Hesi exit RN
What is the normal creatinine value
0.6-1.5
An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAP's behavior? Place the action in order from 1st on top to last on bottom?
1) Note the date and time 2) Discuss the issue privately with the UAP 3) plan for scheduled break times 4) Evaluate the UAP for signs of improvement
An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been 7 days since his last bowel movement, his abdomen is distended and he just vomited 150 ml of dark brown emesis. In what order should the nurse implement these interventions? Arrange with the highest priority intervention on top, and lowest priority intervention on bottom
1) elevate head of bed (to reduce complication related to intestinal bleeding and regurgitation) 2) offer PRN pain medication (to reduce abdominal pain 3) complete focused assessment( to releave from constipation) 4) Send emisis sample to lab (to rule out cause of emisis)
A client who is admitted for primary hypothyroidism has early signs of myxedema coma and associating the client at which sequence should the nurse complete these actions rank the first action at the top with the remaining in their descending order
1. Observe breathing patterns. 2. Assess blood pressure. 3. Measure body temperature. 4. Palpate for pedal edema.
What is the normal magnesium level
1.5 to 2.5 mEq shut down OK serum sodium is 135 to 145 that's good serum potassium potassium glucose fun's
What is the normal platelets value
100,000-400,000 /cu
What is the normal sodium value
135-145
The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 ml bottle labeled, "Digoxin elixir 0.05 mg/mL...
150 125/1000=0.125 is the D 0.05 is H 0.125/0.05 X 60ml= 150
A client with HIV begins active labor at 38 weeks gestation and recieves a prescription for Zidovvudine 2mg/kg IV, to be administered over 1 hour. The client weighs 185 lbs. Based on the clients weight, how many mg should the nurse prepare to administer...
168 If 1 lb = 0.452 kg Then 185lbs into kg = 84 kg If ordered dose is 2mg/kg zidovudine , which means for -1 kg of weight of patient ordered dose = 2 mg Then 84 kg of patient will have dose of = 84×2 = 168 mg Thus dose which is given to patient by nurse in mg = 168 mg Answer is 168 mg.
A heparin infusion is prescribed for a client who weighs 220 pounds after administering a bolus dose of 80 units/kg the nurse calculates the infusion rate for the heparin solution at 18 units /kg the available solution is heparin sodium 25,000 units and 5% dextrose injection 250 ml. the nurse should program the infusion pumps deliver how many ml/hr
18 units/ml wt 220lb /2.2kg=100kg 18 units/100kg = 1800 units (1800 units/25000) X 250ml 450,000/25,000 18 units/ml
A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only)
18Rationale: 450000/25000=18
what is the normal PTT value
24 to 36 seconds
What is the normal value of potassium
3.5-5 mEq
what is the normal red blood cells value
3.8-5.5
The healthcare provider prescribes penicillin 2,400,000 units intramuscularly for a client who has a postoperative wound infection the prefilled syringe is labeled penicillin 1,200,000 units/2ml how many ml should the nurse administer to this client enter the numeric value only round to the nearest whole number
4
Penicillin G procaine 2,400,000 units intramuscularly is prescribed for a 4-year-old child who has streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2mL. How many mL should the nurse administer?
4 ML D/HX2ml
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused intravenously over 4 hours. The Iv administration set delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion
42 1000/4=250 250/60*10
Hey client who receives multiple antihypertensive medications experiences centipede due to a drop in blood pressure to 70 / 40 what is the rationale for the nurses decision to hold the clients scheduled antihypertensive medications is additive effect of multiple medications has caused is blood pressure to drop too low
57
what is the normal BUN value
6-20mg
What is the normal serum glucose value
60 to 110mg
What is the normal pH value
7.35 to 7.45
The nurse plans to administer a bolus dose of IV heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer?
9000
nurse's immediate attention
A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby
Which client is the most likely candidate for total parenteral nutrition?
A client experiencing an acute exacerbation of Chrons disease
The charge nurse is making client assignments in the intensive care department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12- week internship, which client should the nurse assign the new graduate RN
A client with chest tubes secondary to a stab wound to the chest
The charge nurse is making client assignments in the intensive care Department. The healthcare team consist of One registered nurse (RN) with 10 years experience, One RN with 5 years experience, and a new graduate RN who just completed a 12 week internship. Which client should the nurse assign the new graduate RN? A) a client with end stage liver failure who is experiencing a esophageal bleeding. B) A client with multisystem failure secondary to a motor vehicle collision C) A client with chest tubes secondary to a stab wound to the chest D) a client with adult respiratory distress syndrome who is on a ventilator
A client with chest tubes secondary to a stab wound to the chest.
after reviewing the Braden scale findings of residents of a long term care facility the charge nurse should to tell the unlicensed assistive personnel to prioritize skin care for which client
A older man whose sheets are damp each time he is turned
The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nauseas, vomiting, and abdominal distention. Which pathophysiological mechanism supports the client's clinical presentation?
A weakened diaphragm with high abdominal pressure
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) A.)A client must be willing to accept palliative care, not curative care. B.)The healthcare provider must project that the client has 6 months or less to live. C.)The client must be diagnosed with clinical depression D.)The client must be of sound mind
A.)A client must be willing to accept palliative care, not curative care. B.)The healthcare provider must project that the client has 6 months or less to live.
A client with bacterial meningitis is receiving phenytonin which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytonin
Absence of seizure activity for the duration of treatment
A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung...
