HESI EXIT 2023

A client who is a veteran comes to the emergency department appearing tense, anxious, and having difficulty concentrating on the questions the nurse is asking during the health history. Which client statement is most important for the nurse to document?

"I can't forgive myself for leaving my buddy behind"

Nurses working on a surgical unit are concerned about a physician's treatment of clients during invasive procedures, such as dressing changing and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, which actions should the nurse take?

1. talk to the physician as a group in a non-confrontational manner 2. document concerns and report them to the charge nurse 3. submit a written report to the director of nursing 4. contact the hospital's Chief of Medical Services 5. File a formal complaint with the state medical board

What is the primary goal when planning nursing care for a client with degenerate joint disease (DJD)?

Achieve satisfactory pain control.

A client receiving radiation therapy for squamous papilloma of the hard palate is experiencing mouth pain. Which is the best initial nursing action?

Administer a topical analgesic.

The nurse is caring for a client admitting to the unit for testing of suspected hyperthyroidism. The client describes weakness, nervousness, a racing heart beat, and recent weight loss of 15 pounds. Which action should the nurse implement first?

Administer beta-adrenergic blocking agent

At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client's electronic heath record, which priority nursing action should the nurse implement?

Administer insulin per sliding scale

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Administer prescribed antibiotics.

A male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administered a one- time dose of morphine sulfate intravenously. What action should the nurse take?

Administered the dose of morphine sulfate as prescribed.

The nurse enters a client's room to administer oral medications and finds unlicensed assistive personnel providing person the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which priority nursing action is taken?

Advise the UAP to stop providing care so the nurse can assess the client's condition

The nurse brings an oral medication prescribed to be given daily to a male client who tells the nurse that he will take his medication later. Which action should the nurse implement?

Agree upon a time to return to the client's room with the medication.

The nurse prepares to teach four clients about diabetes mellitus. Which client has the greatest need for instructions?

An adult who has type 2 diabetes and has a glycosylated hemoglobin at 10%

A male client who arrives in the Emergency Department after a motor vehicle collision tells the nurse, "The care started to slide, and I just decided to let it go. Everyone would be better off if I was no longer around." How should the nurse respond?

Ask the client of the MVC was a suicide attempt

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Ask the client to describe the pain

Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?

Assist the client in developing a goal of managing the pain.

The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consults first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond?

Assume responsibility for discussing the concern with the provider.

The nurse is caring for a client with a chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/min per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first?

Auscultate the client's bilateral lung sounds and oxygen saturation.

The nurse is providing teaching to a client about management of type 2 diabetes mellitus. Which information stated by the client indicates understanding?

Avoid seasoning foods with salt and salt-containing spices

A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?

Avoid stimulation of the breasts and wear a tight bra.

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Avoid straining at school, bending, or lifting heavy objects.

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

Avoid the consumption of wine, beer, and coffee

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begins to show signs of improvement in affect

A mother brings her 2-month-old infant to the clinic for a well-baby appointment. The nurse obtains a history and conducts a physical assessment. Which finding requires the most immediate intervention?

Bilateral retinal hemorrhages

Which part of the vascular system is affected most by blood pressure from minute to minute?

Capillary refill

A client with megaloblastic anemia who takes folate 1 mg by mouth daily reports to the nurse of feeling increasingly fatigued. Which laboratory value should the nurse review?

Complete blood count.

Which information is most important to include in the teaching plan for a client who is discharged after a thyroidectomy for Grave's disease?

Daily hormone replacement will be needed for the rest of the client's life.

An older client is admitted with pneumonia, and the healthcare provider prescribes penicillin G potassium intravenously. Which assessment finding increases the risk of adverse reactions in this client?

Daily use of spironolactone for hypertension.

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

Defibrillate with one shock.

A morbidly obese client is scheduled for gastric bypass surgery. The client completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement?

Discuss small, low fat, low sugar meal preparation techniques.

A client diagnosed with schizophrenia is prescribed the atypical antipsychotic clozapine. Which intervention should the nurse include in the discharge teaching?

Discuss the importance of checking the white blood count weekly

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

Divide the medication into two injections with volumes under 1 mL.

The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit?

Document that the client has remained NPO

An older adult client is diagnosed with severe shingles and starts a new prescription for acyclovir, an antiviral medication. Which action should the nurse include during client teaching prior to discharge?

