HESI practice
A 4-year-old admitted with pneumonia weighs 18 kg. The healthcare provider has prescribed vancomycin 40 mg/kg/day IV. The order states to divide the dose and give it three times daily. How many milligrams of vancomycin should the child receive in each dose? (Round the answer to the nearest whole number.) _____________________ mg/dose
240mg/dose
The outpatient clinic nurse is reviewing phone messages from the previous night. Which client should the nurse call back first? A.) A woman at 30 weeks' gestation who has been diagnosed with mild preeclampsia and was unable to relieve her heartburn. B.) A woman at 24 weeks' gestation who was crying about painful vulvar lesions and urinary frequency for the past 8 hours. C.) A woman at 12 weeks' gestation who was recently discharged from the hospital with hyperemesis gravidarum and had had two episodes of vomiting in 6 hours. D.) A woman with type 1 diabetes who tested positive with a home pregnancy kit and was worried about managing her diabetes.
A. A woman at 30 weeks' gestation who has been diagnosed with mild preeclampsia who was unable to relieve her heartburn. A sign of a potential complication of eclampsia is epigastric pain, which may be indicative of liver damage and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, a medical emergency.
The nurse receives change-of-shift report on her four acute care clients. Which action should the nurse take first? A.) Administer an antiemetic to a postoperative client who has been nauseated and is now vomiting. B.) Notify a family member of a client's impending transfer to the intensive care unit for angina and ST segment changes. C.) Inform the healthcare provider of a potassium level of 5.2 mmol/L (mEq/L) in the client with end-stage renal disease. D.) Begin assessment rounds, starting with the palliative care client having a diagnosis of congestive failure.
A. Administer an antiemetic to a postoperative client who has been nauseated and is now vomiting. Postoperative nausea and vomiting (PONV) are among the most common reactions after surgery. PONV can stress and irritate abdominal and gastrointestinal wounds, increase intracranial pressure in patients who had head and neck surgery, elevate intraocular pressure in patients who had eye surgery, and increase the risk for aspiration. Obtaining a prescription for relieving PONV will decrease these risks.
A victim of a motor vehicle collision is dead on arrival at the emergency department. The significant other arrives and is noticeably upset. What action should the nurse take to assist the significant other with this crisis? A.) Ask whether there are family, friends, or clergy to call. B.) Talk about the former relationship with the significant other. C.) Provide education about the stages of grief and loss. D.) Assess the significant other's level of anxiety.
A. Ask whether there are family, friends, or clergy to call. The nurse should help the significant other identify support systems and resources that are helpful in coping with a crisis situation, such as the sudden death of a spouse.
The nurse is updating the plan of care for a client who has a borderline personality disorder. Which intervention is most important to implement? A.) Assign the same nurse to care for the client. B.) Avoid challenging inappropriate behavior. C.) Limit the client's contact with other clients. D.) Remove consequences for acting-out behaviors.
A. Assign the same nurse to care for the client. The best intervention is to provide consistency and avoid splitting the staff by assigning the client to only one nurse.
The nurse is caring for a client who had a thoracotomy 48 hours earlier and has left lower lobe chest tubes. The nurse notes that a chest tube is not tidaling. Which action should the nurse take first? A.) Check for kinks in the chest drainage system. B.) Assess the heart rate and blood pressure. C.) Notify the rapid response team immediately. D.) Reconnect the chest tube to wall suction.
A. Check for kinks in the chest drainage system. Normal fluctuation of the water, called tidaling, reflects the intrapleural pressure during inspiration and expiration. If no tidaling is observed (rising with inspiration and falling with expiration in a spontaneously breathing patient), the drainage system may be blocked. An absence of fluctuation may mean that the lung has fully healed (which is unlikely at 48 hours), or it can mean that there is an obstruction in the chest tube. A simple step is to ensure that there are no kinks that would occlude the chest tube and prevent lung drainage and expansion.
A hospitalized client has been newly diagnosed with type 2 diabetes. Which task(s) can the RN delegate to the UAP? (Select all that apply.) A.) Contacting the dietitian for a prescribed consult. B.) Reviewing the client's insulin injection technique. C.) Obtaining the fingerstick blood glucose level before each meal and at bedtime. D.) Reminding the client to dry the toes carefully after a shower. E.) Talking to the client about foods that raise the blood glucose level.
A. Contacting the dietitian for a prescribed consult. C. Obtaining the fingerstick blood glucose level before each meal and at bedtime. D. Reminding the client to dry the toes carefully after a shower. The UAP can collect and report data such as vital signs, height and weight, and capillary blood sugar results (C); perform hygiene tasks (D); and carry out clerical duties (A). Clients who need education or reinforcement of education require intervention by the RN or PN (B and E).
