HESI practice questions

A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only)

1 Rationale: 1 gram = 1000 mg 0.1 gram = 100 mg 100 mg = 1 capsule

The nurse prepares a 1,000 mL IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?

21 Rationale: 1000 mL / 8 hours = 125 mL/hour 125 x 10 = 1250 gtt/hr 1250 / 60 = 20.8 21 gtt/min

99.2 degrees Fahrenheit is what in Celsius degrees?

37.3

The healthcare provider prescribes a continuous infusion of 5% dextrose in 0.45% sodium chloride at 85 mL/hour. The IV administration set delivers 10 gtt/mL. The nurse should regulate the drop rate to deliver how many gtts/minute? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

14 Rationale: Volume / Times (minutes) x drop factor (gtt/mL) = 85 mL /60 minutes x 10 gtt/mL = 14.6 = 14 gtt/minute

The healthcare provider prescribes a continuous intravenous infusion of dextrose 5% and 0.45% sodium chloride with KCl 20 mEq/100 mL to be delivered over 8 hours. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

125 Rationale: Using the formula volume/time: 1000 mL / 8 hours = 125 mL/hour

The nurse is preparing a tube feeding of Ensure 280 mL (50% solution). Full strength Ensure is available in a 240 mL can. The nurse should use how many mL of Ensure to prepare the feeding? (Enter numeric value only. Round to the nearest whole number if needed.)

140 Rationale: Using the formula Desired % / % on Hand x Total volume desired: 50% / 100% x 280 mL = 0.5 x 280 mL = 140 mL Ensure + 140 mL water = 280 mL (50% solution)

The healthcare provider prescribes acetaminophen elixir (Tylenol elixir) 600 mg PO q6 hours for an adult client experiencing pain associated with maxillofacial surgery. The bottle is labeled 500 mg/15 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

18 Rationale: Using the formula D/H x Q= 600 mg / 500 mg x 15 mL = 18 mL

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain?

A 55-year-old woman who has had moderate low back pain for three months. Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?

A large body surface area favors heat loss to the environment.

A client asks the nurse to explain the meaning of a narrow therapeutic index of a medication. What information should the nurse use to answer the question?

A small margin exists between safe and toxic plasma levels.

Which response by a client with a nursing diagnosis of "spiritual distress" indicates to the nurse that a desired outcome measure has been met?

Accepts that punishment from God is not related to illness. Rationale: Acceptance that she is not being punished by God indicates a desired outcome for some degree of resolution of spiritual distress.

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?

Achieve a sense of control. Rationale: 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 a key need.

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

Acknowledge that she is supporting the arm correctly. Rationale: The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact.

When providing a discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?

Elimination of hazards to home safety.

A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement?

Apply a Fox shield to the affected eye and any type of patch to the other eye. Rationale: The treatment for a penetrating eye injury is the application of a Fox shield, if available (not a regular eye patch) with another eye patch placed over the unaffected eye to prevent bilateral movement, and the child transported to the emergency department immediately.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement FIRST?

Assist the ambulating client back to the bed. Rationale: An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood.

The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

Auscultation Rationale: Auscultation of the client's abdomen is performed next because manual manipulation (Percussion, Deep palpation, Light palpation) can stimulate the bowel and create false sounds heard during auscultation.

Miotic drug therapy for the treatment of glaucoma is based chiefly upon which physiologic action?

Enhancing aqueous humor outflow. Rationale: Miotic drugs act to enhance aqueous outflow through papillary constriction.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?

Calcium loss from bones can be slowed by increasing calcium intake and exercise. Rationale: Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can prevent further bone loss.

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. Rationale: 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-cath at home.

The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan?

Ensure that sterile technique is followed when changing surgical dressings.

Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription?

Every 12 hours. Rationale: A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours provides the best around-the-clock pain management.

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

Examine the effectiveness of nursing interventions toward meeting client outcomes.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?

Examining a chest x-ray obtained after the tubing was inserted.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?

Client. Rationale: A primary source of information for a health assessment is the client. Subjective data can only be provided directly from the client.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?

Closed-ended questions.