Encourage increased oral fluid intake while taking the medication

The nurse notes that a client with depression has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Engage the client in non-threatening conversations

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Ensure client takes a diuretic every morning

In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. Which action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

A school-aged child with chronic renal failure receives a prescription from the healthcare provider for losartan. Which action should the nurse implement prior to administering the medication?

Evaluate the ability to swallow medication.

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions?

Events requiring steroid dose adjustments

A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 sec. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?

Explain the postictal state that usually follows seizure

A client is admitted to the labor and delivery unit in early labor and the nurse assesses the status of her contractions. The frequency of contractions is most accurately by counting the minutes and seconds in which manner?

From the beginning of one contraction to the beginning of the next contraction.

When developing a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Give a dose of regular insulin as prescribed

The nurse is developing the plan of care for a hospitalized child with von Willebrand's disease. What priority nursing interventions should be included in this child's plan of care?

Guard against bleeding injuries

The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greater risk for which pathophysiological condition?

Guillain-Barre syndrome

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen on the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

Impaired gas exchange

What is the primary purpose the initiating nursing intervention that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with an HIV infection?

Improve function of the immune system.

A client who is HIV positive receives a prescription for megestrol 400 mg daily. Which finding should the nurse identify as a therapeutic response to this prescription?

Increased appetite.

A woman with an anxiety disorder called her obstetrician's office and tells the nirse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medication, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that soe antianxiety medication are safe to take while breastfeeding

The client who has emphysema and recently experienced a stroke receives a prescription for a metered-dose inhaler with a spacer device. The client asks the nurse if using the spacer is necessary. What information should the nurse provide?

It allows time to inhale the entire dispensed dose.

A postterm infant is delivered with meconium-stained skin and cord. The newborn is having substernal retractions, grunting, and nasal flaring. Surfactant is administered. Which statement should the nurse provide to the family about the purpose of surfactant?

It increases lung compliance and decreases surface tension.

A client with cancer develops tumor Luis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome?

Maintain intravenous therapy.

A client with a gram-negative bacterial infection develops disseminated intravascular coagulation. Which intervention should the nurse prioritize in the client's plan of care?

Maintain vascular volume with fluid replacement

An older adult male with the heart failure (HF) develops cardiac tamponade. After the healthcare provider performs pericardiocentesis, which intervention is most important for the nurse to implement?

Monitor for recurrence of tamponade and cardiovascular collapse.

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

Monitor the client's white blood cell count. Institute contact precautions for staff and visitors. Send wound drainage for culture and sensitivity.

A client with ureterolithiasis is preparing for discharge after a ureteroscopic removal. Which instruction should the nurse include in the client's postoperative discharge teaching?

Monitor urinary stream for decreased output.

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Move the client to a quiet place on the unit

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Musical and drumlike.

While caring for a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Neutrophil count.

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

Notify your healthcare provider if you start having abdominal pain.

Which breakfast selection should he nurse recommend for a 16-year-old with diarrhea?

Oatmeal, banana, and herbal tea.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse perform in the immediate management of the client?

Obtain a focused history to determine recent bleeding and use of anticoagulants

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?

Onset of mild confusion.

A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the UAP to implement?

Orient the client to the location of the food on the plate.

The nurse places a client in the supine position on the operating table for abdominal surgery that is expected to extend beyond 2 hours. Which measure is most important for the nurse to provide?

Place protective padding at all dorsal pressure points.

The nurse finds a client at 33-week gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Position bedside table so the client can lean across it.

While transferring a client with a chest tube from the bed to a stretcher, the chest tube becomes disconnect from the water-seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. Which action should the nurse implement next?

Prepare a new water-seal system and reattach the chest tube.

A client hospitalized with pleural effusion has a history of heart failure. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Provide a bedside commode for toileting

The nurse is providing discharge instructions to a client with atopic dermatitis who received a prescription for dexamethasone 8 mg by mouth daily. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

Rapid weight gain.

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Red streak tracking the vein.

An 18-year-old female client is seen at the health department for treatment of condylomata acuminata (perineal warts) caused by the human Papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual Papanicolaou (pap) smears.

A mal client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement?

Replace the transfusion with normal saline

Six weeks after the birth of child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another clid with Trisomy 21. The couple begins literature form the counselor with them, and asks the nurse to explain it. Which actions should the nurse take?

Review the literature and answer any questions the nurse is able to answer.

