HESI LIVE REVIEW

A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and two UAPs. Which client(s) would be assigned to the RN? (Select all that apply.) A. A client from the previous shift with unstable angina B. A client with a stage 3 pressure ulcer who needs a bed bath C. A client with an enteral feeding absorbing at 30 mL/hr D. A cardiotomy client who is day 2 postoperative and who has chest tubes E. A client with quadriplegia for whom urinary catheterization has been prescribed

A. A client from the previous shift with unstable angina D. A cardiotomy client who is day 2 postoperative and who has chest tubes

The nurse is administering 0900 medications to three clients on a telemetry unit when the UAP reports that another client is complaining of a sudden onset of substernal discomfort. What action should the nurse take? A. Ask the UAP to obtain the client's vital signs. B. Assess the client's discomfort. C. Advise the client to rest in bed. D. Observe the client's ECG pattern.

B. Assess the client's discomfort.

Four clients arrive in the emergency department after an explosion at an apartment complex. In which order should they be assessed? All options must be used. A. A 70-year-old who is complaining of a pain level of 8/ 10 from a hand burn B. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion

B. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion A. A 70-year-old who is complaining of a pain level of 8/ 10 from a hand burn C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest

A client with burn injuries has lost a significant amount of body fluid. An IV of lactated Ringer's solution is infusing at 200 mL/hr, and the urine output for the past 8 hours is 400 mL. Which sign or symptom relates to early distributive shock? A. A change in BP from 118/60 to 102/68 B. A change in level of consciousness from awake to restless C. A decrease in O2 saturation from 98% to 93% D. A decrease in urine output over 8 hours from 400 to 240 mL

B. A change in level of consciousness from awake to restless

The charge nurse is planning client assignments for the unit. The collaborative care team consists of an RN, a PN, and a UAP. Which client (s) should be assigned to the PN? (Select all that apply.) A. A client with a history of heart failure who has had no urinary output for the past 2 hours B. A client with a history of angina who requires his morning medications C. A client recently admitted and anticipating oral antibiotics for cellulitis D. A client with a history of Raynaud syndrome who is pending a dressing change E. A client with an acute deep vein thrombosis who requires a heparin hourly infusion

B. A client with a history of angina who requires his morning medications C. A client recently admitted and anticipating oral antibiotics for cellulitis D. A client with a history of Raynaud syndrome who is pending a dressing change

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for a pain rating of8/10. The family member requests that her father be checked immediately. On arrival to the room you find the client difficult to arouse, with a respiratory rate of 6. What is the priority nursing action? A. Elevate the head of bed. B. Administer naloxone 0.4 mg IV. C. Assess breath sounds. D. Check vital signs and pulse oximetry.

B. Administer naloxone 0.4 mg IV.

In the elevator, the newly licensed nurse overhears two nurses talking about a client who will lose her leg because of the negligence of the staff. Which action by the newly licensed nurse should be implemented first? A. Monitor the nurses closely for further occurrences. B. Advise them to cease their communication. C. Inform the nurse manager of the conversation. D. Submit an occurrence or variance report.

B. Advise them to cease their communication.

A nurse admits a client with suspected early DIC. Which symptoms may indicate early organ ischemia? (Select all that apply.) A. Slight gingival bleeding B. Alterations in mental status C. Petechial hemorrhage to chest D. Slight decrease in urine output E. Bluish discoloration of fingertips

B. Alterations in mental status D. Slight decrease in urine output E. Bluish discoloration of fingertips

pH= 7.28 PCO2= 35 HCO3= 18 This client is ______________________________.

Metabolic Acidosis

pH= 7.56 PCO2= 44 HCO3= 38 This client is ______________________________.

Metabolic Alkylosis

pH= 7.43 PCO2= 40 HCO3= 24 This client is _____________________________

Normal ABGs

A client is receiving an infusion of dobutamine hydro-chloride. The order reads: infuse dobutamine IV at 5 mcg/kg/min, 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hr. The flow rate is ____________ mL/hr

9.75mL/hr

The charge nurse is planning client assignments for the unit. The collaborative care team consists of a registered nurse (RN), a practical nurse (PN), and unlicensed assistive personnel (UAP). Which client(s) should be assigned to the RN? (Select all that apply.) A. A client pending a blood transfusion for chronic gastrointestinal bleeding with an Hgb 70 g/L (7.0 mg/dL) B. A client with pernicious anemia who is awaiting vita-min B12 injection C. A client with resolving sickle cell crisis awaiting IV fluid conversion to saline lock D. A client with a pressure ulcer who has been prescribed negative pressure wound (vacuum assisted closure, VAC) care E. A client who received two blood transfusions yesterday and is awaiting morning care

A. A client pending a blood transfusion for chronic gastrointestinal bleeding with an Hgb 70 g/L (7.0 mg/dL) C. A client with resolving sickle cell crisis awaiting IV fluid conversion to saline lock

The charge nurse is planning client assignments for the shift. The care team includes a registered nurse (RN), a practical nurse (PN), and unlicensed assistive personnel (UAP) on the care team. Which client(s) could be assigned to the PN? (Select all that apply.) A. A client scheduled for a STAT x-ray after a fall on his hip B. A client receiving IV vancomycin (Vancocin) through a peripherally inserted central catheter (PICC) line C. A client with sickle cell crisis who was transferred from the intensive care unit to the acute care area and who is receiving hydromorphone (Dilaudid) via a patient-controlled analgesia pump D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care E. A postoperative client who has been prescribed two units of packed red blood cells

A. A client scheduled for a STAT x-ray after a fall on his hip B. A client receiving IV vancomycin (Vancocin) through a peripherally inserted central catheter (PICC) line D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care

The nurse has just received report on four clients. Which client should the nurse assess first? A. A client with pericarditis with pain relieved by leaning forward B. A client with fractured ribs with pain reported at 8/10 on a 1 to10 scale C. A client with stable angina who is awaiting discharge instructions D. A client with heart failure who needs transporting for an echocardiogram

A. A client with pericarditis with pain relieved by leaning forward

The nurse is orienting a graduate nurse (GN) caring for a client dependent on the ventilator. Which action by the GN demonstrates understanding of ventilator-associated pneumonia (VAP) care? (Select all that apply.) A. Administers a proton pump inhibitor as prescribed B. Rinses client's oral cavity with chlorhexidine every 2 hours C. Elevates the HOB to 60 degrees D. Implements spontaneous breathing trial E. Performs hand hygiene before and after care

A. Administers a proton pump inhibitor as prescribed B. Rinses client's oral cavity with chlorhexidine every 2 hours D. Implements spontaneous breathing trial E. Performs hand hygiene before and after care

The nurse is assigned to receive a client in the emergency department with suspected anthrax exposure pre-decontamination.Which transmission precautions would be most appropriate for the client? (Select all that apply.) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard

The emergency department nurse is assessing a client with a vesicular rash as a result of suspected smallpox exposure. Which of the following transmission precautions would be most appropriate for this client? Which type of transmission precautions? (Select all that apply.) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard

A client is admitted to the acute care unit with stable angina. At 7:00 AM the client has had stable vital signs and is on 2 L nasal cannula. At 10:00 a.m., the client reports chest pain as 6 on a scale of 1 to 10, is slightly diaphoretic and pale, blood pressure (BP) is 100/52, and respiratory rate is 24. Which action will the nurse implement first? A. Apply 4 L of oxygen as ordered. B. Administer a fluid bolus of 0.9 normal saline. C. Administer the prescribed opioid for pain control. D. Obtain a full set of vital signs including temperature

A. Apply 4 L of oxygen as ordered.

The nurse is caring for a client in shock of unknown etiology and observes the above rhythm on the monitor. What is the nurse's first priority intervention? ((RHYTHM IS SHOWING V-FIB)) A. Check for a carotid pulse. B. Defibrillate the patient with 360 joules of energy. C. Administer an intravenous saline bolus. D. Give two breaths via Ambu® bag.

A. Check for a carotid pulse.

The nurse is caring for a client when the client sud-denly becomes unconscious. The nurse identifies the following rhythm on the monitor. Which action is the highest priority ((RHYTHM IS V-TACH)) A. Check for a carotid pulse. B. Begin chest compressions. C. Administer epinephrine 1:10,000 IV. D. Initiate bag-valve mask ventilations.

A. Check for a carotid pulse.

The nurse is caring for a client who is 24 hours post-procedure for a hemicolectomy with temporary colostomy placement. The nurse assesses the client's stoma, which is dry and dark blue. What action should the nurse take based on this finding? A. Notify the healthcare provider of the finding. B. Document the finding in the client's record. C. Replace the pouch system over the stoma. D. Place petrolatum gauze dressing on the stoma.

A. Notify the healthcare provider of the finding.

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation(s) should the PN immediately report to the RN? (Select all that apply.) A. The client complains of incisional pain, rating it 8 on a scale of 0 to 10. B. The client has had a change in orientation to person but not to time or place. C. Swelling and redness have developed in the client's lower left leg. D. The PN emptied 15 mL of bloody drainage from the Jackson-Pratt drain. E. The client's last set of vital signs was temperature 37.9° C (100.2° F), pulse 87, respiration 12, blood pressure 108/74, and O2 saturation 93%.

