HESI Med-Surg Practice 1
A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease."
"Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." Anger is a common emotional reaction when confronted with the diagnosis of a STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.
A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? "Tell your friends and family so that they can help you." "Get involved with a support group. I will give you some names." "Talk only to other friends who are infertile since only they can help." "Start adoption proceedings immediately since obtaining an infant is very difficult."
"Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and let's them know they are not alone in their situation.
A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? "Well, I don't have to worry about getting pregnant anymore." "I can't wait to go on the cruise that I have planned for this summer." "I know I will miss having sexual intercourse with my husband." "I have asked my daughter to stay with me next week after I am discharged."
"I know I will miss having sexual intercourse with my husband." Further teaching is needed in response to the client's misunderstanding of not being able to have sexual intercourse after a hysterectomy, needs to be addressed.
Which client is at highest risk for compromised psychological adjustment after a hysterectomy? A 46-year-old woman with three children and a recent promotion at work. A 55-year-old woman with abnormal bleeding and pain for 3 years. A 62-year-old widow who has three friends who had uncomplicated hysterectomies. A 29-year-old woman whose uterus ruptured after giving birth to her first child.
A 29-year-old woman whose uterus ruptured after giving birth to her first child. The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities.
Which client should the nurse assess first? A 27-year-old complaining of severe back pain. A 63-year-old complaining of foot and ankle pain. A 49-year-old with pancreatitis complaining of unrelenting abdominal pain. A 55-year-old newly admitted client complaining of jaw pain and indigestion.
A 55-year-old newly admitted client complaining of jaw pain and indigestion. The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury.
The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis? A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." B. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." C. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease." D. "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer."
A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleeping six to eight hours. Achieve a sense of control. Utilize problem solving skills. Increased focus of attention.
Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan.
When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? Acute pain related to movement of the stone. Impaired urinary elimination related to obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to need for prevention of recurrence of calculi.
Acute pain related to movement of the stone. The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement".
The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? Administer medications for pain relief, shortness of breath, and nausea. Clarify family members' feelings about the meaning of client behaviors and symptoms. Develop a plan of care after assessing the needs of the client and family. Teach the family to recognize restlessness and grimacing as signs of client discomfort.
Administer medications for pain relief, shortness of breath, and nausea. Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects is within the scope of practice for the PN.
A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? Keep the client on bed rest for eight hours. Check vital signs every 15 minutes for two hours. Allow the client nothing by mouth until the gag reflex returns. Encourage fluid intake to promote elimination of the contrast media.
Allow the client nothing by mouth until the gag reflex returns. The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions.
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? Ventricular irritability is prevented by the constant rate setting of pacemaker. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. An impulse is fired every second to maintain a heart rate of 60 beats per minute. An electrical stimulus is discharged when no ventricular response is sensed.
An electrical stimulus is discharged when no ventricular response is sensed. The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed.
The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer.
An image that describes metastatic sites of cancer. PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis.
The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? Elevate the arm with an IV infusing on the operative side with a pillow. Apply the blood pressure cuff to the arm on the non-operative side. Position the arm on the operative side close to the body. Collect a fingerstick blood specimen from the arm on the operative side.
Apply the blood pressure cuff to the arm on the non-operative side. The nurse give the UAP the following instructions when providing care to a post-op mastectomy client. Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury of the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.
A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? Progress activity as soon as possible. Assess for signs of bleeding and hypovolemia. Place the client in the left lateral position. Monitor blood pressure, pulse and breathing every 4 hours.
Assess for signs of bleeding and hypovolemia. Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy. Having the client placed a right lateral position, not left the left side applies pressure at the biopsy site.
The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? Increase fluid intake. Monitor sodium chloride intake. Assist the client in coping with hot flashes. Encourage milk products to increase calcium intake.
Assist the client in coping with hot flashes. Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? Obtain a prescription for a laxative. Withhold all oral fluid and food. Assist the client to ambulate in the hall. Administer the prescribed morphine sulfate.
Assist the client to ambulate in the hall. Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.
The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? Percussion. Auscultation. Deep palpation. Light palpation.
Auscultation. Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create inaccurate assessment of bowel sounds heard during auscultation.
The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.
Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.
The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? A. Method of insertion. B. Location of the tubes. C. Diameter of the tubes. D. Procedure for feedings.
B. Location of the tubes. The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does not require general anesthesia and less invasive due to being inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall and held in place by a tiny plastic device called a "bumper" that holds the g-tube in place inside the stomach and a small water-filled balloon which keeps the stomach in place against the abdominal wall.