A male client with a peritoneal dialysis (PD) catheter calls the clinic to report that he feels poorly and has a fever. What is the best response by the nurse? A.) Encourage him to come to the clinic today for an assessment. B.) Instruct him to increase his fluid intake to 3 L/ day. C.) Review his peritoneal dialysis regimen. D.) Inquire about his recent dietary intake of protein and iron.
A. Encourage him to come to the clinic today for assessment. PD catheters are used in peritoneal dialysis. They are often used at home by the client, placing the client at risk for peritoneal infection. Because dialysis clients usually have some degree of compromised immunity, the client should come to the clinic for assessment.
The home health nurse evaluates the insulin preparation and administration technique of a 36-year-old male client newly diagnosed with diabetes. The client has been prescribed lispro insulin before meals and glargine insulin once daily in the morning. A.) Which finding indicates that the client needs further education? B.) He mixes glargine and lispro in the same syringe for the morning dose. C.) He leaves the insulin syringe in place for 10 seconds after injection. D.) He stores the opened insulin vials at room temperature in the cabinet. E.) He recaps and disposes of the single-use insulin syringe.
A. He mixes glargine and lispro in the same syringe for the morning doses. Glargine and lispro must not be mixed with any other insulin.
A nurse has been assigned a pregnant client who has heart disease. The client's condition has been diagnosed as New York Heart Association (NYHA) class II cardiac disease. What important fact(s) about activities of daily living while pregnant should the nurse teach this client? (Select all that apply.) A.) Increase fiber in the diet. B.) Anticipate the need for rest breaks after activity. C.) Notify the healthcare provider if her rings do not fit. D.) Maintain bed rest with bathroom privileges. E.) Start a low-impact aerobic exercise program.
A. Increase fiber in the diet. Restrictions in activities of daily living for clients with NYHA Class II cardiac disease create a risk factor for constipation. B. Anticipate the need for rest breaks after activity. Individuals with NYHA Class II cardiac disease may have limitations on activity and need periods of rest throughout the day, but especially after periods of activity. C. Notify the healthcare provider if her rings do not fit. Tight rings may indicate weight gain, and the client is at risk for congestive heart failure
The charge nurse reminds clients on the mental health unit that breakfast is at 8 AM, medications are given at 9 AM, and group therapy sessions begin at 10 AM. Which treatment modality has been implemented? A.) Milieu therapy. B.) Behavior modification. C.) Peer therapy. D.) Problem-solving.
A. Milieu therapy. Milieu therapy uses resources and activities in the environment to assist with improving social functioning and activities of daily living.
The nurse is teaching a client who has chronic urinary tract infections about a prescription for ciprofloxacin 500 mg PO bid (twice daily). What side effect(s) could the client expect while taking this medication? (Select all that apply.) A.) Photosensitivity. B.) Dyspepsia. C.) Diarrhea. D.) Urinary frequency. E.) Anemia.
A. Photosensitivity. This is a side effect of ciprofloxacin; exposure to sunlight or tanning beds should be avoided. The client should be instructed to use sunscreen and protective clothing. B. Dyspepsia. Ciprofloxacin causes gastrointestinal irritation, nausea and vomiting, and abdominal pain, which should be reported. C. Diarrhea. Watery, foul-smelling diarrhea is an adverse reaction to ciprofloxacin that indicates pseudomembranous colitis; this should be reported and requires immediate intervention.
When accessing the medication dispensing system (Pyxis), the nurse finds chlorpropamide in the drawer instead of the expected chlorpromazine. Which actions should the nurse take? (Select all that apply.) A.) Remove the tablets of chlorpropamide. B.) Notify the pharmacy about the mistake. C.) Place an incident occurrence report. D.) Be extra vigilant because pharmacy is making mistakes. E.) Place a warning note on the Pyxis machine.
A. Remove the tablets of chlorpropamide. B. Notify the pharmacy about the mistake. C. Place an incident or occurrence report. The nurse needs to ensure that others do not give the wrong medication, so the tablets of chlorpropamide need to be removed and returned to the pharmacy (A). The pharmacy needs to be made aware of the error (B) and an incident (also called an occurrence) report completed (C) to help prevent the error in the future. The other options (E and D) are not needed at this time.
An RN working on a hospice unit finds a client crying. The client states that he is afraid to die. Which actions should the RN implement? (Select all that apply.) A.) Sit quietly with the client and listen to his concerns. B.) Provide the client with privacy. C.) Give the client an antianxiety medication. D.) Contact the client's spiritual counselor or pastor. E.) Assess the patient for signs of impending death.