A. The client complains of incisional pain, rating it 8 on a scale of 0 to 10. B. The client has had a change in orientation to person but not to time or place. C. Swelling and redness have developed in the client's lower left leg E. The client's last set of vital signs was temperature 37.9° C (100.2° F), pulse 87, respiration 12, blood pressure 108/74, and O2 saturation 93%.

The unlicensed assistive personnel (UAP) reports to a staff nurse that a client who had surgery 4 hours ago has had a decrease in blood pressure (BP), from 150/ 80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressing for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's or province's nurse practice act. B. The need to complete an adverse occurrence report. C. Hospital protocols regarding the frequency of vital sign assessment every hour postoperatively. D. The healthcare provider's prescription for changing the postoperative dressing

A. The parameters of the state's or province's nurse practice act.

An elderly man comes to the emergency department (ED) complaining of shortness of breath. The health-care provider (HCP) determines that the client has pneumonia. The client's condition deteriorates in the ED, and he now has impending respiratory failure. Which set of arterial blood gas (ABG) values demonstrates acute respiratory failure? A. pH-7.30; PCO2-52; PO2-56; HCO3-26 B. pH-7.35; PCO2-44; PO2-86; HCO3-28 C. pH-7.35; PCO2-62; PO2-66; HCO3-31 D. pH-7.30; PCO2-39; PO2-88; HCO3-22

A. pH-7.30; PCO2-52; PO2-56; HCO3-26

A client who is 1 day postoperative from a left pneumonectomy is lying on his right side with the head of the bed (HOB) elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A. Further elevate HOB. B. Assist the client into the supine position. C. Measure the client'sO2 saturation. D. Administer intravenous (IV) PRN (as needed) morphine

B. Assist the client into the supine position.

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin, 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count, 6.5×109/ L (6,500 cells/mm3). Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

B. Broiled steak, whole wheat rolls, spinach salad, coffee

The cardiac monitor alarm goes off, and the nurse arrives to find the 59-year-old client slumped in the chair. Place the nurse's actions in order of priority for this client from first to last. A. Activate the code team and obtain defibrillator. B. Determine unresponsiveness. C. Assess the cardiac rhythm using the "quick look" paddles. D. Assess for a pulse (carotid). E. Open airway and give two rescue breaths by bag-valve mask. F. Move the client to a flat position in bed or on the floor. G. Begin compressions

B. Determine unresponsiveness. A. Activate the code team and obtain defibrillator. D. Assess for a pulse (carotid). F. Move the client to a flat position in bed or on the floor. G. Begin compressions E. Open airway and give two rescue breaths by bag-valve mask. C. Assess the cardiac rhythm using the "quick look" paddles.

A 22-year-old client is admitted through the emergency department with a 2-day history of cough, fever, and fatigue. The medical history is positive for type I diabetes and recent upper respiratory infection. Vital signs are heart rate 109, blood pressure 102/58, respiratory rate 24, temperature 104° F (40° C), and SpO2 of 92% on 2 L nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large bore IV access. B. Draw two sets of blood cultures. C. Administer the ordered IV antibiotics. D. Draw serum lactate and glucose levels

B. Draw two sets of blood cultures.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twin girls. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, what action has the highest priority? A. Assess the client's temperature. B. Notify the healthcare provider. C. Clean the blood from the incision site. D. Draw labs for PT, PTT, CBC and fibrinogen.

B. Notify the healthcare provider.

After the change of shift report, the nurse reviews her assignments. Which client should the RN assess first? A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48 hours postoperative for a colectomy and is reported to be having nausea and vomiting C. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours D. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/ min, and has a respiratory rate of 12 breaths/min

B. The adult client who is 48 hours postoperative for a colectomy and is reported to be having nausea and vomiting

An awake and alert client with impending pulmonary edema is brought to the emergency department. The client provides the nurse with a copy of a living will stating that "no invasive" medical procedures should be used to "keep her alive." The healthcare team is questioning whether the client should be intubated. What information should guide the team's decision? A. The living will removes the obligation to involve the client in any medical decision making. B. The client is awake and alert, which makes the living will irrelevant and nonbinding. C. Lifesaving measures do not need to be explained to the client because of the signed living will. D. The family should be contacted to determine who has durable power of attorney for health care for the client.

