Hesi Comprehensive exam 3 72

The nurse is evaluating the external fetal monitor and identifies variable FHR decelerations...

Umbilical cord compression

The nurse is teaching a client with Addison's disease about this new diagnosis

Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex

A male client gives a copy of his living will to the nurse...

Allow the client to die with dignity and without life-prolonging techniques.

An adolescent female who lost fifty pounds...

Amenorrhea

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child

Body surface area

What is the largest contributing factor for the increase in the need for home care?

Clients are more acutely ill when discharged from acute care facilities

A patient returns from surgery following an abdominal-perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. On the first postoperative day, the nurse gives the highest priority to a. teaching about a low-residue diet. b. monitoring drainage from the stoma. c. assessing the perineal drainage and incision. d. encouraging acceptance of the colostomy site.

Maintain dry perineal dressings C Assessing the perineal drainage and incision

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide?

Social smiling begins at approximately 2 months of age.

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

Use of a compression dressing for firm pressure to the site

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client?

Use of prescribed eye drops since last exam by ophthalmologist.

A male client with gastric cancer is 1 week postoperative....

Vitamin B12

A male client has a prescription for disulfiram

Vomiting

The nurse is assessing a client who is receiving risperidone...

Weight gain

A client is receiving an opioid analgesic every 2 hours for intractable pain...

Respiratory acidosis.

The charge nurse assigns one nurse to care for a client with shingles

Safe and effective care environment

The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin

Shakiness

Pulse oximetry is being used to monitor a client's oxygen saturation

Smoking Jaundice Hypotension Type 1 diabetes mellitus

A 50-year-old male client with ALS...

Spiritual distress

The nurse is suctioning the trach for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting?

Each pass of the suction catheter should take no longer than five seconds.

The nurse identifies the nursing diagnosis of visual sensory/perceptual alterations

Encourage compliance with drug therapy to prevent loss of vision.

Which intervention demonstrates the nurse's accountability...

Evaluating a client's outcomes after implementation of care.

An adolescent client is admitted to the mental health unit for impulsivity...

Explain the consequences for breaking the unit rules

Which components are characteristic of practice context?

Factors and systems that contribute to delivery of nursing care

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement?

Firmly inform the client that acting out anger is not acceptable.

A mother asks the nurse to explain how using time-out

Removes a reinforcer that a child is receiving

The nurse is providing care for a 6-year-old boy who has a broken arm and multiple bruises

Report the situation to appropriate authorities

When conducting an assessment interview with a new client, which question should the nurse use...

Tell me about your family.

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client

Check residual volume every four hours.

An older client who is admitted with terminal cancer...

"I notice you have a Bible"

A male client with degenerative arthritis of the knees and hips takes an OTC NSAID for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get sleep, I find that I wake up a number of times during the night." Which info should the nurse obtain first?

How intense does the client rate his pain on a scale of 1 to 10?

Which infant is at risk for Rh incompatibility?

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.

A client is prescribed a STAT dose of IV insulin...

Insulin regular (Humulin R)

What information in a client's history indicates the highest risk factor for hepatitis C?

Intravenous drug abuse

A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement?

Irrigate the NGT with normal saline.

The parents of a 4-month-old infant who is hospitalized...

Assign the same nurse to care for the child each day.

Which FHR finding should the nurse report to the HCP immediately?

Late decelerations

The nurse is caring for a client who is scheduled for surgery in 2 hours

Ask the surgeon to return to clarify questions for the client.

Which individual may legally sign an informed consent?

A 16-year-old mother for her newborn

A male client calls the crisis center and tells the nurse...

A loaded gun.

A client with cellulitis is recovering at home after experiencing a severe reaction

A malpractice suit based on lack of reasonable and prudent care

A client is comatose upon arrival to the emergency room department after falling from the roof. The client flexes with painful stimuli, and the nurse determines the client"s Glasgow Coma Scale is 6. Which intervention should the nurse prepare to implement to maintain the client"s airway?

A nasopharyngeal tube

The nurse is obtaining a client's consent for a paracentesis...

A needle is inserted to remove excessive fluid from the abdominal peritoneal cavity.

A client with advanced cirrhosis and hepatic encephalopathy is manifesting....

Apply a pressure-relieving mattress under the client.

A woman is having her first child. She has been in labor for 15 hours. Two hours ago her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0. Five minutes ago her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description?

Arrest of active phase.

Three days after a colon resection, the nurse is assessing a client with a NGT...

Aspirate the tube contents to test the pH

A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication?

Aspiration pneumonia.

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement?

Assess the client's needs for food, liquids, and rest.

A female client who is diagnosed with an eating disorder...

Dance and movement therapy

The healthcare provider prescribes digital evacuation

Decrease risk for bradycardia

During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. Which statement by the client reassures the nurse that teaching has been effective? a."I will need to eat 600 more calories per day because I am pregnant." b."I can continue with the same diet as before pregnancy as long as it is well balanced." c."Diet and insulin needs change during pregnancy." d."I will plan my diet based on the results of urine glucose testing."

Diet and insulin needs will change significantly throughout my pregnancy.

The nurse is supervising a UAP who is feeding....

Divides solid food items into one inch cube pieces.

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement?

Document a possible Type I latex allergy.

To avoid a false positive result for fecal occult blood in a stool specimen

Fish Beef Vitamin C Tablets Ibuprofen

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem Wrap the neck Break the neck Stabilize the ampule Withdraw the solution

The nurse is assessing an adult who displays stagnation,....

Generativity versus stagnation

Which change in sleep patterns is most likely to occur in an older adult?

Has a decline in stage 4 sleep

The nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. which interventions should the nurse include in the teaching plan

Incorporate favorite foods into the adolescent's diet.

Upon admission, the nurse determines a male client with alcohol withdrawal syndrome...

Monitor vital signs

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement?

Notify the healthcare provider.

Which action should the nurse implement to assess for JVD in a client with HF?

Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

The nurse is caring for a client who is one-day post cardiac catheterization with stent placement

Obtain urine output for the past 4 hours.

At what phase of the therapuetic relationship...

Orientation phase

Which action should the hospice nurse

Plan regular visits with the client throughout the day

The neonatologist requests a mother to provide breast milk for her 32 week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the brest milk. Which additional information should the nurse include to ensure the mother understands the request?

Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients.

A 32-year-old male client is admitted with paranoid schizophrenia

Reassure the client that he is safe and should rest.

The nurse is instructing a client about the use of podofilox...

Redness, peeling, and itching may occur at the site of application.

An older Chinese client refuses to perform...

Reliance on family members to assist with care.

Which therapeutic response should the nurse identify that best evaluates the use of reminiscence strategies with an older adult?

Stimulate memory chains through associations.

An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation.

Tell the child to go to the gym to play basketball.

When administering an intramuscular (IM) injection to an adult client...

The anterosuperior iliac spine and the greater trochanter.

What clinical problem is a suitable for research utilization in nursing?

The value of calcium channel blockers use over ACE inhibitors

A client who is taking nitroglycerin for angina is concerned....

This is a common side effect due to the vasodilatory effects of the medication.

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers

Tissue ischemia