A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration.
Bluish periumbilical skin discoloration. immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration (D) and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury. (A, B, and C) indicate inflammation of the appendix or gallbladder but do not represent an acute finding as a result of blunt abdominal trauma.
What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? Catheterize every 3 to 4 hours. Maintain sterile technique. Use the Cred maneuver before catheterization. Drink 500 ml of fluid within 2 hours of catheterization.
Catheterize every 3 to 4 hours. The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse implement? Encourage fluids to 3000 ml/day. Check stools for occult blood. Provide oral hygiene every 2 hours. Check for fever every 4 hours.
Check stools for occult blood. Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Presence of carbonaceous particles in sputum.
Cherry red color to the mucous membranes. The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.
A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? Serum amylase of 132 units/L. Serum sodium of 134 mEq/L. Chest x-ray indicating a mediastinal shift. Abdominal x-ray air throughout intestines.
Chest x-ray indicating a mediastinal shift. Immediate action is required for findings of a mediastinal shift, which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax.
The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins.
Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present.
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? Acute pain. Risk for infection. Disturbed body image. Risk for deficient fluid volume.
Risk for infection. A wound healing by secondary intention is an open wound that is at risk for infection and the location of the wound near the anal area increases the risk for infection even more so.
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? Perform active range of motion three times daily. Monitor for Battle's sign every four hours. Teach measures to avoid the Valsalva maneuver. Maintain the head of bed in a flat position.
Teach measures to avoid the Valsalva maneuver. The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels.
A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? Determine the client's level of discomfort using a pain rating scale. Ask the client about her past experience with chronic pain. Observe the client's facial expressions for pain and discomfort. Evaluate the client's ability to adjust the voltage to control pain.
Evaluate the client's ability to adjust the voltage to control pain. The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage.
What is the primary nursing problem for a client with asymptomatic primary syphilis? Acute pain. Risk for injury. Sexual dysfunction. Deficient knowledge.
Deficient knowledge. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology.
The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? Assessment of the client's vital signs. Document the finding as the only action. Determine the time the client last voided. Insert a rectal tube for the passage of flatus.
Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next.
A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection? Inform the client how to protect sexual and needle-sharing partners. Teach the client about the medications that are available for treatment. Identify the need to test others who have had risky contact with the client. Discuss retesting to verify the results, which will ensure continuing contact.
Discuss retesting to verify the results, which will ensure continuing contact. Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education, retesting encourages the client to maintain medical follow-up and management.
A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? Notify the healthcare provider. Decrease the IV solution flow rate. Document the finding as the only action. Administer potassium replacement as prescribed.
Document the finding as the only action. Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time.
The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the nurse implement? Document the temperature reading on the vital sign graphic sheet. Report the temperature to the healthcare provider immediately. Instruct the UAP to take the client's temperature again in 30 minutes. Advise the UAP to assist the client in returning to her bed.
Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the nurse should document the findings and continue with the plan of care.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what information is important to include? Dry, itchy skin changes may occur. There is a possibility of long bone pain. Permanent pigment changes to the breast may result. A low-residue diet may be ordered to reduce the likelihood of diarrhea.
Dry, itchy skin changes may occur Side effects from radiation to the breast most often include temporary skin changes such as: dryness, tenderness, redness, swelling, and pruritis.
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? Limit the client's intake of oral fluids and food. Evaluate the effectiveness of narcotic analgesics. Encourage the client to ambulate as tolerated. Teach the client about prevention of crises.
Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.
A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? Body mass index. Skin elasticity and turgor. Thought processes and speech. Exposure to cold environmental temperatures.
Exposure to cold environmental temperatures. TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? Extend the left arm laterally with the left palm upward. Extend the arm, dorsiflex the wrist, and extend the fingers. Extend the arms and hold this position for 30 seconds. Extend arms with both legs adducted to shoulder width.
Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? Suprapublic pain and distention. Bounding pulse at 100 beats/minute. Fingerstick glucose of 300 mg/dl. Small vesicular perineal lesions.
Fingerstick glucose of 300 mg/dl. Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth.
A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify? Increased anxiety since the transfusion began. Drowsiness after receiving diphenhydramine (Benadryl). Complaints of feeling cold. Flushed skin and headache.
Flushed skin and headache. The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing.
A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance.
Gastrointestinal disturbance. Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this drug be taken with food to avoid gastrointestinal upset.