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Review the need for the UAP to wear a face mask while in close contact with the client

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound?

S1 S2 S3

A client on the cardiac telemetry unit unexpectedly begin manifesting ventricular fibrillation and the advanced cardiac life support team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member questions why the code was called, telling the nurse that the client has a living will. How should the nurse respond.

Seek clarification of the type of advance directive the client has.

A female client calls the clinic with a report of fever, dizziness, and a diffuse rash. When obtaining a health history, the nurse confirms the use of tampons for her menstrual cycle. Which instruction should the nurse provide?

Seek immediate emergency medical care.

The nurse is preparing to administered an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?

Serum creatinine of 4.5 mg/dL (398 mcmol/L).

AN adult client who is admitted to the mental health unit for treatment of bipolar disorder has slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Serum lithium of 1.6 mEq/L or mmol/L

A 6-month-old infant is admitted to the hospital with diarrhea. The parent is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last 4 hours. Which laboratory finding is most important for the nurse to monitor?

Serum sodium levels

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

Sharp fundal pain and uterine tenderness.

The school nurse is called to the soccer field because a child has a nosebleed. I which position should the nurse place the child?

Sitting up and leaning forward.

The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?

Soft abdomen, absent bowel sounds, no bleeding on dressing.

In providing nursing care for a client after gastric endoscopy, which commonly occurring problem should the nurse include interventions for in the post-procedure plan of care?

Sore throat.

The nurse is planning group therapy for clients in a substance abuse program. The focus of the group is, "Risk factors for hepatitis." What intervention should the nurse plan for the gorup?

Summarize what the group talked about

A client who has asthma receives a new prescription for a corticosteroid inhaler. The client expresses concern about taking steroid medications. What information should the nurse provide the client about the use of this maintenance inhaler?

Systemic side effects are reduced when taken by inhalation

Two hours after an abdominal aneurysm repair, a client remains sedated and mechanically ventilated in the post-anesthesia care unit (PACU). Which assessment finding warrants immediate intervention by the nurse?

Systolic blood pressure less than 90 mm Hg.

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Take before bedtime

The nurse is preparing a client for discharge who was hospitalized with a flare of symptoms from rheumatoid arthritis. Which instruction is most important for the nurse to include?

Take prescribed cortisone accurately

While caring for a client who had an exploratory laparotomy yesterday, the nurse notes that coffee ground material is draining from the nasogastric tube. Which intervention should the nurse implement?

Test nasogastric drainage for the presence of blood.

A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor. Which assessment finding places the client at greatest risk?

Unresponsive to painful stimuli.

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

Use cold and allergy medications only as directed by a healthcare provider.

An older client with dementia who is refusing to allow an unlicensed assistive personnel bathe he, is becoming increasingly agitated and stating the UAP want to hurt her and tie her up. Which approach should the nurse use with the client?

Use distraction and therapeutic communication skills

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the nurse provide to address the client's problem?

arrange an appointment with a pain specialist

The mother of a child with cerebral palsy asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

brain damage with CP is not progressive but does have a variable course

The nurse observes the practical nurse placing a client on the right side with the right arm behind the head for a scheduled echocardiogram. Which action should the nurse implement?

demonstrate to the PN how to position the client more effectively for the procedure

The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) ot exhibit what initial symptoms?

diarrhea, abdominal pain, and weight loss

The nurse is managing the care of a client who has partial-thickness burns over 60% of the body. The client's risk for acquiring bacterial infections is increased due to which factors?

epithelium produces antimicrobial peptides that kill bacteria acidic nature of skin protects against bacterial invasion

The mother of a 10-year-old who has sickle cell anemia expresses concern that her child will become addicted to pain medication if she follows the instructions on the prescription. Which information is most important for the nurse to provide?

giving pain medication around the clock will help control the pain

A client with an active gastrointestinal bleeding ulcer is to receive two units packed red blood cells. By rapid infusion. Vital signs are 96F, heart rate 132 beats/minute, respirations 22 bpm, and blood pressure 100/80 mmhg, And peripheral oxygen saturation 85%. Based on these findings, which intervention should the nurse implement first?

insert two large bore intravenous catheters

A male client with suspected lung cancer tells the nurse that he does not want to have a schedules biopsy performed, and states, "They already found the cancer when I had my chest x-ray." Which action should the nurse implement?