B. The client is awake and alert, which makes the living will irrelevant and nonbinding.

The nurse is precepting a nurse orientee caring for a client with a chest tube who is 12 hours postoperative from a left partial pneumonectomy. Which assessments will the nurse advise should be reported to the HCP immediately? (Select all that apply.) A. Pain level of 6 out of 10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of 50 mL in the last hour D. Oxygen saturation of 90% on 2L/min E. Vigorous bubbling in the suction chamber

B. Tracheal deviation toward the right side D. Oxygen saturation of 90% on 2L/min E. Vigorous bubbling in the suction chamber

The nurse is the first responder at the scene of a mass casualty incident. The nurse is tasked to triage the victims from highest to lowest priority. Arrange the victims from highest to lowest priority. All options must be used. A. Victim A is an elder adult with agonal respirations and open head injury. B. Victim B is a confused adult with bright red blood pulsating from a leg wound. C. Victim C is a young adult with multiple compound fractures of the arms and legs. D. Victim D is an adult with multiple shrapnel wounds of the face and arms complaining of abdominal pain. E. Victim E is a sobbing adult with several minor lacerations on the face, arms, and legs.

B. Victim B is a confused adult with bright red blood pulsating from a leg wound. C. Victim C is a young adult with multiple compound fractures of the arms and legs. D. Victim D is an adult with multiple shrapnel wounds of the face and arms complaining of abdominal pain. E. Victim E is a sobbing adult with several minor lacerations on the face, arms, and legs. A. Victim A is an elder adult with agonal respirations and open head injury.

A hospitalized client reports to the nurse he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the healthcare provider and request a prescrip-tion for a stool softener. C. Assess the client's medical record to determine his nor-mal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

C. Assess the client's medical record to determine his nor-mal bowel pattern.

A 62-year-old client who has a history of coronary heart disease was admitted to the acute care unit 2 days ago for management of angina. During the assessment, the client states, "I feel like I have indigestion." In what order should the nurse implement care? (Arrange from first action to last.) A. Notify the rapid response team. B. Administer PRN (as needed) nitroglycerin prescription. C. Check the pulse, respirations, blood pressure, and oxy-gen saturation. D. Document assessment on the electronic medical record. E. Provide 2 L of oxygen via nasal cannula.

C. Check the pulse, respirations, blood pressure, and oxy-gen saturation. E. Provide 2 L of oxygen via nasal cannula. B. Administer PRN (as needed) nitroglycerin prescription. A. Notify the rapid response team. D. Document assessment on the electronic medical record.

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A. Reassure the client that the admission is only for a limited time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need for admission. D. Advise the client about the legal rights of all hospitalized clients.

C. Determine the behaviors that resulted in the need for admission.

A nurse is preparing for change of shift. Which action by the nurse is characteristic of ineffective handoff communication? A. The nurse states to the nurse coming on duty: "The client is anxious about his pain after surgery. Review the information I gave him about how to use an incentive spirometer." B. The nurse refers to the electronic medical record (EMR) to review the client's medication administration record. C. During rounds the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. D. Before giving report, the nurse performs rounds on her assigned clients so that there is less likelihood of interruption during handoff.

C. During rounds the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client.

In completing a client's preoperative routine, the RN finds that the consent has not been signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next? A. Witness the client's signature on the consent. B. Answer the client's questions about the surgery. C. Inform the healthcare provider that the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered.

C. Inform the healthcare provider that the client has questions about the surgery.

The charge nurse is making assignments for each of four staff members, including a registered nurse (RN), a practical nurse (PN), and two unlicensed assistive personnel (UAPs). Which task is best assigned to the PN? A. Maintain a 24-hour urine collection. B. Wean a client from a mechanical ventilator. C. Perform sterile wound irrigation. D. Obtain scheduled vital signs

C. Perform sterile wound irrigation.

A client who has chronic obstructive pulmonary dis-ease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. What action should the RN take first? A. Call the healthcare provider. B. Obtain a bedside pulse oximeter. C. Raise the head of the bed higher. D. Assess the client's vital signs.

C. Raise the head of the bed higher.

A client recovering from ARDS is awake and alert, has residual fatigue and generalized weakness. His current vital signs are heart rate 83, blood pressure 104/64, respiratory rate 25, SpO2 on 2 L/min nasal oxygen air is 92%. Which vital sign value should unlicensed assistive personnel report immediately to the nurse? A. Heart rate of 88 beats per minute B. Blood pressure of 104/64 mm Hg C. Respiratory rate of 25 breaths per minute D. SpO2 92%

C. Respiratory rate of 25 breaths per minute

Which laboratory result for a preoperative client would prompt the nurse to contact the healthcare provider? A. Platelet count: 151109/L (151,000/mm3) B. White blood cell (WBC) count: 85109/L (8500/mm3) C. Serum potassium level: 2.8 mmol/L (mEq/L) D. Urine specific gravity: 1.030

