neutrophil count (ANC) OF 500/MM2 after completing chemotherapy. Which intervention is most to the nurse to implement? A. Place the client in protective isolation B. Implement bleeding precautions C. Assess vital signs every 4 hours D. Review need for pneumococcal vaccine

A Normal ANC is 1000/mm2

After 3 days of persistent epigastric pain, a female pt presents to the clinic. She has been taking oral antacids w/o relief. Her vital signs are HR 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? a. ST elevation in three leads b. irregular pulse rate c. complaint of radiating jaw pain d. bile colored emesis

A - ST elevation is a medical emergency and it's in 3 of the 12 leads.

A pt suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this pt's plan of care? a. continuous cardiac monitoring b. perform passive range of motion c. evaluate LOC d. assess lung sounds q4h

A - correct

A pt with pheochromocytoma reports the onset of a severe headache. The nurse observes that the pt is very diaphoretic. Which assessment data should the nurse obtain next? a. BP b. body temp c. cap glucose d. O2 sat

A Pheochromocytoma is a tumor of the adrenal gland that causes severe episodic hypertension and presents with classic trials including headache, diaphoresis and tachycardia. The pt is exhibiting two of the three symptoms

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A) Prevention of deformities. B) Avoidance of joint trauma. C) Relief of joint inflammation. D) Improvement in joint strength.

A) Prevention of deformities. Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A) Propanolol (Inderal). B) Captopril (Capoten). C) Furosemide (Lasix). D) Dobutamine (Dobutrex).

A) Propanolol (Inderal). Rationale: Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate.

A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? A) Start an IV nitroglycerin infusion. B) Nasogastric lavage with cool saline. C) Increase the vasopressin infusion. D) Prepare for endotracheal intubation.

A) Start an IV nitroglycerin infusion. Rationale: Vasopressin is used to promote vasoconstriction, thereby reducing bleeding. Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction, and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may be needed if respiratory distress occurs (D).

When preparing a patient for a noncontrast computed tomography (CT) scan STAT, what nursing intervention should the nurse implement? A) Determine if the client has any allergies to iodine B) Explain that the client will not be able to move her head throughout the CT scan. C) Premedicate the client to decrease pain prior to having the procedure. D) Provide an explanation of relaxation exercises prior to the procedure.

B) Explain that the client will not be able to move her head throughout the CT scan. Rationale: Because head motion will distort the images, Nancy will have to remain still throughout the procedure. Allergies to iodine is important if contrast dye is being used for the CT scan. Premedicating the client to decrease pain prior to the procedure is unnecessary because CT scanning is a noninvasive and painless procedure. Providing an explanation of relaxation exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of highest priority.

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A) Limit dietary selection of cholesterol to 300 mg per day B) Increase intake of soluble fiber to 10 to 25 grams per day. C) Decrease plant stanols and sterols to less than 2 grams/day. D) Ensure saturated fat is less than 30% of total caloric intake.

B) Increase intake of soluble fiber to 10 to 25 grams per day. Rationale: To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total daily calories.

A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT carefully allows them to fall back to the bed and notifies the primary nurse. Which written documentation should the nurse put in the client's record? A) Client experienced orthostatic hypotension when getting out of bed. B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness. D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance report completed.

B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to allow client to fall back onto the bed. Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the pertinent facts are included in this documentation. D) A variance report should never be documented in the client's record.

A client is experiencing left-sided homonymous hemianopia as the result of a brain attack. Which nursing intervention would the nurse implement to address this condition? A) Turn Nancy every two hours and perform active range of motion exercises. B) Place the objects Nancy needs for activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy in forming sounds to words. D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays.

B) Place the objects Nancy needs for activities of daily living on the left side of the table. Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed side. This results in the client neglecting that side of the body, so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so her right side is the weak side. Speaking slowly and clearly would address the client's verbal deficits due to aphasia. Requesting all liquids to be thickened would address dysphagia. Turning the client every 2 hours and performing active range of motion exercises would address the client's risk for immobility due to paralysis.