instruct the client that biopsy results are important to determine the best treatment

Four days after exposure to the coronavirus a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

move the client to a private room, keep the door closed, and initiate droplet precaution

The nurse caring for a toddler with Kawasaki disease who is receiving intravenous immunoglobulin for severe coronary inflammation is planning discharge teaching for the parents. Which instruction should the nurse provide during the discharge education?

plan for a follow-up echocardiogram occurring in 4-6 weeks

A 4-year-old-child is brought to the emergency department by a parent after being bitten by a non-venomous snake. The child is anxious and fearful, with a heart rate of 120 bpm and respirations of 42 bpm. The nurse anticipates the child developing which acid base imbalance?

respiratory alkalosis

The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate intervention by the nurse?

sharp pain related to a crushed femur

The nurse is caring for an adolescent 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?

talk directly to the adolescent while providing care

The nurse is performing an admission assessment of a client with generalized malaise and non-specific symptoms of not feeling well. Which finding is most important for the nurse report to the healthcare provider?

the trachea is to the right of the suprasternal notch

The nurse assesses a child in a 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome?

tip of the toes of the foot that is on traction

The nurse is caring for a client with irritable bowel syndrome who presents with diarrhea and cramping abdominal pain. Which pathophysiologic mechanism supports this client's clinical presentation?

tissue swelling die to an autoimmune response

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse assign to unlicensed assistive personnel?

transport a client with an IV to the radiology department

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observation by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply)

• A full pitcher of water is on the bedside table. • The client is lying in a supine position in bed.

The nurse is triaging victims of an explosion from a housing area outside of town. The nurse should issue a black disaster tag to which client?

• An older client with a head injury, fixed pupils and absent vital signs.

An older client with heart failure (HF), coronary artery (CAD), and hypertension (HTN), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply)

• Blood pressure. • Daily weight

An adult male with end-stage liver disease has been unresponsive for the past 3 days. This electroencephalography reveals no active brain activity. The family wants to discontinue feeding and donate his viable organs. Which action should the nurse to take?

• Contact the regional organ procurement agency

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which interventions should the nurse include in this client's plan of care?

• Encourage family to bring the client old photographs • Encourage family to visit frequently • Teach the client how to use guided imagery

When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? (Select all that apply)

• Fresh or frozen vegetables without sauce • Fruits without sauce

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply)

• Monitor stools for presence of blood • Auscultate bowel sounds in all quadrants • Review last partial thromboplastin time results.

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply.)

• Observe for evidence of hypokalemia • Teach the client how to restrict dietary sodium • Weight the client daily, in the morning

An older adult ids admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation?

• Place a bedside commode next to bed. • Encourage family to participate in the client's care. • Measure neurological vital signs every 4 hours.

An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to the redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints?

• Range-of-motion and circulation.

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse gathers equipment, including an intravenous catheter and insertion kit, and a 4x4 gauze dressing to apply over the insertion site. Which action should the charge nurse take?

• Remind the nurse to use a transparent dressing over the site.

The nurse provides teaching about a schedule procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asks the nurse for information about the scheduled procedure. What action should the nurse implement?

• Repeat the client teaching and leave written instructions for the client

A client who is newly diagnosed with type 2 diabetes mellitus receives a prescription for metformin 500mg PO twice daily. What information should the nurse include in this clients teaching plan?

• Report persistent polyuria to the healthcare provider • Take metformin with the morning and evening meal • Recognize signs and symptoms of hypoglycemia

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication?

• Report unusual bruising or bleeding.

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

• Serum potassium, calcium, and phosphorus.

A middle-aged client, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism?

• T3 and T4 hormone levels are increased • Large protruding eyeballa are a sign of hyperthyroidism • Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care?

• Teach the client to use incentive spirometer every 2 hours while awake. • Remove urinary catheter as soon as possible and encourage voiding.

The nurse observes unlicensed assistive personnel begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction should the nurse provide the UAP?

• Turn the clients head to the side • Remove the gloved finger from the mouth • elevate the head of bed to semi-fowler's

The health care provider prescribes a placebo instead of pain medication. What intervention should the nurse implement.

• discuss ethical concerns about placebo use with the healthcare provider

The nurse is interacting with a client who is diagnosed with postpartum depression. Which finding should the nurse document as objective signs of depression?

• interacts with a flat affect • Has a disheveled appearance