A. Sit quietly with the client and listen to his concerns. Silence, or offering one's presence, is an effective technique that lets the client share as he desires and also indicates that the nurse cares. D. Contact the client's spiritual counselor or pastor. Facing death is a spiritual issue. Requesting help from the client's spiritual provider is appropriate.
The nurse needs to initiate an IV on an 8-year-old child. Which intervention(s) is/are appropriate? A.) Start the IV in the treatment room, not the child's room. B.) Apply a lidocaine-based cream for a few minutes before starting the IV. C.) Ask the parents to leave the room while performing the procedure. D.) Encourage the child to use guided imagery to cope. E.) Offer the child a reward if they cooperate during the procedure.
A. Start the IV in the treatment room, not the child's room. The child's room is a safe zone, and painful treatments should not be performed in the child's room. D. Encourage the child to use guided imagery to cope. Children at this age can understand and participate in guided imagery.
The triage nurse in the emergency room is assessing four clients. Which client requires the most immediate intervention? A.) The adult client who arrived via ambulance with numbness and tingling of his left arm and face. B.) The adult client who had a seizure at home who is sleeping on his left side. C.) The 60-year-old client who complains of frequent urination and has a blood sugar of 16.7 mmol/L (300 mg/dL). D.) The middle-aged client who presents with severe unilateral back pain and previous history of kidney stones.
A. The client who arrived via ambulance with numbness and tingling of his left arm and face. The client may be experiencing a stroke and requires immediate assessment and interventions. If interventions are initiated quickly, the complications may be mitigated.
The nurse is returning phone calls to clients who are cared for at an outpatient mental health center. Which client should the nurse call first? A.) The young mother diagnosed with schizophrenia who is hearing voices saying that they are pursuing her children. B.) The elderly man at an assisted living facility who says he wants to end it all. C.) The female client diagnosed with bipolar disorder who has not slept for 48 hours. D.) The teenager diagnosed with bulimia whose mother called and reported that she found her daughter purging.
A. The young mother diagnosed with schizophrenia who is hearing voices say that they are pursuing her children. This client is at risk for hurting herself or her children. She needs to be seen first.
A nurse is planning the client assignments for the night shift. The nursing team includes a registered nurse, a licensed practical nurse, and two unlicensed assistive personnel (UAP). Which duty (or duties) could be delegated to the UAPs? (Select all that apply.) A.) Transport a client to the radiology department for a computed tomography (CT) scan. B.) Bathe a client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C.) Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate order. D.) Report to the healthcare provider the fingerstick blood glucose level of 2.72 mmol/L (49 mg/dL) E.) Feed a female client her first meal after she experienced a stroke.
A. Transport a client to the radiology department for a computed tomography (CT) scan. B. Bathe a client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C. Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate order. The UAP can perform noninvasive and nonsterile activities (options A, B, and C).
The nurse is reviewing the cardiac markers for a client who was admitted with the diagnosis of chest pain. Which marker is the best to determine cardiac damage? A.) Troponin levels. B.) Myoglobin level. C.) Creatine kinase myocardial band (CK-MB) level. D.) Lactate dehydrogenase (LDH) level.
A. Troponin levels. A rise in the troponin levels is diagnostic of myocardial injury and is considered the gold standard.
Which client is at the highest risk for respiratory complications? A.) A 21-year-old client with dehydration and cerebral palsy who is dependent in daily activities. B.) A 60-year-old client who has had type 2 diabetes for 20 years and was admitted with cellulitis. C.) An obese 30-year-old client with hypertension who is noncompliant with the medication regimen. D.) A 40-year-old client who takes a loop diuretic, has a serum K+ of 3.4 mmol/L (mEq/L), and complains of fatigue.
A.) A 21-year-old client with dehydration and cerebral palsy who is dependent in daily activities. A client with dehydration and cerebral palsy, characterized by uncoordinated, spastic muscle movements, is at increased risk for respiratory problems because of impaired mobility and impaired swallowing.
A client at 41 weeks' gestation who is in active labor calls the nurse to report that her membranes have ruptured. The nurse performs a vaginal examination and discovers that the umbilical cord has prolapsed. Which intervention should the nurse implement first? A.) Move the presenting fetal part off the cord. B.) Cover the cord with sterile moist saline gauze. C.) Prepare for an emergency caesarean delivery. D.) Administer O2 by face mask at 10 L/min.