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement? Administer antiemetics every 2 to 3 hours. Position on the left side with knees drawn up. Encourage ice chips sparingly. Give IV fluids with electrolytes.
Give IV fluids with electrolytes. When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration.
A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic.
Give a sublingual nitroglycerin tablet. After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation.
The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement? A mask should be worn by anyone entering the client's room. Handwashing is required before and after contact with the client. Gloves should be worn during direct contact with the client's skin. No precautions in addition to standard precautions are necessary.
Gloves should be worn during direct contact with the client's skin. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on "contact precautions".
The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week.
Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids.
A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? Heart palpitations. Anorexia. Hypersomnia. Stress incontinence.
Heart palpitations. Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis.
Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? Neisseria gonorrhoea. Chlamydia trachomatis. Herpes simplex virus. Human papillomavirus.
Human papillomavirus. According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? Risk for injury. Impaired comfort. Disturbed body image. Ineffective health maintenance.
Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "Impaired comfort".
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? Thinning hair and dry scalp. Increase in appetite and taste-bud acuity. Increase in muscle tone but decreased muscle strength. Increase in abdominal fat deposits.
Increase in abdominal fat deposits. An increase in the abdominal girth is a risk factor for the development of metabolic syndrome. According to the American Heart Association, men with a waist size 40 inches or larger and women 35 inches or larger double their risk factor of developing CAD and increase their chances 5Xs of developing DMII.
The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? Large amounts of expelled flatus with mucus. Tympanic abdomen and hyperactive bowel sounds. Increased abdominal pain with rebound tenderness. Complaint of feeling weak with watery diarrheal stools.
Increased abdominal pain with rebound tenderness. Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately.
A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis? Production of replacement cartilage is stimulated. Further destruction of the articular cartilage is prevented. Inflammation is reduced by inhibiting prostaglandin synthesis. Bradykinin is inhibited, thereby reducing acute and chronic pain.
Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? Cleanse perineum with warm soapy water 3 times per day. Instill the first dose of nystatin (Mycostatin) vaginally per applicator. Perform glucose measurement using a capillary blood sample. Obtain a blood specimen for sexually transmitted diseases (STDs).
Instill the first dose of nystatin (Mycostatin) vaginally per applicator. Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance and vaginal nystatin (Mycostatin) should be implemented first to initiate treatment to provide relief of symptoms.
The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Change drainage unit tubing.
Irrigate the catheter. Obstruction urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.
The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? It is quickly digested. It does not cause diarrhea. It does not dilate the stomach. It is slow to leave the stomach.
It is slow to leave the stomach. This type of diet is slowly digested and is slow to leave the stomach, thereby the possibility of dumping syndrome is reduced as a result of its density from proteins and fats, and the reduction of fluids.
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.) Select all that apply Assessing residual amounts once a day. Keeping the head of the bed elevated 30 degrees. Changing the enteral-feeding bag every 24 hours. Checking the placement of the tube by means of gastric aspiration. Flushing the tube with 50 ml of normal saline solution after each feeding.
Keeping the head of the bed elevated 30 degrees. Changing the enteral-feeding bag every 24 hours Checking the placement of the tube by means of gastric aspiration. Flushing the tube with 50 ml of normal saline solution after each feeding. Keeping the head of the bed elevated 30 degrees, changing the enteral-feeding bag every 24 hours, checking the placement of the tube by means of gastric aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding are interventions used to provide care of the client with a PEG tube. Residual amounts should be assessed each time, prior to each feeding.
A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? Rub a liberal amount of cream into the skin thoroughly. Cover the skin with a gauze dressing after applying the cream. Leave the cream on the skin for 1 to 2 hours before the procedure. Use the smallest amount of cream necessary to numb the skin surface.
Leave the cream on the skin for 1 to 2 hours before the procedure. Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone.
Left lateral, supine, brief periods on the right side, and prone. After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulating.
A client with osteoarthritis requests information from the nurse about what type of exercise regimen would be most beneficial for him. The nurse should communicate which information? Low impact exercise, walking, swimming and water aerobics. Repetitive strength-building exercises with weights or resistance bands. Circuit training alternating with frequent rest periods. High-impact aerobic exercise.
Low impact exercise, walking, swimming and water aerobics. Low impact exercises such as walking or swimming, that do not put additional pressure and strain or cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage.
A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which conclusion regarding this lab data is accurate? Probable prostatitis. Low risk for prostate cancer. The presence of cancer cells. Biopsy of the prostate is indicated.
Low risk for prostate cancer. Clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer.