A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the client's cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin immediate treatment since her cancer is likely to spread quickly

C

A male pt with a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the trach tube, which action is most important for the nurse to take? a. place knots of the ties laterally to prevent irritation and pressure b. remove ties to secure a disposable, soft foam collar with velcro. c. leave the old ties in place until the new ones are secure d. secure trach ties by making knots close to the tube

C

A pt with a medical dx of ruptured cerebral aneurysm exhibits these symptoms: .... and flexion to pain (decorticate posturing). What score on the GCS should the nurse document? a. 13 b. 9 c. 5 d. 3

C

An older adult is transferred to the hospital with anorexia, nausea, vomiting and confusion. The client was s... (Lanoxin) 0.25 mg, furosemide (Lasix) 40 mg, and potassium chloride (Micro-K) 10 mEq 3 months ago. Which .. take first? A. Administer a prescribed dose of digoxin immune fab (Digibind) B. Administer the doses of any home medications yet yet taken that day C. Apply a cardiac telemetry monitor D. Complete a neurological assessment

C

The high-pressure alarm on a mechanical ventilator is sounding. What intervention should the nurse implement immediately? A. Verify that all ventilator tubing is connected to the endotracheal tube B. Check for leaks in the tubing connecting the endotracheal tube to the ventilator C. Auscultate bilaterally for breath sounds then perform endotracheal suctioning D. Assess mental status for impact of sedation on respiratory depression

C

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A) Present knowledge related to the skill of injection. B) Intelligence and developmental level of the client. C) Willingness of the client to learn the injection sites. D) Financial resources available for the equipment.

C) Willingness of the client to learn the injection sites. Rationale: If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching (C). To determine learning needs, the nurse should assess (A), but this is not the most important factor for the nurse to assess. (B and D) are factors to consider, but not as vital as (C).

The nurse applies an automatic external defibrillator (AED) to a client who collapsed in an exam room at a community event. What should the nurse do next? A. Bring a crash cart to the exam room B. Measure the client's BP C. Assess the client's O2 sat D. Determine the defibrillator reading

D

Which condition is considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age.

D) Advanced age. Rationale: People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable means the client cannot do anything to change the risk factor. All the other options are modifiable risk factors.

Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia.

D) Global aphasia. Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with right-sided brain attack.

The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 1. Removing all clothing, including gloves and shoes 2. Determining the antidote for the chemical and placing the antidote on the burn site 3. Leaving all clothing in place until the client is brought to the emergency department 4. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing

In a chemical burn injury the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves and shoes, is removed immediately, and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed off the client before lavage is performed.

The nurse is planning care for an older male who experienced CVA several weeks ago. Bc of his expressive aphasia, the pt often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. speak slowly to the pt b. ask the pt simple qustions c. teach the pt use of basic sign language d. encourage pt's use of picture charts

Maybe D pic said D

A male tells the nurse that he is experiencing burning on urination and assessment reveals that he had sex four days ago with a woman he casually met. Which action should the nurse implement? a. assess for perineal itching, erythema, and excoriation b. obtain a specimen of urethral drainage for culture c. observe the perineal area for a chancroid-like lesion d. identify all sexual partners in the last four days

Maybe b

The UAP reports to the nurse that a pt who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first? a. test the stool for occult blood b obtain consent for a blood transfusion c. review hx for gi bleeding d. notify RRT

Maybe c word says A Black, sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the healthcare provider promptly

A male client with a primary lung cancer was told by his healthcare provider that he now has a secondary tumor. After the provider leaves, the pt asks the nurse what "secondary tumor" means. What response would be best for the purse to provide? A. Tell me why you are concerned about this term B. Your original cancer has spread to another location C. You need to remain hopeful. Tx can still be effective D. Let me call your provider back to explain the meaning of 2ndy tumors

Maybe d

A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle.

Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

The nurse has developed a client problem of ineffective airway clearance for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 1. Elevate the head of the bed. 2. Monitor oxygen saturation levels every 4 hours. 3. Encourage coughing and deep breathing every 4 hours. 4. Assess respiratory rate and breath sounds every 4 hours.

Nursing interventions for the client with an inhalation burn injury include assessing the respiratory rate every hour, monitoring oxygen saturation levels every hour, and assisting the client in coughing and deep breathing every hour. The head of the bed is elevated to facilitate lung expansion.

The nurse is providing pre op education for a Jewish pt scheduled to rcv a xenograft graft to promote burn healing. Which info should the nurse provide this pt? a. the xenograft is taken from nonhuman sources b. grafting incrses the risk of bacterial infections c. grafts are later removed by a debriding procedure d. as the burn heals. the graft permanently attaches

maybe A WORD says A

A pt who has a hx of long-standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this pt's pain management during the post op period? a. maintain pt's methadone, and medicate surgical pain based on pain rating. b. use minimal parenteral opioids for surgical pain, in addition to oral methadone c. make no changes in standard pain management for this surgery and hold methadone d. consult with surgeon about increasing methadone in lieu of parenteral opioids

maybe A pic says A

During spring break, a young adult presents at the urgent care clinic and reports a stiff neck, fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement? a. initiate isolation precuations b. prepare for a lumbar puncture c. admin an antipyretic d. draw blood cultures

maybe A pic says A or B WORD says B

A male pt is recovering from an episode of urinary tract calculi. During discharge teaching, the pt asks about the dietary restrictions he should follow. In discussing fluid intake, the nurse should include which type of fluid limitations? a. low sodium soups b. teac and hot chocolate c. citrus fruit juices d. over-all fluid intake

maybe B

The nurse is preparing the pt for a bronchoscopy. While obtaining consent, the pt complains of thirst and admits to drinking a small amount of oj two hours ago. What action should the nurse take? a. offer the pt ice chips b. admin an antiemeitc c. delay procedure for 6 hrs d. incrs iv flow rate

maybe C

A male pt is admitted to the ed with vomiting of dark brown, foul-smelling emesis. he reports he had surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive which prescription should the nurse implement first? a. place an indwelling urinary catheter and attach a bedside drainage unit b. give a prescribed analgesic for temp above 101 F c. insert a NGT and attach to low suction d. send the pt to x-ray for a flat plate of the abdomen

maybe C (betty's lecture suggests NGT) pic says C Mechanical obstruction: incrs Peristalsis, Secretions Worsens abdominal distention and edema -leading to emesis Metabolic Alkalosis if high in the small intestine- causes you vomit

The nurse is planning care for a pt with CKD who is a resident at a long term care facility. The pt is anuric and has hemodialysis 3x per week. Which intervention should the nurse include in the pt's plan of care? a. plan meals that include dark leafy veg b. use adult briefs to prevent skin breakdown c. monitor for signs of bleeding d. record strict urinary output

pic says C

A client develops an anaphylactic reaction after receiving morphine sulfate. The nurse should plan to institute which actions? Select all that apply. 1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response. 4. Leave the client briefly to contact a health care provider. 5. Keep the client supine regardless of the blood pressure readings. 6. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

1 2 3 An anaphylactic reaction requires immediate action, starting with quickly assessing the client's respiratory status. Although the health care provider and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal.

A 60-year-old female client with a positive family hx for ovarian cancer has developed an abdominal mass is being evaluated for passible ovarian cancer. Her PAP smear results are negative. What information should the nurse include in the client's teaching plan? A. Further evaluation involving surgery may be needed B. A pelvic exam is also needed before cancer is ruled out C. Pap smear evaluation should be continued every six months D. One additional negative pap smear is six months is needed

A

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately

A

A male client is admitted with flash burns to the anterior surface of both arms. anterior trunk, and anterior surface of both le.. Using the rule of nines, what total percentage of the client's skin surface is burned? (Enter number value only. If round...)

45 Add 4.5+4.5+18+9+9 = 45

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a brain attack.

A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated? A) Encourage the client to use the incentive spirometer and to cough. B) Administer oxygen by nasal cannula. C) Request a prescription for sodium bicarbonate from the health care provider. D) Inform the charge nurse that no changes in therapy are needed.

A) Encourage the client to use the incentive spirometer and to cough. Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client will need interventions as described in A above or may progress to a state of somnolence and unresponsiveness.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? A) Loss of thirst, weight gain. B) Dependent edema, fever. C) Polydipsia, polyuria. D) Hypernatremia, tachypnea.

A) Loss of thirst, weight gain. Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D).