Absent of lung sounds on operative side
what does it mean if the ABGs are less than 7.45
Acidosis
A client with a history of heart failure and type 1 diabetes mellitus is admitted with unstable angina. Which problem requires the most immediate intervention by the nurse?
Acute anginal pain
The nurse is caring for a group of clients with the help of the practical nurse which nursing action should the nurse assigned to the PN select all that apply
Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM), Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty, & Perform daily surgical dressing change for a client who had an abdominal hysterectomy
A client who is scheduled for a bronchoscopy in the morning is anxious in asking the nurse numerous questions about the procedure and preparing for the client for the procedure which intervention has the highest priority
Administer a sedative to alleviate anxiety.
A client's morning assessment includes bounding peripheral pulses, weight gain of 2 lbs (0.91kg) pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this clien'ts plan of care
Administer prescribed diuretic
A male client being treated for testicular cancer with chemotherapy has decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement?
Advise the client that the treatment is having beneficial effect
The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be retrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager?...
Advise the staff nurse to remove the restrains from the client's wrists
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take?
Advise to sit up slowly from a reclining position
A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care?
Airway, Monitor for tracheal deviation and swelling at biopsy site
The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the clients history
Alcohol abuse
A client diagnosed with calcium kidney stones has a history of gout a new prescription for aluminum hydroxide is scheduled to begin at 0730 which client medication should the nurse bring to the health care providers attention
Allopurinol (Zyloprim)
The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first?
An adult who has a collapsed lung related to a fall from a ladder 8 hours ago..
A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
An distended bladder
The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling...
Ankle brachial index
At the end of the preoperative teaching session on pain management techniques, a client starts to cry and states, I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? A) knowledge deficit B) anxiety C) anticipatory grieving D) Pain
Anxiety
The nurse observed an elderly male client walking aimlessly in the hallway and staring straight ahead blankly how should the nurse enter computer documentation of this finding
Appears confused and depressed.
While admitting a client to the surgical unit who had a pneumonectomy 4 Hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement?
Ask a coworker to respond to the client whose call bell is alarming
a young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that the schizophrenia mother was difficult indeed which response is best for the nurse to provide
Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficle in the stool. Which action should the nurse take before administering the first dose?
Assess body temperature
A nurse receives report on a client who is 4 hours post total abdominal hysterectomy the previous nurse reports that it was necessary to change the clients pernille pad hourly and that it has again saturated the previous nurse also reports that the client's urinary output has decreased which action should the nurse implement first
Assess for weakness or dizziness
The nurse who works in labor and delivery is assigned to the cardiac care unit for the day because of a low census in labor and delivery which assignment is best for the charge nurse to give the nurse
Assist cardiac nurses with their assignments
A client with postpartum depression who was admitted to the behavior youth behavioral health unit reduces refuses to leave her room or eat meals in addition to maintaining physical safety which short outcome should the nurse include in the plan of care
Attends one group activity per day
A female client with a history of heart failure arrives at the clinic after what she describes as a very long trip following the initial physical assessment and chart review which priority action should the nurse implement
Auscultate lung and heart sounds
The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds
A nurse is preparing a discharge teaching plan for a client who has had a liver transplant which instruction is most important to include in this plan
Avoid crowds for first two months after surgery
the nurse is preparing a client for discharge who was hospitalized with an acute flare of systemic lupus erythematosus symptoms which instruction is most important for the nurse to include
Avoid extreme environmental temperatures
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?
Avoid large crowded areas during the colder months of the year
Which breakfast selection indicates that the client understand the nurses instructions about the dietary management of osteoporosis?
Bagel with jelly and skim milk
The nurse is evaluating the client teaching of a client with hypertension what dinner selection indicates that the client understands the dietary recommendations for hypertension
Baked pork chop , applesauce , corn on is cob , 2 % milk , and key - lime pie
When preparing a client who is to undergo a resection of a lelomyosarcoma of the uterus, the nurse notices that apixaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention?
Bleeding gums
The nurse observes a client prepare a meal in the kitchen of a rehab facility prior to discharge which behaviors indicate the client understands how to maintain balance safely select all that apply
Brings a heavy can close to body before lifting & Locks knees while preparing food on the counter
The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an arterial septic defect the health care provider promotes aspirin prescribed aspirin and an antibiotic for the first six months postoperatively to prevent ineffective endocarditis which information is most important for the nurse to discuss with the parents about the child's recovery and prevention of
Brush the child 's teeth every day and ensure that the child receive regular dental follow
The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat
Calcium fortified juice. good source of vitamins and minerals, and it can help the client stay hydrated, To prevent gastrointestinal side effects from the antibiotic. it can help to prevent these side effects by binding to the antibiotic in the gastrointestinal tract and preventing it from being absorbed. It will help this client to maintain their calcium levels while taking the antibiotic cephradine
A female client with metastic breast cancer is admitted with shortness of breath and pleural effusion the client has a living will and the family is requesting Hospice information what information should the nurse provide regarding Hospice
Can be provided within comforts of home, Provides comfort, dignity, and emotional support, Hospice services can be initiated prior to discharge, & Family members can be involved in the plan of care
Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS) A) capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema B) A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS C) Functional residual capacity and lung compliance increase as the disease progresses D) Interstitial edema that occurs due to the capillary fluid shifts is usually more serious than alveolar edema
Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema.
Which assessment finding places a client at risk for problems associated with impaired skin integrity?
Capillary refill of 5 seconds
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 node C) Jugular vein distention D) Carotid bruit
Carotid Bruit
After falling down the basement steps, a client is brought to the emergency room. X-rays confirm that the client's right leg is fractured...
