HESI Fundamentals I

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide?

"It's highly likely that she will recover and return to her pre-illness state." Rationale Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, "Integrity vs despair." (C and D) are judgmental and not therapeutic.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?

Accused of diversion. Rationale Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome.

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises?

Active ROM exercises to both arms and legs two or three times a day. Rationale Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures.

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process?

Analysis. Rationale The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care.

What is the rationale for using the nursing process in planning care for clients?

As a tool to organize thinking and clinical decision making about clients' healthcare needs. Rationale The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care.

A client is demonstrating a positive Chvostek's sign. What action should the nurse take?

Ask the client about numbness or tingling in the hands. Rationale A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

Ask the client if this decision has been discussed with his healthcare provider. Rationale Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B).

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement?

Ask the client to relax and run a small amount of fluid into the rectum. Rationale If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken.

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction?

Assault and battery with deliberate intent to deviate from the consent form. Rationale The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice.

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client?

Assist and support the client in establishing short-term goals. Rationale Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide?

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation. Rationale Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. (D) is an accurate statement concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide correct information about biofeedback.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use?

Cassette infusion pump. Rationale A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

Check capillary refill of toes on lower extremity with Unna's paste boot. Rationale The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D).

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu?

Combination of plant proteins to provide essential amino acids. Rationale A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs.

What action should the nurse implement when adding sterile liquids to a sterile field?

Consider the sterile field contaminated if it becomes wet during the procedure. Rationale Wet or damp areas on a sterile field allow organisms to "wick" from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D).

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?

Continue gabapentin. Rationale Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given "around the clock" rather than by the client's PRN requests.

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement?

Continue the planned nursing interventions to restore the client's fluid volume. Rationale Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D).

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next?

Cradle the client's heel. Rationale Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement?

Document the presence and volume of the pulse palpated. Rationale Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D).

An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

Drape the sheets over the footboard of the bed. Rationale The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint.

When making the bed of a client who needs a bed cradle, which action should the nurse include?

Drape the top sheet and covers loosely over the bed cradle. Rationale A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics.

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?

Draw up the irrigating solution into the syringe. Rationale To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?

Eats anything and does not think diet makes a difference in health. Rationale The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintainance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit.

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information?

Elicit specific facts about past hospitalizations with direct questions. Rationale Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate?

Evaluate the client's mental status for competence to refuse treatment. Rationale Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration?

Examine one's own culturally based values, beliefs, attitudes, and practices. Rationale Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias.

What activity should the nurse use in the evaluation phase of the nursing process?

Examine the effectiveness of nursing interventions toward meeting client outcomes. Rationale In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes.

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care?

Fluid volume imbalance Rationale Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?

Flush the lumen with the saline solution and administer the medication through the lumen. Rationale Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication (A), then flush the lumen with saline again. (B and C) are not necessary. The aspirated blood can be flushed back through the closed system into the client's bloodstream, but does not need to be withdrawn (D).

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first?

Foods and liquids consumed during the past 24 hours. Rationale A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be elicited after confirming the client's dietary history.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage?

Generativity. Rationale Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?

Herbs should be obtained from manufacturers with a history of quality control of their supplements. Rationale The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading.

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement?

Identify the break in surgical asepsis and provide another set of sterile supplies. Rationale Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members.

Which statement is an example of a correctly written nursing diagnosis statement?

Ineffective coping related to response to positive biopsy test results. Rationale The first part of the nursing diagnosis statement is the "diagnostic label" and is followed by "related to" the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's "response," which the nurse can provide support, reflection, and dialogue.

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority?

Inform the family that death is imminent. Rationale An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches.

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action?

Locate the perineum. Rationale Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D).

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first?

Notify family members of the client's condition Rationale The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D).

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter?

Obtain a prescription for removal of the catheter as soon as possible. Rationale The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis.

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?

One-inch pressure sore draining serous fluid. Rationale Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?

Position prone with a small pillow below the diaphragm. Rationale The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point.

What action is most important for the nurse to implement when placing a client in the Sim's position?

Raise the bed to a waist-high working level. Rationale A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take?

Refuse to perform the task that is beyond the nurse's experience. Rationale According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C).

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first?

Reposition the client's arm. Rationale If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion.

The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care?

Risk for aspiration. Rationale Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?

Sensory pattern, area, intensity, and nature of the pain. Rationale The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A).

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time?

Serum albumin. Rationale Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C).

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first?

Slow the IV infusion to keep vein open rate. Rationale The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.)

Snack of potato chips, and diet soda. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. Breakfast of eggs, bacon, toast, and coffee. Bedtime snack of crackers and milk. Rationale Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

The clamp on the urinary drainage bag is open. Rationale Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed.

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement?

Turn the client q2h. Rationale (D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D).

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease?

Upon discharge, the client will list three ways to protect the feet from injury. Rationale An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan?

Vitamin B12. Rationale Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegetables and fruits.

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first?

Wet to moist dressing. Rationale To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface.

A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement?

Witness the client's signature on the consent form. Rationale Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained.