HESI Final Exam

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A) Support the client to a sitting position. B) Ask the client to walk slowly back to the room. C) Administer a sublingual nitroglycerin tablet. D) Provide oxygen via nasal cannula.

A. The nurse should safely assist the client to a resting position and then perform C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle.

The nurse is providing instructions regarding the complications of peritoneal dialysis. The nurse emphasizes that onset of peritonitis, a serious complication, is most likely to be associated with which clinical manifestation? A) Fever. B) Fatigue. C) Clear dialysate output. D) Leaking around the catheter site.

A. The signs of peritonitis include: fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output. Fatigue may be associated with peritonitis, but fever is the most likely sign.

A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder? A) Altered RBC production. B) Altered production of lymph nodes. C) Malignant exacerbation in the number of leukocytes. D) Malignant proliferation of plasma cells within the bone.

D. Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow.

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A) Urine specific gravity of 1.03 B) Frothy, tea-colored urine. C) Clay-colored stools. D) Elevated serum amylase and lipase levels.

D. Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. B and C are expected findings with jaundice.

The nurse receives the client's newt scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A) Hang the solution at the current rate. B) Refrigerate the solution until needed. C) Prepare the solution with new tubing. D) Return the solution to the pharmacy.

D. Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned tot he pharmacy.

A client is placed on a mechanical ventilator following a cerebral hemorrhage. Which is the primary nursing diagnosis for this client? A) Impaired communication r/t paralysis of skeletal muscles. B) High risk for infection r/t increased ICP. C) Potential for injury r/t impaired lung expansion. D) Social isolation r/t inability to communicate.

A is a serious outcome because the client cannot communicate his/her needs. Infection is not r/t increased ICP.

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? A) Fever. B) Nausea. C) Lethargy. D) Tremors. E) Confusion. F) Bradycardia.

A, B, D, E. Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include fever, nausea, tremors, confusion, restlessness, anxiety and tachycardia.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A) Place the client on NPO status. B) Assess the client's temp C) Obtain a stool specimen. D) Administer IV fluids.

A. A client with severe acute diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO to reduce risk of intestinal rupture.

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding? A) An irregularly shaped lesion. B) A small papule with a dry, rough scale. C) A firm, nodular lesion topped with crust. D) A pearly papule with a central crater and a waxy border.

A. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white or blue toned color.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A) Provide a room that can be kept warm. B) Make sure that the room can be kept dark. C) Keep the client close to the nursing unit. D) Select a room that is visible from the nurses' desk.

A. Abnormal blood flow in response to cold (Raynaud's phenomenon) is precipitated in clients with scleroderma.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet at this time? A) Protein. B) Calories. C) Minerals. D) Carbs.

A. Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status.

The nurse is reviewing the lab results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? A) Low-protein diet. B) High-protein diet. C) Moderate-fat diet. D) High-carbohydrate diet.

A. Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The liver breaks down protein, which results in the formation of ammonia.

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? A) Fatigue. B) Pale urine. C) Weight gain. D) Spider angiomas.

A. Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas are commonly seen in cirrhosis of the liver.

Based on the clinical manifestations of Cushing's syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing's syndrome? A) Monitor blood glucose levels daily. B) Increase intake of fluids high in potassium. C) Encourage adequate rest between activities. D) Offer the client a sodium-enriched menu.

A. Cushing's syndrome results from a hypersecretion of glucocorticouds in the adrenal cortex. Clients with Cushing's syndrome often develop diabetes mellitus. Fatigue is usually not an overwhelming factor in Cushing's syndrome, so an emphasis on the need for rest is not indicated.

The nurse is monitoring a client for early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A) Sweating and pallor. B) Bradycardia and indigestion. C) Double vision and chest pain. D) Abdominal cramping and pain.

A. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is reviewing the lab results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? A) Increased calcium level. B) Increased WBCs. C) Decreased blood urea nitrogen (BUN). D) Decreased number of plasma cells in the bone marrow.

A. Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen (BUN) level. An increased WBC count may or may not be present and is not related specifically to multiple myeloma.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? A) Stridor. B) Occasional pink-tinged sputum. C) Respiratory rate of 24 breaths/min. D) A few basilar lung crackles on the right.

A. Following the removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the HCP immediately. This is a high-pitched, coarse sound that is heard with a stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.

A resident in a long-term care facility is diagnosed with Hep B. Which intervention should the nurse implement with the staff caring for this client? A) Determine if all employees have had the Hep B vaccine series. B) Explain that this type of hepatitis can be transmitted when feeding the client. C) Assure the employees that they cannot contract Hep B when providing direct care. D) Tell the employees that wearing gloves and a gown are required when providing care.

A. Hep B vaccine should be administered to all health care providers. Hep A (not Hep B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract Hep B if exposed to the client's blood and/or body fluids, therefore C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? A) Encouraging fluids. B) Providing frequent oral care. C) Coughing and deep breathing. D) Monitoring the RBC count.

A. Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain urine output. The fluid is also needed to prevent protein from precipitating in the renal tubules.

The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? A) Vital signs. B) Intake and output. C) BUN results. D) Urine for glucose and ketones.

A. Pheochromocytoma is a catecholamine-producing tumor. HTN is the hallmark of pheochromocytoma. Severe HTN can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client, the priority is to monitor vital signs, particularly the blood pressure.

During assessment of a client in the ICU, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A) Prepare the client for a pericardial tap. B) Administer IV Lasix. C) Assist the client to cough and breathe deeply. D) Instruct the client to restrict the oral fluid intake.

A. The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for a tamponade is a pericardial tap. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as A.

The nurse is observing a UAP performing morning care for a bedridden client with Huntington's disease. Which care measure is most important for the nurse to supervise? A) Oral care. B) Bathing. C) Foot care. D) Catheter care.

A. The client with Huntington's disease experiences problems with motor skills such as swallowing and is at high risk for aspiration. B, C, and D do not necessarily require RN supervision because they do not ordinarily post life-threatening consequences.

A client with HTN has been receiving ramipril (altace), 5mg, PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70. Which action should the nurse take? A) Administer the prescribed dose at the scheduled time. B) Hold the dose and contact the HCP. C) Hold the dose and recheck the BP in 1 hour. D) Check with the HCP's prescription to clarify dose.

A. The client's BP is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. B and C would be appropriate if the client's BP was excessively low (<100 systolic) or if the client were exhibiting signs of hypotension such as dizziness.

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the HCP before the chest tube is removed? A) Tidaling of water in water seal chamber. B) Bilateral muffled breath sounds at bases. C) Temp of 101. D) Absence of chest tube drainage for 2 days.

A. Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the HCP before the chest rube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. D is an expected finding.

The nurse is counseling a healthy 30 -year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis? A) Cross-country skiing. B) Scuba diving. C) Horseback riding. D) Kayaking.

A. Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Cross-country skiing includes the most weight-bearing exercise out of the choices.

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? A) Lower the head of the bead. B) Test the drainage for glucose. C) Obtain a culture of the drainage. D) Continue to observe the drainage.

B. After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a CSF leak. If this occurs, the drainage should be collected and tested for the presence of CSF. Clear nasal drainage would not indicate the need for a culture.

The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A) Antianginal with a therapeutic effect of vasodilation. B) Anticholinergic with a side effect of pupillary dilation. C) Antihistamine with a side effect of sedation. D) Corticosteroid with a side effect of hyperglycemia.

B. Clients with angle-closure glaucoma should not take medications that dilate the pupil because they can precipitate acute and severely increased IOP. A, C, and D do not cause increased IOP, which is the primary concern with angle-closure glaucoma.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and battle signs. Which new symtom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? A) Bilateral jugular vein distension. B) Oral temp of 102. C) Intermittent focal motor seizures. D) Intractable pain in the cervical region.

B. Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temp because the fracture leaves the meninges open to bacterial invasion.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A) Ecchymosis over the right elbow area. B) Deep unrelenting pain in the right arm. C) An edematous right elbow. D) The presence of crepitus in the right elbow.

B. Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids, and neurovascular compromise. A and D are expected.

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A) Placing cool compresses on the affected arm. B) Elevating the affected arm on a pillow about heart level. C) Avoiding arm exercises in the immediate post op period. D) Maintaining an IV site below the anticubital area on the affected site.