Change in color
A female client is taking to the urgent care clinic after a fainting while exercising at the gym. She is weak, pale, and diaphoretic. Which intervention should the nurse implement first?
Check blood glucose level
a nurse who is working in the emergency department triage area is presented with four clients at the same time the client presenting with which symptoms requires the most immediate intervention by the nurse
Chest discomfort one hour after consuming a large, spicy meal
A 3 year old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall his parents are very concerned that the child has regressed in his toileting behaviors which information should the nurse provide to the parents
Children usually resume toliet behavior once leave hospital
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic which outcome indicates that the program was effective
Clients who developed disease complications promptly received rehabilitation
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding?
Complete a thorough neurological assessment
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse take?
Confirmation of the autoimmune disease process
A client who sustained a head injury following an automobile collision isadmitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?
Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.
A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client rations, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the states board of nursing?
Consult with appropriate state legislative representative
Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with tetralogy of fallot
Contact their healthcare provider immediately
Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which is most important for the nurse to implement?
Continue resuscitative efforts
The nurse assesses a chest or a client one hour after starting a infusion of packed red blood cells and determines that there are no indications of a transfusion reaction. Which instruction should the nurse provide the unlicensed assistive personnel (uap) who is working with the nurse?
Continue to measure the clients vital signs every 30 minutes until the transfusion is complete
While the nurse is assessing an older clients fall risk the client reports living at home alone and never falling which action should the nurse take
Continue to obtain client data needed to complete the fall risk survey
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries?
Decrease prevalence of glaucoma in the population
A client has a new prescription for the maximum recommended dosage of pipercillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose?
Decrease serum creatine
As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids on which pathophysiological process?
Decreasing the formation and secretion of pancreatic enzymes
The parents of a 4-week old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitating and pyloric stenosis, which is most important for the nurse to obtain? A) Degree of forcefulness of vomiting. B) Level of infants distress after vomiting C) odor and texture associated with emesis D) Position of the infant when vomiting occurs
Degree of forcefulness of vomiting.
The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups?
Designation of clinics conveniently located in target neighborhoods
An older client's daughter calls the home health nurse and reports that her mother has become forgetful and very confused at night the daughter states that her mother's behavior changed suddenly a few days ago and now getting worse which action should the nurse take select all that apply
Determine if mother experienced fall recently, Instruct the daughter to take her mother's temp, & Ask if mother is experiencing pain on urination
The nurse assesses a client who had bilateral total knee replacements four hours ago the nurse notes that the dressing on the client's right knee is saturated with serosanguinous Jane drainage which action should the nurse implement
Determine if the wound drainage device is functioning correctly.
The client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? A) administer prescribed pain medications B) assess the surgical site C) Determine the clients vital signs D) apply warmed blankets
Determine the clients vital signs
Two days prior to discharge from the rehabilitation facility the nurse is teaching a client who is recovering from guillain Barre syndrome about home health which action should the nurse include when providing discharge teaching to the client and spouse select all that apply
Develop a nutritional plan, Review safe transfer strategies, & Help identify community support.
A client is in the emergency center demonstrates rapid speech flight of ideas and reports sleeping only three hours during the past 46 hours based on these findings it is most important for the nurse to review the laboratory value for which medication
Divalproex.
During the admission assessment of a terminally ill client, the client expresses being an agnostic. What is the best nursing action in response to this statement
Document the statement in the clients spiritual assessment
A client who in an avid hiker expresses concern about losing too much potassium while hiking...
Dried apricots Seedless raisins Dried bananas
A client with acute pancreatitis is admitted with severe piercing abdominal pain with an elevated serum amylase which additional information is the client most likely to report to the nurse
Drinks alcohol until intox at least 2 x weekly Abdominal pain decreases when lying supine RUQ pain refers to R scapula
During the administration of albuterol per nebulizer, the client complains of shakiness. The clients vital signs are heart rate 120 beats/min, respirations 20 breaths/minutes, blood pressure 140/88. What action should the nurse take? Administer an anxiolytic Obtain 12 lead electrocardiogram. Educate client about side effects of Albuterol. Stop the albuterol administration and restart in 30 min
Educate client about side effects of Albuterol
Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first
Elevate the client's right hand on one or two pillows
A client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left fields... a.
Elevate the head of the bed 45 degrees Apply a high-glow oxygen by face mask Place in Trendelenburg position & Obtain a chest tube insertion kit
The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?
Elevate the presenting part off the cord
What might the nurse suggest to a client with fibrocystic breast in an attempt to help relieve her symptoms?
Eliminate caffeine from your diet
Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's Syndrome?
Eliminate caffeine intake
The nurse instructs the client in use of an incentive spirometer the client performs a return demonstration as seen in the video which action should the nurse take in response to the return demonstration please view the video
Emphasize the need to inhale slowly into the spirometer
After a sudden loss of consciousness, a female client is taken to the ED and Initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?
Encourage a low carb and high protein diet
The home health nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?
Encourage family member to cook meals outdoors and bring the cooked food inside
A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. The promote parent-infant attachment behaviors, which intervention should the nurse implement?...
Encourage rooming-in while in the hospital
A client is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, what action should the nurse implement?
Encourage the client to continue using the walker as observed.
A male client tells the nurse that he is concerned that he may have a stomach ulcer because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats what is the best response by the nurse
Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer
A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition...
Encourage the client to reflect on personal goals and priorities
An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?