A.) Move the presenting fetal part off the cord. This action is the most critical intervention. The nurse must prevent compression of the cord by the presenting part because that would impair fetal circulation, leading to morbidity and, possibly, death.
A client's arterial blood gas results are as follows: pH 7.29, Pco2 55 mm Hg, and Hco3 26 mEq/L. Which compensatory response should the nurse expect to see? A.) Respiratory rate of 30 breaths/min. B.) Apical rate of 120 beats per minute. C.) Potassium level of 5.8 mmol/L (mEq/L). D.) Complaints of pounding headache.
A.) Respiratory rate of 30 breaths/min. The client is experiencing respiratory acidosis. In addition to the metabolic system compensating, the respiratory system may also compensate.
The arrythmia alarm sounds on a client on the telemetry unit, indicating that the client is in ventricular tachycardia. Place the nurse's actions for this client in order of priority from first to last. A.) Call the rapid responses team. B.) Assess for blood pressure. C.) Give oxygen via nasal cannula. D.) Bring defibrillator/crash car to the bedside. E.) Document the incident.
B, A, C, D, E. The nurse needs to first assess the client before calling the rapid response team. Also, if the patient is truly in ventricular tachycardia, it needs to be determined if it is pulseless v-tach or if the client has a pulse and blood pressure. If there is a pulse, the second action would be to call the rapid response team so that additional help is available. Then, the patient needs to have oxygen to maximize oxygenation of the circulating blood. The defibrillator needs to be brought to the bedside to be used for the cardioversion. The final activity is to document the findings.
The nursing supervisor calls the charge nurse on a step-down unit about the need for a bed for an unstable patient from the medical unit. Which client should the nurse transfer to the medical unit to receive this unstable client? A.) A client admitted for an ST-elevation myocardial infarction (STEMI) who just returned from having a cardiac catheterization performed. B.) A client diagnosed with congestive heart failure who is receiving an IV infusion of furosemide. C.) A client with possible Guillain-Barré syndrome who may need an exchange transfusion. D.) A client in hypertensive crisis who is prescribed a sodium nitroprusside drip.
B. A client diagnosed with congestive heart failure who is receiving IV infusion of furosemide. This patient could be safely taken care of on a medical-surgical unit.
After a change-of-shift report on an orthopedic floor, which client should the nurse assess first? A.) A client who had surgery yesterday and has a temperature of 37.6°C (99.7°F). B.) A client who is complaining of numbness and tingling distal to the fracture site. C.) A client who had a left leg amputation and states he is experiencing pain in the left foot. D.) A client who is extremely upset with their care and is requesting to speak to the manager.
B. A client who is complaining of numbness and tingling distal to the fracture site. This is a sign of compartment syndrome. This client needs to be assessed first.
The nurse is teaching a young adult female who has a history of Raynaud disease how to control her pain. What information should the nurse offer? A.) Take oral analgesics at regularly spaced intervals. B.) Avoid extremes of heat and cold. C.) Limit foods and fluids that contain caffeine. D.) Keep the affected extremities in a dependent position.
B. Avoid extremes of heat and cold. In Raynaud disease, vascular spasms of the hands and fingers are triggered by exposure to extremes of heat or cold, which causes the characteristic pallor and cold-to-the-touch symptoms of the upper extremities.
The nurse is admitting a client who is a paraplegic and has a nonhealing pressure injury with a possible methicillin-resistant Staphylococcus aureus infection. A PN and UAP are assigned to the nurse's team. Which tasks should be delegated to the PN? (Select all that apply.) A.) Place the client in isolation. B.) Complete a dressing change. C.) Assess and document the wound. D.) Insert a urinary catheter. E.) Administer oral pain medications.
B. Complete a dressing change. D. Insert a urinary catheter. E. Administer oral pain medications. These tasks are within the scope of practice for the PN.
A client with type II diabetes is scheduled for an intravenous pyelogram (IVP). Which assessment is most important for the nurse to complete before the test is performed? A.) Baseline vital signs. B.) Current medication list. C.) Coagulation status. D.) Electrolyte levels.
B. Current medication list. This is a priority. If the client is taking an oral diabetic agent with metformin, the nurse may need to hold the medication for 48 hours before the IVP because of potentially decreased kidney function.
The nurse is administering medications to a client admitted for an overdose and a history of substance abuse. Which intervention(s) is (are) a priority to include in this client's plan of care? (Select all that apply.) A.) Allow the client to take medications independently. B.) Ensure that all medications have been swallowed before leaving the client's room. C.) Request that oral pain medications be changed from tablet to oral suspension. D.) Administer flumazenil as prescribed every 6 hours around the clock. E.) Administer all medications to the client via the intravenous route.