B. Following mastectomy, the arm should be elevated about the level of the heart. Simple arm exercises should be encouraged. No BP readings, injections, IV lines or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.

The nurse is caring for a client admitted to the hospital with uncontrolled type 1 diabetes mellitus. In the event that DKA does occur, the nurse anticipates that which medication would most likely be prescribed? A) Glucagon. B) Regular insulin. C) Glyburide (DiaBeta). D) Neutral protamine Hagedorn (NPH) insulin.

B. Giving regular insulin by the IV route is the treatment of choice for DKA. A short-acting insulin is the only insulin that can be given IV because it can be titrated to the client's blood glucose levels.

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? A) Diarrhea. B) Polyuria. C) Polyphagia. D) Weight gain.

B. Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels product osmotic diuresis and thus polyuria. This diuresis leads to dehydration.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A) Hypophosphatemia. B) Hypocalcemia. C) Hyponatremia. D) Hypokalemia

B. Hypocalcemia develops in CKD because of chronic hyperphosphatemia. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with C or D.

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? A) Call the HCP to reinsert the tube. B) Grasp the retention sutures to spread the opening. C) Call the respiratory therapy department to reinsert the tracheostomy. D) Cover the tracheostomy site with a sterile dressing to prevent infection.

B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. Covering the tracheostomy site with a sterile dressing will block the airway.

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A) Turns on the continuous wall suction to -190 mm Hg. B) Inserts the catheter until resistance or coughing occurs. C) Withdraws the catheter while maintaining suctioning. D) Reclears the tracheostomy after suctioning the mouth.

B. Indicates correct technique for performing suctioning. Suction pressure should be between -80 and -120 mm Hg, not -190 mm Hg. The catheter should be withdrawn 1-2 cm at a time with intermittent, not continuous suction. D introduces pathogens unnecessarily into the tracheobronchial tree.

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A) The vaccine is given annually before the flu season to those older than 50 years. B) The immunization is administered once to older adults or those at risk for illness. C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

B. It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. The vaccine is usually given once in a lifetime, but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

Which change in lab values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy? A) Increase in rheumatoid factor. B) Decrease in hemoglobin level. C) Increase in blood glucose level. D) Decrease in erythrocyte sedimentation rate (ESR; sed rate)

B. Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. A indicates disease progression but is not a side effect of the medication. C is not related to this medication. D indicates that inflammation associated with the disease has diminished.

Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A) Hypokalemia. B) Microalbuminuria. C) Elevated serum lipid levels. D) Ketonuria.

B. Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.

A client with CHF and Afib develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation? A) Assess for bilateral jugular vein distention. B) Increase oxygen flow via nasal cannula. C) Administer PRN Lasix. D) Auscultate for a pleural friction rub.

B. The client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A) Immediately after feeding. B) Just prior to tube feeding. C) Continuous inflation is required. D) Inflation is not required.

B. The cuff should be inflate before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuff tracheostomy tube is in place. It should remain inflated throughout feeding to prevent aspiration of food into the respiratory system. C places the patient at risk for tracheal wall necrosis.

A female client with an NG tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the NG tube in the last 2 hours. Which action should the nurse take? A) Irrigate the NG tube with sterile normal saline. B) Reposition the client on her side. C) Advance the NG tube 5cm. D) Administer an IV antiemetic as prescribed.

B. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first followed by the others.

An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A) Measure the client's calf circumference. B) Auscultate the client's breath sounds. C) Observe for ecchymosis and petechiae. D) Obtain the client's BP.

B. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A) Review the client's history for diabetes mellitus. B) Observe the extremity distal to the IV site. C) Monitor the client's serum potassium and blood glucose levels. D) Evaluate the client's oxygen saturation and breath sounds.

C. Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1-10 scale, with a BP os 127/78, pulse of 88, and respirations of 20. The PACU recovery prescription is "Morphine, 2-4 mg IV pulse, while recovering for pain level over 5." Which intervention should the nurse implement? A) Give the medication as prescribed to decrease the client's pain. B) Call the anesthesia provider for a different medication for pain. C) Use nonpharmacologic techniques before giving the medication. D) Reassess the pain level in 30 minutes and medicate if it remains elevated.