The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? Helps to minimize pain and anxiety. Maintains correct spinal alignment to protect the surgical area. Prevents dizziness while stabilizing the spine. Allows the nurse to move the client freely without assistance.
Maintains correct spinal alignment to protect the surgical area. Log-rolling technique maintains the spine in a straight superior-inferior plane that aligns the spine without movement while protecting the surgical area, which is especially important when the procedure involves bone grafts that may several weeks for the bone to fuse.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? Palpate the pedal pulse volume. Count the brachial pulse rate. Measure the blood pressure. Assess for a carotid bruit.
Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured.
Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? Carotid stenosis. Steatosis hepatitis. Metastatic cancer. Clavicular fracture.
Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava.
A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings? Serum myoglobin levels are needed to confirm myocardial damage. The most reliable indicator of myocardial necrosis is serum CK-MB. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. Myocardial damage that occurred several days earlier is best validated by serum troponin levels.
Myocardial damage that occurred several days earlier is best validated by serum troponin levels. An elevated serum troponin has become the cardiac marker of choice for diagnosing an acute MI, according the American College of Cardiology (ACC) guidelines (2017) for NSTEMI. An elevated troponin will become evident within 2-3 hours of an MI in comparison to the CK-MB and other cardiac enzymes that can take up to 6-9 hours after the MI occurrence.
The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Select all that apply Nail polish. Hearing aid. Wedding band. Left leg brace. Contact lenses. Partial dentures.
Nail polish. Hearing aid. Contact lenses. Partial dentures. The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place.
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? The xray procedure may last for several hours. A nasogastric tube (NGT) is inserted to instill the barium. Enemas are given to empty the bowel after the procedure. Nothing by mouth is allowed for 6 to 8 hours before the study.
Nothing by mouth is allowed for 6 to 8 hours before the study. The client should be NPO, to include smoking or chewing gum for at least 6 hours before the UGI study
A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? Notify the client's healthcare provider. Document the finding in the client record. Prepare a warm enema solution for rectal instillation. Obtain a large bore needle for aspiration of the corpora cavernosa.
Notify the client's healthcare provider. Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider.
A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement? Notify the healthcare provider. Increase the IV flow rate. Place the client in the supine position. Prepare the client for an emergency echocardiography.
Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication.
During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? Notify the surgeon. Document the assesment. Secure a colostomy pouch over the stoma. Place petrolatum gauze dressing over the stoma.
Notify the surgeon. The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? Ask the client to try to speak. Assess for respiratory distress. Auscultate for pulmonary crackles after the client drinks a small amount of clear water. Observe the client for coughing colored sputum after drinking a small amount of colored water.
Observe the client for coughing colored sputum after drinking a small amount of colored water. To evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water.
Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? Obtain a prescription for an adjusted dose of insulin. Administer an oral anti-diabetic agent. Give an insulin dose using parameters of a sliding scale. Withhold insulin while the client is NPO.
Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.
A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Select all that apply Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure.
Obtain consent for the procedure. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Treatment of acute osteomyelitis requires administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
The nurse obtains a client's history that includes right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest.
Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.
A nurse is preparing a teaching plan for a client who is post-menopausal. Which measure is most important for the nurse to include to prevent osteoporosis? Take a multivitamin daily. Use only low fat milk products. Perform weight resistance exercises. Bicycle for at least 3 miles every day.
Perform weight resistance exercises. Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises is most important in the prevention of osteoporosis in post-menopausal women.
The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy.
Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid.
During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? Promotion of comfort. Prevention of pregnancy. Instruction in condom use. Information about transmission.
Promotion of comfort. The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority.
A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? Obtain a specimen for serum glucose level. Administer insulin per sliding scale. Provide cheese and bread to eat. Collect a glycosylated hemoglobin specimen.
Provide cheese and bread to eat. Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.
The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to160 beats/minute lasting more than 10 minutes. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.
Pulse change from 85 to160 beats/minute lasting more than 10 minutes. The RRT should be called to intervene for a client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time in a post-operative client.
The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) Select all that apply Some correct answers were not selected Empty surgical drains once a week using procedure gloves. Report inflammation of the incision site or the affected arm. Wear clothing with snug sleeves over the arm on the operative side. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head.
Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 lb) or reaching above her head. Part of a client's s/p mastectomy teaching plan should include reporting evidence of inflammation at the incision site or the affected arm, and to avoid lifting or reaching above their head.
The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client? Free from injury of drug side effects. Return to pre-illness weight. Adequate oxygenation. Maintenance of intact perineal skin.