Encourage the client to weight herself daily at bedtime
The nursing staff expresses concerns about a new policy that increases the nurses to patient ratio by 25% on all shifts which action is best for the nurse manager to take
Encourage the nursing staff to organize a group meeting to voice their complaints
Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter?
Ensure continued sterility of the specimen container
In assessing a 70-year-old client with Alzheimer's disease, the nurse notes that the client has deep inflamed cracks at the corners of the mouth. What intervention should the nurse include in this clients plan of care?
Ensure that the client gets adequate B vitamins in foods or supplements
A client is recovering in the critical care unit following a cardiac catheterization Ivy nitroglycerin and heparin are infusing the client is sedated but responds to verbal instructions after changing positions the client complaints of pain at the right groin insertion site what action should the nurse implement
Evaluate the integrity of the IV insertion site.
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA)> the nurse includes activities to strengthen and mobilize the joints surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
Exercise in the swimming pool
A client with uremia is experiencing uremic frost. Which action should the nurse implement?
Explain that hemodialysis is needed
When performing postural drainage on a client with Chronic Obstructive Pulmonary disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
A client in the third trimester of pregnancy reports that she feels some lumpy places in her breast and her and her nipples sometimes leak a yellowish fluid she has an appointment with her health care provider in two weeks which action should the nurse take
Explain that this normal , but can be assessed further at the next prenatal visit
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her she keeps hoping that he will change which action should the nurse first take
Explore client 's readiness to discuss the situation
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?
Fatigue
The nurse is taking the blood pressure measurement of a client with Parkinson's disease which information in the client's admission assessment is relevant to the nurses plan for taking the blood pressure reading?
Flat affect, blurred vision, & frequent syncope
The nurse identifies several nursing problems for clients who is immobile and who has been experiencing people incontinence and diarrhea for several days the client spouse is the primary caregiver in planning care which problem has the highest priority
Fluid volume imbalance
A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L (24mmol/L). Which assessment finding warrants immediate intervention by the nurse?
Fruity breath
A client arrives in the emergency department (ED) with deep, full-thickness burns over the anterior surface of both upper legs. Which priority intervention should the nurse implement?
Give IV bolus of normal saline
In caring for a client of Cushing syndrome, which serum laboratory value is most important for is nurse to monitor? a)Lactate b)Glucose c)Hemoglobin d)Creatinine
Glucose
When assessing a recently delivered multi gravida client the nurse finds that the vaginal bleeding is more than expected which factor is in the clients history is related to this finding
Gravida 6 Para 5
Which pathological characteristics are seen with magnificent cellular growth select all that apply
Growth rate is rapid, infiltrates and metastasizes Magnificent cellular growth is defined by an increase in cell size, cell number, and cell function
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? A) Heat loss B) Hypoglycemia C) Fluid balance D) Bleeding tendencies
Heat loss
A client is admitted with a diagnosis of your urolithiasis which finding is most important for the nurse to report to the health care provider
Hematuria that is beginning to turn pink
A 60-yea-old female client asks the nurse about hormone replacement therapy (HRT) as a means of preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT?
Her mother and sister have a history of breast cancer
When taking a healthy history which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral artery insufficiency
History of intermittent claudication
The nurse plans to administer a schedule dose of Metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that clients telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?
Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.
The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take?
Hold the walker securely to prevent slipping while the client raises
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication? A) excessive Lochia B) Saturation of the more than one pad per hour. C) Hypertension D) Difficulty locating the uterine Fundus
Hypertension
The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?
Hypoalbuminemia that results in a decreased colloidal oncotic pressure
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
Hypokalemia
Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?
I have a headache that gets worse when I sit up
The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout?
I need to take this drug every day to prevent from having flare ups
When is it most important for the nurse to assess a pregnancy clients deep tendon reflexes (DTRs)?
If the client has an elevated blood pressure
When is the best time for the nurse to assess a client for residual urine?
Immediately after the client voids
Arterial blood gas (ABG) results indicate that a client with respiratory failure who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute,
Increase the ventilator rate
A order client is brought to the emergency department with a sudden onset of confusion that occurred after experiencing a fall at home the client's daughter who has power of attorney has brought the client's prescriptions which information should the nurse provide first when reporting to the health care provider using sbar situation background assessment recommendations communications
Increasing confusion of the client
The nurse on a pediatric unit observes a distraught mother in the hallway holding her three year old son wetting his pants what initial action should the nurse take
Inform the mother that toilet training is slower for boys
Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement? A) administer second dose of Nitroglycerin B) Infuse a rapid IV normal saline bolus. C) Begin external chest compressions D) Give A PRN antiemetic medication
Infuse a rapid IV normal saline bolus.
A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take?
Initiate an ethics committee review
When admitting a client with a diagnosis of transient ischemic attack Tia which intervention is most important for the nurse to include in the client's plan of care
Initiate neurological monitoring every 2 hours
A client of 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum which action is most important for the nurse to implement
Initiate prescribed intravenous fluids
After an older client receives treatment for drug toxicity the health care provider prescribes a 24 hour Creighton claritin test prior to starting the urine collection the nurse notes that the client server Creighton is 0.3 which action should the nurse implement
Initiate the urine collection as prescribed
While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing...
Insert the catheter an additional inch
The nurse preparing a client who had a BKA (below the knee amp) for discharge to home. Which recommendations should the nurse provide this client? (select all that apply
Inspect skin for redness ● Use a residual limb shrinker ● Wash the stump with soap and water
A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement?
Instruct family to offer client only soft bland foods
The nurse is reviewing a clients urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding?
Instruct the client to increase oral fluids to a min of 2400 ML per day
A new nurse preparing to irrigate and intravenous catheter is attaching a 24 gauge needle which action should the charge nurse implement
Instruct the nurse to remove the needle
While interviewing an elderly client, the nurse observes that the clients hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding?
Intention tremor
The nurse is teaching the mother of a 5 month old about providing a safe home environment for the infant which instructions is most important for the nurse to provide the mother
Keep floor clear of small objects
A client with a new Diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharge teaching plan? A) hire a caregiver for 8 hours daily B) develop a walking exercise routine C) Keep room Temperature 80 D) Wear TeD stockings at night
Keep room Temperature 80
The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
Kidney beans
The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?
Large amounts of fluid and electrolyte replacement
A client who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse?
Lethargy
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury
Limit fluid intake
The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the clients clinical recovery?
Lipase
The nurse is caring for a seated client who is experiencing a tonic clonic seizure which actions should the nurse implement select all that apply
Loosen restrictive clothing, ease the client to the floor, note the duration of the seizure
A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.
Maintain contact transmission precautions
An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client?
Maintain prescribed eye drop regimen
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125...
Maintain prescribed fluid restriction
Which long-term outcome is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis?
Manages activities of daily living independently
A client who is hypotensive is recieving dopamine, an adrenergic agonist, IV at the rate of 5mcg/kg/min. Which intervention should the nurse implement while administering this medication? Monitor serum potassium frequently. Assess pupillary response to light hourly Measure urinary output every hour. Initiate seizure precautions
Measure urinary output every hour.
A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement?
Measure urine output
A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement?
Measure vital signs
A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective?
Minimize stationary standing as much as possible. Protect legs from trauma as this can lead to ulcerations. Elastic compression stockings are recommended for clients with chronic venous insufficiency to prevent pooling and promote venous return. Leg elevation decreases edema, promotes venous return, and provides symptomatic relief. Legs should be elevated frequently throughout the day (for at least 15-30 minutes every 2 hours). During the night, the client should sleep with the foot elevated approximately 6 inches (15.24 cm).
which interventions should the nurse include in the plan of care for a child with tetanus
Minimize the amount of stimuli in the room
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
Monitor for signs of bleeding
A client with cancer complains of fever, chills, malaise, and headache following administration of a colony-stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms?
Monitor lab values for an increase in WBCs
A client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. The client states, "I just had a little case of the sniffles and a bit of a sore throat
Muscle weakness is an elderly sign of crisis and means that you need more rest
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis, which expected outcome has the highest priority
Names three home safely hazards to be resolved immediately
A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy..
Normal Saline (NS) at 20 mL/hr
A client tells the nurse that he is "very nervous" about the surgery he is scheduled to have in the morning. Which actions should the nurse implement?
Notify the healthcare provider about the clients expressed fears and anxiety
A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102..
Notify the healthcare provider and obtain a tracheostomy tray
A mother brings her three year old sons to emergency room and tells the nurse that she has an upper respiratory infection for the past two days assessment of the child reveals a rectal temperature of 102 he is drooling and becoming increasingly more restless. What action should the nurse take first?
Notify the healthcare provider and obtain a tracheostomy tray
A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?
Observe aspiration site
In evaluating the effectiveness of a postoperative client intermediate pneumatic compression devices which assessment is most important for the nurse to complete
Observe both lower extremities for redness and swelling
In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include?
Observe client during movement of the affected joints
When the nurse enters the room of a male client who was admitted for a fractured femur his cardiac monitor displays a normal sinus rhythm but he has no spontaneous respirations and his carotid pulse is not palpable which intervention should the nurse implement
Obtain a 12-lead ECG
A client who is hemorrhaging from severe leg injuries receives 430 milliliters of whole blood before being taken to the operating room for emergency surgery which nursing intervention is most important for the nurse to complete before the client surgery
Obtain partial thromboplastin time
A client is hospitalized with inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid...
Obtain vital sign measurements
In observing a clients face, which assessment finding requires the most immediate intervention by the nurse?
Oral mucosa is cyanotic Blue lips
During a 24-hour chart review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed
Order the lab work as prescribed and follow procedures for completing an incident report
To auscultate for a carotid bruit the nurse places the stethoscope at which location
Over the neck
A 26 year old female client is admitted to the hospital for treatment of a simple groiter and levothyroxine sodium as prescribed which symptoms indicate to the nurse that the prescribed dosage is too high for this client the client experiences
Palpitations and shortness of breath
The nurse has received funding to design A health promotion project for African American women who are at risk for developing breast cancer rich resources most important in designing this program
Participation of community leaders in planning the program
A woman is brought to the labor and delivery unti after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first?
Perform a fundal massage
A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care...
Peritonitis
The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on a rehab unit the UAP asks the nurse how to safely move a physically disabled client from the wheelchair to the bed which action should the nurse recommend
Place a client 's locked wheelchair on the client 's strong side next to the bed
Prior to obtaining an axillary temperature, the nurse should perform which action?
Place a protective sheath over the thermometer
A client is receiving enoxaparin 30 milligrams subcutaneously twice a day in assessing for adverse effects of the medication which serum laboratory value is most important for the nurse to monitor
Platelet count
A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains blood glucose of 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement?