C. Serum potassium level: 2.8 mmol/L (mEq/L)

Which assignment should the nurse delegate to a UAP in an acute care setting? A. Checking blood glucose hourly for a client with a continuous insulin drip B. Giving PO (by mouth) medications left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humeral and left tibial fractures D. Replacing a client's pressure ulcer dressing that has been soiled by incontinence

C. Taking vital signs for an older client with left humeral and left tibial fractures

The nurse is monitoring the status of a client recovering from a myocardial infarction. Which symptom indicates an evolving problem? A. A steady pulse of 88 beats/min B. Rising systolic pressure from 110 to 120 mm Hg C. Three premature ventricular contractions/min D. Central venous pressure of 8 mm H

C. Three premature ventricular contractions/min

The client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3 to 4 months. What would be the nurse's best response? A. To determine the progression of the disease B. To evaluate the enzyme-linked immunosorbent assay (ELISA) C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine

C. To monitor the effectiveness of the treatment

Which dysrhythmia(s) would defibrillation be most appropriate for? (Select all that apply.) A. Asystole B. Pulseless electrical activity C. Ventricular fibrillation D. Pulseless ventricular tachycardia E. Ventricular tachycardia F. Atrial fibrillation

C. Ventricular fibrillation D. Pulseless ventricular tachycardia

A family member of a client who is in a Posey vest restraint (safety reminder device) asks why the restraint was applied. How should the nurse respond? A. The restraint was prescribed by the healthcare provider. B. There are not enough staff members to keep the client safe all the time. C. The other clients are upset when the client wanders at night. D. The client's actions place her at high risk for harming herself.

D. The client's actions place her at high risk for harming herself.

The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the nurse to ask the client? A. "When did the surgeon explain the procedure to you?" B. "Is any member of your family going to be here during your surgery?" C. "Have you been instructed in postoperative activities and restrictions?" D. "Have you received any preoperative pain medication?"

D. "Have you received any preoperative pain medication?"

Which situation warrants a variance (incident) report by the nurse? A. A client refuses to take prescribed medication. B. A client's status improves before completion of the course of medication. C. A client has an allergic reaction to a prescribed medication. D. A client received medication prescribed for another client.

D. A client received medication prescribed for another client.

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code? A. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. A client with bruising and swelling of the right fore-arm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18 C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning

D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The RN notes that the client's serum calcium level is 12.5 mg/ dL. What action should the nurse take? A. Hold the phosphate and notify the healthcare provider. B. Review the client's serum parathyroid hormone level. C. Give an as-needed (PRN) dose of intravenous (IV) cal-cium per protocol. D. Administer the dose of oral phosphate.

D. Administer the dose of oral phosphate.

The nurse palpates a crackling sensation of the skin around the insertion site of a chest tube in a client who has had thoracic surgery. What action should the nurse take? A. Return the client to surgery. B. Prepare for insertion of a larger chest tube. C. Increase the water-seal suction pressure. D. Continue to monitor the insertion site

D. Continue to monitor the insertion site

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Don't blame me; nobody likes this idea." What is the charge nurse's priority action? A. Confront the other staff members involved in the change of unit policy. B. Call a unit meeting to review the reasons the change was made. C. Develop a written unit policy for the expression of complaints. D. Encourage the nurse to be accountable for her own behavior.

D. Encourage the nurse to be accountable for her own behavior.

A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110 beats/ min. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow. B. Obtain arterial blood gas results. C. Insert an indwelling urinary catheter. D. Increase the rate of intravenous (IV) fluids.

D. Increase the rate of intravenous (IV) fluids.

The nurse is preparing to administer aMantoux (PPD, purified protein derivative) test to a client who is enter-ing nursing school. Which action by the nurse is of highest priority? A. Prepare 0.1-mL solution per tuberculin syringe. B. Assess the skin condition on the forearm. C. Teach the client about positive findings. D. Inquire about bacillus Calmette-Guerin (BCG) vaccine history.

D. Inquire about bacillus Calmette-Guerin (BCG) vaccine history.

The charge nurse is assigning rooms for four new clients. Only one private room is available on the oncology unit. Which client should be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intra-cavitary radiation

D. The client with cervical cancer who is receiving intra-cavitary radiation

pH= 7.32 PCO2 =50 HCO3= 25 This client is ______________________________.

Respiratory Acidosis

pH= 7.33 PCO2= 50 HCO3= 29 This client is ______________________________.

Respiratory Acidosis