B. Ensure that all medications have been swallowed before leaving the client's room. To ensure that medications are not being hoarded or kept to be taken at a later time, the nurse needs to watch the client swallow his or her medications. C. Request that oral pain medications be changed from tablet to oral suspension. Liquid forms of medications are harder to save to be taken later so are often used for clients with a history of substance abuse.
The nurse receives report on a client from the emergency department with a diagnosis of pneumonia. Which intervention has the highest priority? A.) Obtain blood cultures. B.) Initiate prescribed antibiotics. C.) Place the client in isolation. D.) Obtain an accurate weight.
B. Initiate prescribed antibiotics. Studies have shown that the sooner antibiotics are started, the better the outcomes. Current requirements include antibiotic administration within 2 hours of diagnosis. This is the priority.
The charge nurse is planning the daily schedule for clients on the mental health unit. A male client who is manic should be assigned to which activity? A.) A basketball game in the gym. B) Jogging at least 1 mile daily. C.) A table tennis game with a peer. D.) Group activity with the art therapist.
B. Jogging at least 1 mile. Jogging is the best activity for this client because it is a noncompetitive physical activity, and it requires the use of large muscle groups that expend energy associated with mania.
The clinic nurse is caring for a client taking argatroban for atrial fibrillation. What information is essential for the nurse to include in the client's teaching plan? (Select all that apply.) A.) Have protamine sulfate available. B.) Notify the healthcare provider of any unusual bleeding. C.) Eat a diet high in green leafy vegetables. D.) Keep the medication in a dark, dry container. E.) Avoid aspirin or aspirin-containing medications.
B. Notify the healthcare provider of any unusual bleeding. Gastrointestinal (GI) bleeding or excessive bleeding is an adverse effect. The client needs to notify their healthcare provider immediately. E. Avoid aspirin or aspirin-containing medications Aspirin and argatroban can have an additive effect and result in bleeding.
The healthcare provider has prescribed the removal of a client's internal jugular central line catheter. To remove the catheter safely, the nurse should give which intervention(s) the highest priority? (Select all that apply.) A.) Carefully remove the bio-occlusive dressing. B.) Place the client in the Trendelenburg position. C.) Send the catheter tip to the laboratory for a culture and sensitivity. D.) Have the client hold a deep breath during removal. E.) Apply pressure for 20 minutes after removal of the catheter.
B. Place the client in the Trendelenburg position. D. Have the client hold a deep breath during removal. The procedure for removing the catheter safely is:(1) place the client in the Trendelenburg position,(2) have the client take a deep breath and hold it, and(3) gently withdraw the catheter while applying direct pressure with sterile gauze. Holding the breath creates positive pressure in the intrathoracic space, and the Trendelenburg position minimizes the risk of air entering the catheter.
The nurse is providing discharge instructions to a client who has been diagnosed with angina pectoris. Which instruction is most important? A.) Avoid activity that involves the Valsalva maneuver. B.) Seek emergency treatment if chest pain persists after the third nitroglycerin dose. C.) Rest for 30 minutes after having chest pain before resuming activity. D.) Keep extra nitroglycerin in an airtight, light-resistant bottle.
B. Seek emergency treatment if chest pain persists after the third nitroglycerin dose. This instruction is most important because chest pain characteristic of acute myocardial infarction persists longer than 15 minutes, and delaying medical treatment can be life-threatening.
A female adolescent is admitted to the mental health unit for anorexia nervosa. In planning care, what is the nurse's highest priority? A.) Teach the client the importance of self-expression. B.) Supervise the client's activities closely. C.) Include the client in daily group therapy. D.) Facilitate social interactions with others.
B. Supervise the client's activities during the day. The nurse should monitor and supervise the client's activities to prevent binging, purging, or avoiding meals.
At change of shift, the charge nurse assigns the UAP four clients. The RN should direct the UAP to take vital signs on which client first? A.) The 89-year-old with chronic obstructive pulmonary disease who is resting quietly on 2 L of oxygen and who needs assistance with a bath. B.) The client who returned from surgery and needs their second set of every-15-minute vitals signs taken. C.) The client newly diagnosed with type 2 diabetes who had a fingerstick glucose level of 5.0 mmol/L (90 mg/dL) and needs help with breakfast. D.) The newly admitted client with rheumatoid arthritis who needs hand splints reapplied to both hands.
B. The client who returned from surgery about 15 minutes ago and is requesting something to drink. This client has a set of time-sensitive vital signs, so this is a priority.
The nurse is calling the healthcare provider (HCP) about a client's current needs. What is the best way to communicate? A.) Call the HCP with the request and a recommendation. B.) Use the SBAR (situation, background, assessment, recommendation) tool for communication. C.) Send a text message or page with the needed order. D.) Ask the HCP to come back to the unit to discuss the client's needs.
B. Use the SBAR (situation, background, assessment, recommendation) tool regardless for communication. Using the SBAR format ensures that all key information is given and is the best way to communicate.
. When entering a client's room, the nurse finds the client threatening to cut herself. What is the priority intervention? A) Call in an extra nurse or UAP for the next shift. B.) Assign one of the current UAPs to sit with the client. C.) Move the client to another room with a roommate. D.) Administer an as-needed (PRN) dose of lorazepam.
B.) Assign one of the current UAPs to sit with the client. Because the client is at risk for self-harm, the charge nurse should assign a staff member to stay with the client.
A client who is immediately postoperative for aortic aneurysm repair has been receiving normal saline intravenously at 125 mL/h. The nurse observes dark yellow urine. The hourly output for the past 3 hours was 30 mL, 18 mL, and 10 mL. What action should the nurse take? A.) Administer a bolus D5 ½ normal saline at 200 mL/h. B.) Contact the healthcare provider. C.) Monitor output for another 2 hours. D.) Draw blood samples for blood urea nitrogen (BUN) and creatinine levels.
B.) Contact the healthcare provider. Acute renal failure can result from interruption of blood flow during an aortic aneurysm repair. Low urinary output may indicate acute renal failure and requires more immediate intervention from the healthcare provider.
A female client presents in the emergency department with right lower quadrant abdominal pain and pain in her right shoulder. She has no vaginal bleeding, and her last menses was 6 weeks ago. Which actions should the nurse take first? A.) Assess for abdominal rebound pain, distention, and fever. B.) Obtain a complete set of vital signs and establish IV access. C.) Observe for recent musculoskeletal injury, bruising, or abuse. D.) Collect specimens for pregnancy test, hemoglobin, and white blood cell count.
B.) Obtain a complete set of vital signs and establish IV access. The nurse should first evaluate the client for vital sign changes related to blood loss due to a possible ruptured ectopic pregnancy (an obstetrical emergency). Vascular access is vital in an emergency situation.
The nurse is assigning tasks to the UAP. Which client situation requires the registered nurse (RN) to intervene? A client with: A.) active tuberculosis who is leaving the room without a mask. B.) end-stage renal disease requesting orange juice to drink. C) anemia who is complaining of fatigue and asking for help getting dressed to go home. D.) chronic obstructive pulmonary disorder who removes his oxygen and is leaving the unit to smoke.
B.) end-stage renal disease requesting orange juice to drink. A UAP can be directed to provide specific types and amounts of fluids, but orange juice is high in potassium, which is contraindicated for patients in end-stage renal disease.
The nurse is part of the triage team at a disaster. Which client should be seen first? A.) A 90-year-old woman with a crushed pelvis and head injuries. B.) A 21-year-old man screaming in pain from a broken leg. C.) A 30-year-old woman with a flail chest secondary to a puncture wound to the chest. D.) A 12-year-old crying with multiple lacerations to both legs.
C. A 30-year-old woman with a flail chest secondary to a puncture wound to the chest. The flail chest causes the heart to become unstable and is life-threatening. This client needs to be seen immediately.
While the nurse is caring for a client who has had a myocardial infarction, the monitor alarm sounds, and the nurse notes ventricular fibrillation. What should be the nurse's first course of action? A.) Notify the healthcare provider. B.) Increase the oxygen concentration. C.) Assess the client. D.) Prepare to defibrillate the client.
C. Assess the client. If a monitor alarm sounds, the nurse should first assess the client's clinical status to see whether the problem is an actual dysrhythmia or a monitoring system malfunction.
A client who has posttraumatic stress disorder is found one night trying to strangle his roommate. Which intervention is the nurse's highest priority? A.) Give the client a sedative or hypnotic. B.) Administer an antipsychotic. C.) Assign a UAP to sit with the client. D.) Process with both clients about event.
C. Assign a UAP to sit with the client. The nurse should implement safety precautions immediately and place a sitter with the patient.
The clinic nurse suspects that a 2-year-old child is being abused. Which assessment finding(s) would support this? (Select all that apply.) A.) Petechiae in a straight line on the chest. B.) Gray-blue pigmented areas on the sacral region. C.) Bald patches on the scalp. D.) Ear tugging and crying. E.) Symmetrical burns on the hands.
C. Bald patches on the scalp. Bald patches typically are symmetrical and are indicative of physical abuse. E. Symmetrical burns on the hands. Symmetrical burns are indicative of physical abuse.
The nurse who usually works on the orthopedic surgery unit is floating to a cardiovascular unit. Which client would be best to assign to the float nurse? A.) Client scheduled for a heart catheterization this morning. B.) Client admitted last night for chest pain. C.) Client who is 1 day postoperative for popliteal bypass surgery. D.) Client with heart failure and scheduled for a stress test today.
C. Client who underwent popliteal bypass surgery yesterday. This would require similar care to a client who had just had lower extremity orthopedic surgery and would be the safest assignment for this nurse.
A client who was admitted to the hospital with cancer of the larynx is scheduled for a laryngectomy tomorrow. What is the client's priority learning need tonight? A.) Anticipated body image changes. B.) Pain management expectations. C.) Communication techniques. D.) Postoperative nutritional needs.
C. Communication techniques. A client who is in crisis and anticipating the immediate postoperative period is concerned with immediate needs, such as the ability to express and convey a subjective symptom (e.g., pain) and obtain the needed intervention.
A client at 39 weeks' gestation plans to have an epidural block when labor is established. What intervention(s) should the nurse implement to prevent side effects? (Select all that apply.) A.) Teach about the procedure and effects of the epidural. B.) Place the client in a chair next to the bed. C.) Administer a bolus of 500 mL of normal saline solution. D.) Monitor the fetal heart rate and contractions continuously. E.) Assist the client to empty her bladder every 2 hours.
C.) Administer a bolus of 500 mL of normal saline solution. Prehydration increases maternal blood volume and prevents hypotension, which occurs as a result of vasodilation, a side effect of epidural anesthesia. A saline solution is used to prevent fetal secretion of insulin that later places the neonate at risk for hypoglycemia.
A nurse working at a clinic finds a client in one of the examination rooms slumped over and apneic. The nurse notes an empty syringe and needle still in the client's arm. Which action has the highest priority? A.) Call 911. B.) Remove the syringe and needle. C.) Assess for a pulse. D.) Obtain the automated external defibrillator (AED).
C.) Assess for a pulse. Assessing for a pulse is the highest priority to determine whether cardiopulmonary resuscitation (CPR) needs to be initiated.
A client with chronic back pain is not receiving adequate pain relief from oral analgesics. Which alternative action should the nurse explore to promote the client's independence? A.) Ask the healthcare provider to increase the analgesic dosage. B.) Obtain a prescription for a second analgesic to be given by the IV route. C.) Consider the client's receptivity to complementary therapy. D.) Encourage counseling to prevent future addiction.
C.) Consider the client's receptivity to complementary therapy. This action supports self-care without the high level of adverse effects associated with additional medication. It is the least invasive measure, and it promotes the active participation (self-care) of the client.
The healthcare provider plans to do a paracentesis on a client with cirrhosis in 1 hour. In what order should the nurse perform the following activities? A.) Ensure that the informed consent has been obtained. B.) Measure the client's abdominal girth. C.) Have the client empty his or her bladder. D.) Assemble needed equipment. E.) Administer oral pain medication.
Correct order: A, E, C, B, D Before a procedure can be completed, it is essential to have an informed consent (A). Oral pain medication can then be given (after the consent has been obtained) to help the patient relax during the procedure (E). The client then needs to empty his or her bladder before the procedure to prevent accidentally puncturing the bladder (C). After the bladder is empty, a baseline abdominal girth is obtained (B). Finally, the nurse needs to assemble the correct equipment for the procedure (D).
1. Which activity should the nurse delegate to an unlicensed assistive personnel (UAP)? A.) Assist a client to ambulate who was just admitted with stroke symptoms. B) Encourage additional oral fluids for an elderly client with pneumonia who has developed a fever. C.) Report the ability of a client with myasthenia gravis to manage the supper tray independently. D) Record the number of liquid stools of a client who received lactulose for an elevated NH3 level.
D) Record the number of liquid stools of a client who received lactulose for an elevated NH3 level. This task encompasses basic care, elimination, and intake and output; it does not require judgment or the expertise of the nurse and can be performed by the UAP.
40. The emergency department staff nurse is assigned four clients. Which client should the nurse assess first? A.) A preschooler with a barking cough, an O2 saturation of 93% on room air, and occasional inspiratory stridor. B.) A 10-month-old infant with a tympanic temperature of 38.9°C (102°F) and green nasal drainage who is pulling at her ears. C.) A crying 8-month-old with a harsh, paroxysmal cough; an audible expiratory wheeze; and mild retractions. D.) A clingy 3-year-old who has a sore throat and drooling and whose tongue is slightly protruding from his mouth.