Position client with head flat and feet elevated
The mother of a one-moth-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
Position the infant on the stomach occasionally when awake and active
While ausculting a client's abdomen, the nurse hears a low pitched blowing sound in the upper midline area. What is likely indication of this finding? A) normal for borborygmus sounds B) A minor variation C) Hyperactive bowel sounds D) Possible renal artery stenosis
Possible renal artery stenosis
During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?
Prepare for the endotracheal tube to be repositioned
The nurse determines that an older female client has kyphosis, has lost two inches of height in the last three years, and has a recent history of spinal vertebral fractures...
Progressive weakening of the muscle fibers of the lower back
A male client approaches the nurse with an angry expression on his face and raises his voice saying my roommate is most selfish most self-centered angry person I've ever met if he loses his temper one more time with me I'm going to punch him out the nurse recognizes that the client is using which defense mechanism
Projection
The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition...
Reassure the mother that beginning to replace the prepared foods with some table foods can provide the needed nutrients
An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest?
Recommend installing gran bars by toilets, bathtub, and shower Have the home health nurse assess the home for fall risk & Wear an emergency response pendant at home
A client in the third trimester of pregnancy complains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
Record the respiratory finding in the clients chart as normal
When assessing an Iv site that is used for fluid replacement and medication administration the client complaints of tenderness when the arm is touched above the site which additional assessment finding warrants immediate intervention by the nurse
Red streak tracking the vein ( indicates vein irritation and necessities discontinuing the IV at the present site )
While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?
Reduce the stimuli in the area before continuing the teaching
An order client with a long history of coronary artery disease hypertension and heart failure arrives in the emergency department in the respiratory distress the healthcare provider prescribes furosemide which therapeutic responses to furosemide should the nurse expected and the client with acute heart failure
Reduced preload
The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfram. What information should the client acknowledge understanding?
Remain alcohol free for 12 hours prior to the first dose
The charge nurse in an emergency center is planning client care assignments for the staff which action may be safely delegated to the practical nurse
Remove a peripheral intravenous (PIV) catheter
After placing a 36- week- gestation newborn in an isolette and drying the infant with several blankets, what should the nurse implement next?
Remove the wet blankets and linen from the isolette
A teenager presents to the emergency department with palpitations after vaping at a party the client is anxious fearful and hyperventilating the nurse anticipates the client developing which acid base imbalance
Respiratory acidosis is the acid base imbalance
A 78-year old male client is admitted with complications related to Chronic Obstructive Pulmonary disease (CODP) He reports progressive dyspnea worsening on exertion, weakness, and dependent edema. Which instruction should the nurse include in the client's teaching plan A) Limit high calorie foods B) replace sodium with salt C) Eat a low protein diet D) Restrict daily fluid intake
Restrict daily fluid intake
Three days after initiating parental fluids for a newborn with a ventricular septal defect the nurse assesses and increase in heart rate and blood pressure which intervention is most important for the nurse to implement
Restrict intake of oral fluids
Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse?
Review with the client the need to avoid foods that are rich in milk and cream
A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client?
Risk for injury
A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority?
Risk for injury related to uterine atony
The nurse should withhold which medication if the client serum potassium level is 6.2 M EQ
SPIRONOLACTONE
After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
ST elevation in three leads
The nurse uses the Glasgow coma scale (GCS) to assess a client who has had a stroke. When the nurse calls out the client's name, the client does not open eyes, does not respond to painful stimulus
Score of 3 on the GCS
Which laboratory value should the nurse review prior to administering the initial dose of a statin medication?
Serum liver enzymes
An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? A. Serum potassium B. Urine ketones C. Urine albumin D. Serum protein
Serum potassium
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
Serum sodium level of 120 mg/dL
The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform?
Set daily goals in the community meeting
A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?
Silence allows the client to reflect on what was said
The nurse is completing the admission assessment of a 3 year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing inter increased intracranial pressure
Sluggish and unequal pupillary responses.
A client who recently received a prescription for ramelton and to treat sleep deprivation reports experiencing several side effects since taking the drug which side effects should the nurse report to the health care provider
Somnambulism
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history form the child's mother, the recent occurrence of what illness is most significant?
Sore throat
An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused
Start intravenous of normal saline
A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?
Stop the normal saline infusion
The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been ...
Stop using the ointment and encourage complete drying of feet and wearing clean socks
A male client with cirrhosis has jaundice and puritis he tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort which action should the nurse take
Suggest that the client take brief showers and apply oil-based lotion after showering
A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse
Takes metformin hydrochloride for type 2 diabetes mellitus
when conducting client teaching for a client who is on a postoperative full liquid diet which food should the nurse encourage the client to eat select all that apply
Tea and lentils
During an evening shift on a medical unit the only nurse on the unit is busy with an unstable client the unit clerk who is also both a certified medication aide and an unlicensed assistive personnel reports to the nurse that a health care providers on the telephone and wishes to prescribe a PRN dose of oral over the counter laxative for a client who is constipated what instructions should the RN provide the unit clerk
Tell the Healthcare provider that the nurse will return the phone call as soon as possible
During an evening shift on a medical unit, the only nurse on the unit is busy with unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personal (UAP), reports to the nurse that a healthcare provider is on the telephone...
Tell the healthcare provider the nurse will return the phone call as soon as possible
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a Psoralen and ultraviolet A light treatment which assessment finding indicates that the client has been over exposed to the treatment
Tenderness upon palpation and generalized erythema
The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side
Tennis shoes with velcro
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery which action should the nurse implement immediately
Test fluid on the dressing for glucose
The nurse is caring for a 24 month old toddler who has sensory sensitivity difficulty engaging in social interactions and has not yet spoken two word phrases which assessment should the nurse administer
The Modified Checklist for Autism in Toddlers
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?