The nurse assess a female client following a hysterectomy in the postanesthesia recovery.. a.. cool, and slightly diaphoretic. Her BP is 92/68 and her pulse is 108 and thready. What initial action should the nurse take? A. Replace the client's nasal cannula with face mask to increase available oxygen. B. Check the client's surgical dressing and estimate the current level of blood loss C. Obtain a prescription for a dopamine (Intropin) infusion from the anesthesiologist. D. Perform a venipuncture to type and crossmatch the client for a blood transfusion

B

The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic ... parameter should the nurse use to evaluate a therapeutic response to dopamine? A. Pupil response B. Urinary output C. Temperature D. Heart sounds

B

A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" What is the best response by the nurse? A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." C) "How do you feel about what the healthcare provider said?" D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition."

B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should give facts first, and then address her feelings after the information is provided.

The nurse is caring for a client who has taken a large quantity of furosemide (Lasix) to promote weight loss. The nurse anticipates the finding of which acid-base imbalance? A) PO2 of 78 mm Hg B) HCO3 of 34 mEq/L C) PCO2 of 56 mm Hg D) pH of 7.31

B) HCO3 of 34 mEq/L Rationale: Diuretics (non-potassium sparing) cause metabolic alkalosis. A) PO2 of 78 mm Hg: This Po2 demonstrates mild hypoxemia, consistent with respiratory disorders, not with diuretic use. C) PCO2 of 56 mm Hg: CO2 retention results from hypoventilation, which is not consistent with diuretic use. D) pH of 7.31: This pH is acidotic; diuretics promote metabolic alkalosis.

The nurse is assessing a client who was admitted 24 hours ago to the critical care unit following a motorcycle collision. which client finding requires intervention by the nurse to reduce the risk of complications related to ICP A. Presence of core body temperature of approx 97 F B. Infusion of mannitol (Osmitrol) despite serum osmolarity of 258 mOsm/L C. Change of PaCO2 to 55mmHg following ventilator setting adjustments D. Prescription for propofol IV through the left subclavian IV

C

The nurse is assessing a group of older adults. What factor in a male pt's hx puts him at greatest risk for developing colon cancer? a. smokes cigars b. eats a high-fat diet c. has intestinal polyps d. is excessively exposed to sunlight

C - Intestinal polyps are precancerous lesions and are a major risk for colon cancer

The nurse is preparing to administer allopurinol (Zyloric) to a client prior to a chemotherapy treatment..... prior to chemotherapy treatments? a. stimulates production of the rbc's and prevents anemia b. helps the body produce wbc's to fight infection c. prevents increased levels of uric acid that could harm the kidneys d. reduces nausea and vomiting that occur during chemo

C - allopurinol prevents the uric acid levels from increasing

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger.

C) Purulent sputum. Rationale: Steroids cause immunosuppression, and a purulent sputum (C) is an indication of infection, so this symptom is of greatest concern. Oral steroids may increase (A) and often cause (D). (B) may remain normal, borderline, or increase while taking oral steroids.

A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A) Elevated blood pressure. B) Allergy to shell fish. C) Right hip replacement. D) History of atrial fibrillation.

C) Right hip replacement. The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect the MRI.

After being transferred from the ED to a medical unit, a pt vomits into an emesis basin. The nurse observes the emesis as seen as coffee grounds. What assessment should the nurse complete first? a. measure abdominal girth b. observe for flushing c. auscultate breath sounds d. obtain current vital sounds

D

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity B. Palpable cervical lymph nodes. C. Jugular vein distention D. Carotid bruit

D

The nurse reports that the client is at risk for a brain attack (stroke) based on which assessment finding: a. nuchal rigidity b. palpable cervical lymph nodes c. jugular vein distention d. carotid bruit

D

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A) Losing weight. B) Decreasing caffeine intake. C) Avoiding large meals. D) Raising the head of the bed on blocks.

D) Raising the head of the bed on blocks. Rationale: Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be effective recommendations but raising the head of the bed is more effective for relief during sleep.

The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1. Hematocrit 60% 2. Serum albumin 4.8 g/dL 3. Serum sodium 144 mEq/L 4. White blood cell (WBC) count 9000 cells/mm3

Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit level ranges from 42% to 52%, depending on gender. Options 2, 3, and 4 identify normal laboratory values.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will check for which item to detect an early sign of this disorder? 1. Edema 2. Dyspnea 3. Frothy sputum 4. Diminished breath sounds

In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would present as a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

Which group of foods is best for the nurse to recommend for pt's with a strong family hx of colon and rectal cancers? a. oatmeal, raisins, and fruit with skin b. chicken, rice, and wheat products c. potatoes, low-fat breaks, and applesauce d. lean beef, salads, and baked potatoes

Maybe A A long history of low-fiber, high-fat, high-protein diets results in a prolonged transit time. The dietary recommendations for the prevention of colon rectal cancer include decreasing the amount of fat, refined sugar, red meats while increasing dietary fiber consumption. Not b because high protein, not d because of red meat and not C because not enough fiber

The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after rcving 10 units of regular insulin for glucose of 255, the pt is perspiring and complaining of shakiness. What intervention should the nurse implement? a. admin an additional dose of insulin b. obtain another cap glucose level c. reevaluate pt's symptoms an hour later d. give pt 8 ounces oj

Maybe B pic says D

A pt with an arterial ischemic leg ulcer is being discharged from the hospital. Which instruction is most important for the nurse to include in this pt's discharge teaching plan? a. wear shoes and socks while awake b. keep legs elevated as much as possible c. inspect feet daily for skin breakdown d. trim toenails straight across

Maybe C pic says C

A pt with COPD is somnolent and having periods of apnea. The pt's O2 sat is 88% while rcving humidified O2 at 6L/nasal cannula. Which intervention should the nurse implement? a. complete a neurological assessment b. adjust the oxygen flow rate to 2L/NC c. admin a narcotic reversal agent d. change O2 to 40% per face mask

maybe D

Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication? 1. An airway 2. A suction setup 3. A cardiac monitor 4. A tracheotomy set

The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring are essential because of the constrictive effects of the medication on the coronary arteries. Options 1, 2, and 4 are not essential items required during the administration of this medication. However, these items may be needed if a complication arises.

What is the normal range for cardiac output?

The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min.

A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being admitted. Why would this client not be a candidate for for thrombolytic therapy?

Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours before being brought to the medical center

Following an ileal conduit urinary diversion, a male pt voices several complaints. Which compliant indicates to the nurse that he is experiencing a complication? a. a bright red, moist ostomy site b. amber colored urine coming out of the stoma c. a small amount of bleeding at the stoma site d. a dark purplish colored stoma

mayb D - pic said D

A male pts with esophageal varices who has been NPO since admission to the ICU is requesting something to eat. He has not had a bleeding episode in 3 days, and he has prescription for diet as tolerated. Which snack is best for the nurse to provide the pt? a. soda crackers, milk and a cup of yogurt b. clear liquid broth, hot tea and ice cream c. ginger ale, strawberry gelatin, and clear soup d. lukewarm broth, iced tea, and a lemon popsicle

maybe D-word says D

A pt who has been taking finasteride (Proscar), an enzyme (5-alpha reductase) inhibitor used to shrink the prostate gland, is admitted bc of continuing benign prostatic hypertrophy (BPH) symptoms. When planning care, which nursing problem should the nurse plan to address first? a. disturbed sleep pattern b. urinary retention c. chronic pain d. risk for infection

maybe b

Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a post op pt? a. change the pt's IV access site to at least q72h b. assist the pt in turning from side to side q2h c. advise the pt to perform leg exercises regularly d. encourage frequent cough and deep breathing exercises

maybe b pic said c but not sure

The nurse learns in report that the x-ray report for a newly admitted pt indicates consolidation in the left lower lung. What action should the nurse take? a. admin prn dose of bronchodilator b. complete an assessment of resp status c. demonstrate use of an incentive spirometer d. prepare the pt for chest tube insertion

maybe c

A pt uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The pt calls the nurse to report incrsd erythema with purulent exudate at the site. What action should the nurse implement? a. advice the pt to apply plastic wrap over the ointment to promote healing b. instruct the pt to continue the ointment until all erythema is relieved c. explain that the pt needs to complete all prescribed doses of the med d. schedule an appt for the pt to see the doc

maybe d the pic said A