D. A clingy 3-year-old who has a sore throat and drooling and whose tongue slightly protrudes from his mouth. Drooling, a history of sore throat, and a protruding tongue are classic manifestations of epiglottitis; this is a medical emergency. The throat can quickly occlude and cause respiratory arrest.
The nurse is accompanying a client to the radiography department when he becomes panic stricken at the elevator and states, "I can't get on that elevator." Which action should the nurse take first? A.) Ask one more staff member to ride in the elevator. B.) Offer a prescribed antianxiety medication. C.) Begin desensitization about riding the elevator. D.) Affirm the client's fears about riding the elevator.
D. Affirm the client's fears about riding the elevator. The nurse should first validate and allow the client to affirm his anxiety and fears about riding the elevator. Then options to initiate desensitization may be considered.
The nurse is providing discharge teaching for a client who has been prescribed diltiazem. Which dietary instruction has the highest priority? A.) Maintain a low-sodium diet. B.) Eat a banana each morning. C.) Ingest high-fiber foods daily. D.) Avoid grapefruit products.
D. Avoid grapefruit products. Grapefruit should be avoided during therapy with calcium channel blockers because it can cause an increase in the serum drug level, predisposing the client to hypotension
An 18-year-old woman is being discharged after delivering a healthy baby. She has a cousin whose baby died from sudden infant death syndrome (SIDS). The client seems to know many of the precautions to take. Which information does the nurse need to correct? A.) Always place infants on their backs to sleep. B.) Room sharing has been shown to decrease SIDS. C.) Keep the crib free of stuffed animals and crib pads. D.) Sleeping with the baby can alert the mother to changes.
D. Sleeping with the baby can alert the mother to changes. Sleeping with the baby increases the risk for injury and SIDS for infants.
The nurse is reviewing the laboratory values of her assigned clients. Which client has an abnormal laboratory report that the nurse should immediately call to the healthcare provider? A.) The client who is post splenectomy after a motor vehicle accident and has a hemoglobin of 109 mmol/L (10.9 g/dL). B.) The client receiving warfarin (Coumadin) who has an international normalized ratio (INR) of 2.3. C.) The 38-year-old client who is 24 hours postthyroidectomy and has a total calcium level of 2.35 mmol/L (9.4 mg/dL). D.) The newly admitted client with bipolar disorder with a lithium level of 2.5 mEq/L.
D. The newly admitted client with bipolar disorder with a lithium level of 2.5 mEq/L. Severe lithium toxicity occurs at 2.0 mEq/L; the nurse should notify the healthcare provider immediately.
The nurse is planning to lead a seminar for community health nurses on violence against women during pregnancy. Which statement describes an appropriate technique for assessing for violence? A.) Women should be assessed only if they are part of a high-risk group. B.) Women may be assessed in the presence of young children but not intimate partners. C.) The assessment only needs to be completed at the beginning of the pregnancy. D.) Women should be reassessed face-to-face by a nurse as the pregnancy progresses.
D. Women should be reassessed face-to-face by a nurse as the pregnancy progresses. More than one face-to-face interview elicits the highest reports of violence during pregnancy.
A UAP is assisting with the care of several clients on a postpartum unit. Which assignment should the nurse delegate to the UAP? A.) Check fundal firmness and lochia for the clients who delivered vaginally. B.) Take vital signs every 15 minutes for a client with preeclampsia. C.) Provide breastfeeding instructions for a primigravida. D.) Assist with daily care activities for all clients as needed.
D.) Assist with daily care activities for all clients as needed. This is the most appropriate assignment for the UAP. The RN should delegate daily care activities to the UAP based on the RN's assessments of each client's needs. The other options require the specialty and scope of the nurse.
The RN is evaluating the effects of the administration of fresh frozen plasma (FFP) on a client diagnosed with cirrhosis. Which finding(s) would indicate a positive outcome? (Select all that apply.) A.) Blood urea nitrogen (BUN) 3.9 mmol/L (11 mg/ dL); creatinine 62 mcmol/L (0.7 mg/dL). B.) Hemoglobin level of 100 mmol/L (10 gm/dL). C.) Return of temperature to normal. D.) Decreased bleeding from the gums. E.) Negative guaiac for occult bleeding.
D.) Decreased bleeding from the gums. FFP replaces clotting factors; therefore, a decrease in bleeding is an expected, positive outcome. E.) Negative guaiac for occult bleeding. FFP replaces clotting factors; therefore, no occult (hidden) bleeding would be an expected, positive outcome.