B. The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. A is unsafe because it puse the client at risk for an asthma exacerbation. Even if the drug were safe for the client, C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

The nurse has assisted a HCP with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is inserted. Based on this assessment, which action is most appropriate? A) Inform the HCP. B) Continue to monitor the client. C) Reinforce the occlusive dressing. D) Encourage the client to deep breathe.

B. The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, the suction is not working properly, or the lung has re-expanded.

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first? A) Administer an anti-dysrhythmic medication. B) Start CPR. C) Defibrillate the client at 200 J. D) Assess the client's pulse oximetry.

B. Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately. A and C are appropriate, but CPR is the priority action.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? A) Excessive bubbling in the water seal chamber. B) Vigorous bubbling in the suction control chamber. C) Drainage system maintained below the client's chest. D) 50 mL of drainage in the drainage collection chamber. E) Occlusive dressing in place over the chest tube insertion site. F) Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

C, D, E, F. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70-100 mL/hour is considered excessive and requires HCP notification.

A client with a diagnosis of DKA is being treated in the ER. Which findings would the nurse expect to note as confirming this diagnosis? A) Increase in pH. B) Comatose state. C) Deep, rapid breathing. D) Decreased urine output. E) Elevated blood glucose level. F) Low plasma bicarbonate level.

C, E, F. In DKA, the client would be experiencing polyuria, Kussmaul's respirations (deep and rapid breathing pattern), a low pH, plasma bicarbonate level lower than 15 mEq/L, high blood glucose levels, and ketones present in the blood and urine. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom of duodenal ulcer? A) Weight loss. B) Nausea and vomiting. C) Pain relieved by food intake. D) Pain radiating down the right arm.

C. A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp or "hungry" pain that often localizes in the mid-epigastric area.

The home health nurse is assessing a male client being treated for Parkinson's disease with Sinemet. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement? A) Perform a complete cranial nerve assessment. B) Instruct the client that he may be experiencing medication toxicity. C) Document the presence of these assessment findings. D) Advise the client to seek immediate medical evaluation.

C. A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Signs of toxicity of Sinemet include dyskinesia, hallucinations, and psychosis.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A) Continuous IV infusion of magnesium. B) One-time infusion of albumin. C) Continuous epidural infusion of morphine. D) Intermittent infusion of IV vancomycin.

C. All four of these clients have a potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first.

The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A) "Have you ever experienced any paralysis of your arms or legs?" B) "Do you have frequent blackout spells?" C) "Have you ever been frozen in one spot, unable to move?" D) "Do you have headaches, especially ones with throbbing pain?"

C. Clients with parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move. Parkinson's disease does not typically cause A, B, or D.

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A) Sodium. B) Phosphate. C) Potassium. D) Glucose.

C. Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium.

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level was 950. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now 240. The nurse would next prepare to administer which item? A) Ampule of 50% dextrose. B) NPH insulin subQ. C) IV founds containing dextrose. D) Phenytoin (Dilantin) for the prevention of seizures.

C. During management of DKA, when the blood glucose level falls to 250-300, the infusion rate is reduced and the dextrose solution is added to maintain a blood glucose level of about 250, or until the client recovers from ketosis.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A) CBC reveals increased WBC and decreased RBC. B) Chemistries reveal an increased serum billirubin level with slightly increased liver enzyme levels. C) Urinalysis reveals slight protein in the urine and bacteriuria, with pyurina. D) Serum electrolytes reveal a decreased sodium level and increased potassium level.

C. In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical UTIs, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Lab findings in A, B, and D are not considered to be normal findings in an older adult.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? A) Metastasis is rare. B) It is encapsulated. C) It is highly metastatic. D) It is characterized by local invasion.

C. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic and person's survival depends on early diagnosis and treatment.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of COPD. Which risk factor is the most significant in the development of this client's COPD? A) The client's father was diagnosed with COPD in his 50's. B) A close family member contracted TB last year. C) The client smokes one to two packs of cigarettes per day. D) The client has been 40 pounds overweight for 15 years.

C. Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation.

The nurse is monitoring a client for s/s related to superior vena cava syndrome. Which is an early sign of this oncological emergency? A) Cyanosis. B) Arm edema. C) Periorbital edema. D) Mental status changes.

C. Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early s/s generally occur in the morning and include edema of the face, especially around the eyes and the client c/o tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a NG tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A) Increased serum albumin level. B) Decreased serum creatinine. C) Decreased serum ammonia level. D) Increased liver function test results.

C. The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. A, B, and D will not be significantly affected by the removal of blood.

A nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that the client understands the information if the client states the record which parameters daily? A) Pulse and respiratory rate. B) Amount of activity and sleep. C) Intake and output and weight. D) Blood urea nitrogen and creatinine levels.

C. The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally the dialysis patient should not gain more than 0.5 kg of weight per day.

A client is being discharged to home while recovering from an acute kidney injury (AKI). A reduction in which substance indicates to the nurse that the client understands the dietary teaching? A) Fats. B) Vitamins. C) Potassium. D) Carbohydrates.

C. The excretion of potassium and maintenance of potassium balance are normal functions of the kidneys. In the client with acute kidney injury or chronic kidney disease, potassium intake must be restricted as much as possible. The primary mechanism of potassium removal during AKI is dialysis.

A client is brought to the ER in a unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated HCP prescription? A) Endotracheal intubation. B) 100 units of NPH insulin. C) IV infusion of normal saline. D) IV infusion of sodium bicarbonate.

C. The primary goal of treatment in hyperglycemia hyperosmolar state (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in DKA and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered.

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A) Fluid volume deficit. B) Self-care deficit. C) Risk for infection. D) Impaired nutrition.

C. The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postop infection because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery.

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? A) "I change my pouch every week." B) "I change the appliance in the morning." C) "I empty the urinary collection bag when it is two-thirds full." D) "When I'm in the shower I direct the flow of water away from my stoma."

C. The urinary collection bag should be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options are correct.

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A) 16% increase in overall body fat. B) Reduced melanin production. C) Thinning of the skin, with loss of elasticity. D) Calcium loss in the bones.

C. Thin, nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. D can contribute to broken bones, but is probably not a factor in pressure ulcer formation.

A client calls the ER and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? A) "Come to the ER." B) "Apply calamine lotion immediately to the exposed skin areas." C) "Take a shower immediately, lathering and rinsing several times." D) "It is not necessary to do anything if you cannot see anyth

C. When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. The client does not need to be seen in the ER at this time.

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A) Administer lidocaine, 75mg IV push. B) Perform synchronized cardioversion. C) Defibrillate the client as soon as possible. D) Administer atropine, 0.4 mg IV push.

C. With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. A is a medication used for ventricular dysrhythmias. C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which ECG change would be a concern for a client taking a diuretic? A) Tall, spiked T waves. B) A prolonged QT interval. C) A widening QRS complex. D) Presence of a U wave.

D. A U wave is a positive deflection following the T wave and is often present with hypokalemia. A, B and C are all signs of hyperkalemia.

The nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? A) Flat for 12 hours, then elevated for 12 hours. B) Elevated for 3 hours and then flat for 1 hour. C) Flat for 3 hours and then elevated for 1 hour. D) Elevated on pillows continuously for 24 to 48 hours.

D. A casted extremity is elevated continuously for the first 24-48 hours to minimize swelling and promote venous drainage.

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? A) Folate deficiency. B) Malabsorption of fat. C) Intestinal obstruction. D) Fluid and electrolyte imbalances.

D. A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by IV infusion until the client can tolerate a diet orally.

The home health nurse makes a home visit to a client who has an implantable cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? A) "If I feel an internal defibrillator shock, I should sit down." B) "I won't be able to have an MRI." C) "My wife knows how to call the EMS if I need it." D) "I can stop taking my anti-dysrhythmic medicine now because I have a pacemaker."

D. Clients with an ICD usually continue to receive anti-dysrhythmic medications after discharge from the hospital.

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? A) Diarrhea. B) Hypermenorrhea. C) Abnormal bleeding. D) Abdominal distention.

D. Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding (C) is often associated with uterine cancer.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? A) Right lower quadrant, radiating to the back. B) Right lower quadrant, radiating to the umbilicus. C) Right upper quadrant, radiating to the left scapula and shoulder. D) Right upper quadrant, radiating to the right scapula and shoulder.

D. During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. this is determined by the pattern of dermatomes in the body.

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? A) Fatigue. B) Weakness. C) Weight gain. D) Enlarged lymph nodes.

D. Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver.

The nurse manager is teaching the nursing staff about s/s related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency? A) Headache. B) Dysphagia. C) Constipation. D) ECG changes.

D. Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. ECG changes include shortened ST segment and a widened T wave.

A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? A) Causes profound hypotension. B) Is manifested by severe hypoglycemia. C) Is not curable and is treated symptomatically. D) Causes the release of excessive amounts of catecholamines.

D. Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. HTN is the principle manifestation, and the client has episodes of high BP with pounding headaches. Hyperglycemia and glucosuria occur during attacks. Primary treatment is surgical removal of one or both of the adrenal glands.

One day after a Billroth 2 surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as BP 100/80, pulse 100, and respirations 36. Which action is most important for the nurse to take? A) Provide a paper bag for his hyperventilation. B) Administer a prescribed PRN analgesic. C) Have the client drink a glass of sweetened fruit juice. D) Apply oxygen at 2L via nasal cannula.

D. Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom is an older adult most likely to exhibit? A) Polyuria. B) Polydipsia. C) Weight loss. D) Infection.

D. S/s of hyperglycemia in older adults may include fatigue, infection and evidence of neuropathy. The nurse needs to remember that classic s/s of hyperglycemia such as A, B, and C and polyphagia, may be absent in older adults.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the HCP about for re-verification for this client? A) Vitamin K, 5mg IM daily. B) High calorie, low sodium diet. C) Fluid restriction to 1500 mL/day. D) Pentobarbital at bedtime for rest.

D. Sedatives such as Pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. A is often prescribed because the normal clotting mechanism is damaged. B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? A) Reactivity of deep tendon reflexes, comparing upper with lower extremities. B) VS readings, excluding BP if needed equipment is unavailable. C) Memory of events that occurred before and after the blow to the head. D) Ability to open the eyes spontaneously before any tactile stimuli are given.

D. The LOC should be established immediately when a head injury has occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. Although B is important, VS are not the best indicators of LOC and can be evaluated after the client's LOC has been determined.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to note which sign or symptom in the client as a result of the anemia? A) Bradycardia. B) Muscle cramps. C) Increased respiratory rate. D) Shortness of breath with activity.

D. The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Increased respiratory rate is not an associated finding.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the HCP after assessing the client? A)Leukocytosis and febrile. B) Polycythemia and crackles. C) Pharyngitis and sputum production. D) Confusion and tachycardia.

D. The onset of Pneumonia in the older client may be signaled by general deterioration, confusion, increased HR, and/or increased respirations. A, B, and C are often absent in the older client with bacterial pneumonia.

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis. What does this test assess for the presence of? A) Inflammation. B) Antigens of IgA. C) Infection in the body. D) Unusual antibodies of the IgG and IgM type.

D. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of CT diseases.

Which nursing action is necessary for the client with a flail chest? A) Withhold prescribed analgesic medications. B) Percuss the fractured rib area with light taps. C) Avoid implementing pulmonary suctioning. D) Encourage coughing and deep breathing.

D. Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. A should not be withheld. B should not be applied because the fractures are clearly visible on the chest radiograph.

The nurse is assisting a HCP with the removal of a chest tube. The nurse should instruct the client to take which action? A) Exhale slowly. B) Stay very still. C) Inhale and exhale quickly. D) Perform the Valsalva maneuver.

D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A) Reducing dairy products in the diet. B) Straining all urine. C) Measuring intake and output. D) Increasing fluid intake.

Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but is even more important to strain urine. Straining the urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery.

A client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which should the nurse anticipate when caring for this client? A) The client will be unable to recall past events. B) The client will have difficulty understanding language. C) The client will demonstrate difficulty articulating words. D) The client will have difficulty moving one side of the body.

Wernicke's area consists of a small group of cells in the temporal lobe the function of which is understanding language. Damage to Broca's area (C) is responsible for aphasia where the client will demonstrate difficulty articulating words.