Return to pre-illness weight. MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.
A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A scalp laceration oozing blood. Serosanguineous nasal drainage. Headache rated "10" on a 0-10 scale. Dizziness, nausea and transient confusion.
Serosanguineous nasal drainage. Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.
The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately? Terrible nightmares. Increased nocturia. Severe muscle pain. Visual disturbances.
Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching.
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife. Sexual activity can be resumed whenever you and your wife feel like it because the sexual response is more emotional rather than physical. You should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage. Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.
Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if you do not experience shortness of breath or chest discomfort doing the stairs then you should be okay to resume sexual activity.
Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Full thickness burns rather than partial thickness. Supinates extremity but unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Inability to distinguish sharp versus dull sensations in the extremity.
Slow capillary refill in the digits with absent distal pulse points. A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) Select all that apply Only marijuana cigarettes affect sperm count. Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility. Sperm specimens should be collected in 2 subsequent days.
Smoking can decrease the quantity and quality of sperm. The first semen analysis should be repeated to confirm sperm counts. Cessation of smoking improves general health and fertility. The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.
A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? Side effects are less likely if therapy is started early. Collateral circulation increases as the tumor grows. Sensitivity of cancer cells to CT is based on cell cycle rate. The cell count of the tumor reduces by half with each dose.
The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose.
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands? Ongoing antibiotic therapy is needed for one year. The client should not undergo magnetic resonance imaging. Increased frequency of assessment for prostatic cancer is needed. The client should not be catheterized through the stent for at least three months.
The client should not be catheterized through the stent for at least three months. A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement.
A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A graduate registered nurse (RN) with three weeks of experience. The registered nurse (RN) case-manager for the unit with 1 year's experience. A "floating" registered nurse (RN) with five years of nursing experience. An Korean-American practical nurse (PN) with six years of nursing experience.
The registered nurse (RN) case-manager for the unit with 1 year's experience. The RN case-manager is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care.
The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? Prognosis after treatment is excellent. Techniques for esophageal speech are relatively easy to learn with practice. The stoma should never be covered after this type of surgery. There is a radical change in appearance as a result of this surgery.
There is a radical change in appearance as a result of this surgery. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? Encourage fluids to 3000 ml per day. Change the client's position every two hours. Keep the head of the bed elevated 30 degrees. Turn off the television and darken the room.
Turn off the television and darken the room. To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. To effectively manage the client's symptoms, turn off the television, darken the room by minimizing fluorescent lights, flickering television lights, and distracting sounds
The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? Upper chest subcutaneous emphysema. Tidaling (fluctuation) of fluid in the water-seal chamber. Constant air bubbling in the suction-control chamber. Pain rated "8" (0-10) at the insertion site.
Upper chest subcutaneous emphysema. Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube.
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? Tell another staff member to bring extinguishing equipment to the bedside. Close the doors to the client's area when attempting to extinguish the fire. Use a bag-valve-mask resuscitator while removing the client from the area. Implement an emergency protocol to remove the client from the ventilator.
Use a bag-valve-mask resuscitator while removing the client from the area. A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source.
Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? Use an end-tital CO2 detector. Ascultate for bilateral breath sounds. Obtain pulse oximeter reading. Check symmetrical chest movement.
Use an end-tital CO2 detector. The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus.
Which method elicits the most accurate information during a physical assessment of an older client? Ask the client to recount one's health history. Obtain the client's information from a caregiver. Review the past medical record for medications. Use reliable assessment tools for older adults.
Use reliable assessment tools for older adults. Specific assessment tools designed for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information.
The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Select all that apply Vagal stimulation. An increased level of stress. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells.
Vagal stimulation. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.
The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room.
Wash hands after caring for the client. The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread.
What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? Wheezing becomes louder. Cough remains unproductive. Vesicular breath sounds decrease. Bronchodilators stimulate coughing.
Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that breath sounds and wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive.
A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? Give the drug and allow the client to read and sign the consent form. Counter-sign the client's initials on the consent form after giving the drug. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Call the healthcare provider to explain the surgical procedure before the client signs the consent.
Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered.
The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? Kyphosis with a reduction in height. Dilated superficial veins on both legs. External hemorrhoids with itching. Yellowish discoloration of the sclerae.
Yellowish discoloration of the sclerae. In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment.
Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) Select all that apply pH 6. Nitrate small. Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015.
pH 6. Sugar negative. Bilirubin negative. Specific gravity 1.015. A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035.Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated.