The additive effect of multiple medications has caused the blood pressure to drop too low
A client fell in the bathroom when he left unattended by the unlicensed assistive personnel which information should the nurse include in the client's health record
The client fell sustaining a fracture to the left hip.
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impeding death. After notifying the family of the client's status, what priority action should the nurse implement? A) the impending signs of death should be documented B) The clients need for pain Medication should be determined C) the nurse manager should be updated on the clients status D) the client's status should be conveyed to the chaplain
The clients need for pain Medication should be determined
An older male client who is a retired chef is hospitalized with a diabetic ulcer on his foot his daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital the nurses response should be based on what information
The family needs a social worker to talk to them about how to handle their father when he becomes annoying .
When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?
The medication should be taken with meals
The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment?
The nurse at night is trying to poison me with pills
The nurse is educating a client with end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet?
The protein intake should be decreased to prevent nitrogenous waste Buildup
A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol how should the nurse respond?
This mediation will have no effect on your unborn child
A client with hyperthyroidism is admitted to the post operative unit after a subtotal thyroidectomy which of the clients serum laboratory values requires intervention by the nurse
Total calcium 5.0 mg / dl
A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first?
Trendlenburg
A client is admitted to the hospital with symptoms consistent with a right hemispheric stroke. Which neurovascular assessment requires immediate intervention by the nurse?
Unequal bilateral hand grip strengths
After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied. a)Tenderness over insertion b) Unrelieved back and flank pain c- Cool and pale left leg and foot d- Left groin egg-size hematoma. e- Quarter size red drainage at site.
Unrelieved back and flank pain cool and pale left leg and foot Left groin egg size hematoma tenderness over insertion
The nurse is communicating with a 12-year old who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this client?
Use a picture board to communicate needs
A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground materials is observed in the drainage from the nasogastric tube (NGT), which intervention should the nurse implement?
Verify correct placement of the nasogastric tube
An older client has been diagnosed with chronic venous insufficiency. To promote venous return, which action should the nurse encourage the client to take?
Wear cotton socks and enclosed toe shoes whenever outside
The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply
White blood cell count sputum culture and sensitivity
After receiving report on an inpatient acute care unit which client should the nurse assess first
With a bowel obstruction due to a valvulas who is experiencing abdominal rigidity
The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit?
With atrial fibrillation whose saline lock is infiltrated
The nurse working in a disaster area assess an adult client who has partial-thickness burns on the lower legs, or approximately 10% of the lower body
Yellow
The Healthcare provider prescribes the antibiotic cream cephradine 500 mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? A) Yogurt and/or Buttermilk B) Avocados and cheese C) Green leafy vegetables D) Fresh Fruits
Yogurt and/or Buttermilk
Hey client whose hypothyroidism has not been responsive to medications is admitted for evaluation during the admission assessment the client reports to the nurse of a sudden onset of filling comprehensive and nurse notes that the client is restless and very warm to touch which action should the nurse implement next
access laboratory results to confirm a thyroid crisis/obtain a complete set of vital signs
A client is transferred from the operating room to the postanesthesia care unit with the following vital signs temperature 99.8 heart rate 62 beats per minute respirations 8 breaths per minute blood pressure 95 / 54 and oxygen saturation 94% which medication should the nurse administer
acetaminophen
what does it mean if the blood ABGs are greater than 7.35
acidosis
The nurse is caring for a client with an acute respiratory distress syndrome a RDS who is receiving mechanical ventilation due to a decline in respiratory function which ventilator setting would best support the client
administering heparin via continuous IV infusion
A client with chronic kidney disease has an arteriovenous fistula in the left forearm which observation by the nurse indicates that the fistula is patent
assessment of the bruit on the left forearm
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish brown vaginal discharge which action should the nurse take first
begin continuous fetal monitoring
The nurse leading a care team on a medical surgical unit is assiting client care to a practical nurse in an unlicensed up sensitive personnel which tasks should the nurse delegate to the pn
begin initial sterile wound care for surgical clients
The critical care nurse is giving report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
comatose
A young adult visits the clinic reporting symptoms associated with gastritis which information in the clients history is most important for the nurse to address in the teaching plan
consumes 10 or more drinks of alcohol every weekend
A client is receiving a continuous infusion of normal saline at 125 mL/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL over the past 24 hours with a central venous pressure of 15mm Hg. The nurse notes respiratory 25 breathes/minutes, BP of 160/90. Which intervention should the nurse implement first?
decrease IV fluids to keep vein open (KVO) rate
An older client with cirrhosis of the liver and hepatic failure is places on a lowsodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
decreased abdominal girth
An adult male is admitted to the emergency department with sanguineous draining from a scalp wound and blood from both ears following a fall from a tree that he was trimming, what action is most important for the nurse to take
determine his response on the Glasgow coma scale
Prior to surgery written consent must be obtained which is the nurses legal responsibility with regard to obtaining written consent
determine that the surgical consent form has been signed
A client with multiple burn injuries is being treated in the burn traumatic unit just hours after the injuries occurred the health care provider instructs the nurse to avoid auto contamination when performing dressing changes which intervention is most important for the nurse to implement
dressed each wound separately
The nurse is providing care for a client with severe peripheral arterial disease PAD the client reports a history of rest ischemia with leg pain that occurs during the night which action should the nurse take in response to this finding
elevate the legs to assess for color changes
A young male client is admitted to rehab following a right above knee amputation AKA a persevere traumatic injury he is in the Commons room and anxiously calls out to the nurse stating that his right foot is aching the nurse offers assurance and support which additional intervention is most important for the nurse to implement
encourage discussion of feelings about the loss of his limb
When conducting client teaching for a client who is diagnosed with a myocardial infection which snackfood should the nurse encourage the client to eat select all that apply
fresh vegetable with mayonnaise dip, Fresh turkey slices and berries & Raw unsalted almonds and apples
A 6-year old child who has a medical diagnosis of attention deficit hyperactivity disorder ADHD has been talking has been taken the psychostimulant methylphenidate Ritalin for two weeks which assessment finding providing by the child mothers most significant in planning nursing care for this child
has not had a bm in 2 days
During an admission assessment a client reports currently using heroin which information is most important for the nurse to consider in the plan of care
history of suicide attempts
An unlicensed assistant personnel is assigned to ambulate a client with influenza who has droplet precautions implemented the uap request a change in assignment stating the reasoning of having not been fitted yet for N 95 respirator mask which action should the nurse take
instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
The healthcare provider prescribes a sepsis protocol for a client with multi organ failure caused by rupture appendix which intervention is most important for the nurse to include in the plan of care
is to monitor the client's vital signs and to report any changes to the healthcare provider
The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management which responds by the clients indicate understanding
keep diabetic medications on schedule as prescribed
Which intervention should the nurse indicate in the plan of care for a child with tetanus
minimize the amount of stimuli in the room
The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine?
monitor blood pressure
A client who experienced a cerebral vascular accident CVA is aphasic and has left sided paralysis which nurse should be responsible for coordinating the progression of this client care
nurse case manager
A client taking clopidogrel (Plavix) reports the onset of diarrhea. Which action should the nurse implement first? A) assess the elasticity of the client's skin B) observe the appearance of the stool. C) Review the clients lab values D) auscultate the clients bowel sounds
observe the appearance of the stool.
The father of a four year old child has been battling mastic lung cancer for the past two years after discussing the remaining options with his health care provider the clients request that all treatment stop in that no herotic actions be taken to save his life when the client is transferred to the pallet of care unit which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care
obtained a detailed report from the nurse transferring the client
A Neonate who has congenital adrenal hyperplasia CAH presents with ambiguous genitalia what is the primary nursing consideration when supporting the parents of the child with this anomaly
offer information about u/s and genotyping to determine sex assignment
The charge nurse is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignments is the best to assign to the PN?
one-on-one observation of a suicidal client
A client with rheumatoid arthritis starts a new prescription etanercept for subcutaneously once weekly the nurse should emphasize the importance of reporting which problems to the health care provider
persistent fever
A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates that the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the client's dressing?
place sterile gauze dressing under the penrose drain
A client presents with emergency department with muscle aches headache fever and describes a recent loss of taste and smell the nurse obtains a nasal swab for COVID-19 testing which action is most important for the nurse to take
place the nasal swab specimen for COVID-19 directly into a biohazard bag
An adult client is admitted with diabetic ketoacidosis DKA and a urinary tract infection UTI prescription for intravenous antibiotics and an insulin infusion are initiated which serum laboratory value warrants the most immediate intervention by the nurse
potassium of 2.5 meq
A client who takes nonsteriodal anti-inflammatory drugs (NSAIDs) every day for rheumatoid arthritis is being treated for anemia...
protect skin from bruising
An older female client with progressive dementia fell and broke her hip one week ago the client is unable to communicate her level of pain which intervention is most important for the nurse to include in this client's plan of care
provide non-pharmacological pain management
An adult woman who returns to the telemetry unit following cardiac catheterization has an Ivy infusion with a secondary solution of nitroglycerin she is restless while laying flat and is complaining of a throbbing headache which intervention should the nurse implement
raise the head of the bed to 30 degrees
In planning care for a group of clients which Task should the nurse delegate to the unlicensed assistive personnel
reinforced teaching provided by the nurse about using the call bell
The nurse identifies an electrolyte imbalance a weight gain of 4.4 pounds and 24 hours and an elevated central venous pressure for a client with full thickness burns which intervention should the nurse implement
review arterial blood glass blood glasses results
In older adult client with systematic anti inflammatory response syndrome SIRS has a temperature of 101.8 Fahrenheit heart rate of 110 beats per minute and respiration rate of 24 breaths per minute which additional finding is most important to report to the health care provider
serum creatinine of 2.0 mg/dL. Increase in this serum
While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first?
take vital signs
A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal
talks to an imaginary friend
The nurse is attempting home care for an older client who has a new colostomy following a large bowel resection 3 days ago the client plans to live with a family member which actions should the nurse and permit select all that apply
teach care of ostomy to care provider -provide pain medication instructions -assess the client for self care ability
A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety?
teach him to limit sugar and caffeine
The nurse is developing a plan of care for a client who reports intermittent claudation and who is newly diagnosed with type 2 diabetes...
the nurse will show the client how to perform stress management
The nurse is teaching a group of women about osteoporosis and exercise the nurse should emphasize the need for which type of regular activity
weight bearing exercise
A combination multi drug cocktails being considered for an asymptomatic HIV infected client with a CD4 cell count of 500 which nursing assessment of the client is most crucial in determining whether therapy should be initiated
willing to comply with complex drug schedules