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

Assist and support the client is establishing short-term goals. Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals, such as seeing a family member, or listening to music.

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as subjective findings?

Complains of inability to empty bladder. Rationale: Symptoms the client describes is subjective data.

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. Rationale: Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed.

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

Consider the sterile field contaminated if it becomes wet during the procedure.

The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded?

Crackles in the right and left lower lobes. Rationale: Fine crackles are short, high-pitched sounds heard just before the end of inspiration that are the result of rapid equalization of pressure when collapsed alveoli or terminal bronchioles suddenly snap open.

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

Cradle the client's heel. Rationale: Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle and gently moving the limb in a slow, smooth, firm but gentle manner.

The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition?

Cystocele. Rationale: This constellation of signs in a postmenopausal woman are characteristic of a cystocele.

What affects Absorption in the older adult population?

Decreased gastric pH, delayed gastric emptying, decreased splanchnic blood flow, decreased gastrointestinal absorption surface areas and motility.

What affects Metabolism in older adults?

Decreased hepatic blood flow, decreased hepatic mass, and decreased activity of hepatic enzymes.

What affects Elimination in an older adult?

Decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons.

During a visit to the outpatient clinic, the nurse assess a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?

Degree of flexion and extension of the client's knee joint. Rationale: The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor.

In evaluating client care, which action should the nurse take FIRST?

Determine if the expected outcomes of care were achieved.

An older client with a decreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process?

Distribution. Rationale: A decreased lean body mass in an older adult affects the distribution of drugs, which affects the pharmacokinetics of drugs.

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

Document the presence and volume of the pulse palpated. Rationale: Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse. The site is best palpated with the client supine.

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

Drape the top sheet and covers loosely over the bed cradle.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?

During the Inhalation. Rationale: The client should be instructed to deliver the medication during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication.

The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?

Continue asking the mother questions about the child. Rationale: Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child.

A client is receiving acetaminophen (Tylenol) 0.65 gram PO every 6 hours PRN for pain. Acetaminophen is available in 325 mg tablets. How many milligrams should the nurse administer?

650 Rationale: Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same unit of measurement, which is 0.65 grams = 650 mg.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?

Flush the tube with water.

A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, non-hemolytic reaction. What assessment finding is most important for the nurse to identify?

Flushed skin and headache. Rationale: The most common type of reaction is a febrile, non-hemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing.

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

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

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?

Fowler's.

What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil. Rationale: The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to begin (creates no correction at the beginning of the exam), and should be held in front of the examiner's left eye when examining the client's right eye. For optimum visualization, the ophthalmoscope should be kept within one to three inches of the clients eye. It should illicit a red reflex as the light travels through the crystalline lens to the retina.

When assessing a preschooler, which finding warrants further assessment by the nurse?

Gains 2 pounds in 12 months. Rationale: Preschool children gain an average of 5 pounds per year, so a gain of 2 pounds is less than half of the expected weight gain and should be investigated further.

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

Generativity. Rationale: Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is described by Erikson as the developmental stage of generativity, and is characteristic of middle adulthood.

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?

Genetic and familial health disorders. Rationale: A genogram that is used during the health assessment process identifies genetic and familial health disorders.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?

Healthcare provider notified of client's refusal to have blood specimens collected for testing. Rationale: When a client refuses a treatment, the exact words or the client regarding the client's refusal of care should be documented in a narrative format.

The home health nurse is admitting a client with Parkinson's disease to the home healthcare service. In planning care for this client, which nursing diagnosis has priority?

Impaired physical mobility related to muscle rigidity and weakness. Rationale: Parkinson's disease is a progressive neurologic disorder affecting the brain centers that are responsible for control and regulation of movement. The chief clinical manifestations are impaired movement, muscular rigidity, resting tremor, muscle weakness, and loss of postural refluxes.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response?

Increase in pulse rate. Rationale: When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate. Peripheral vasoconstriction of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output occurs when orthostatic hypotension occurs.

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

Ineffective coping related to response to positive biopsy test results. Rationale: The first part of the nursing diagnosis statement is the "diagnostic label" and is followed by "related to" the cause, which should direct the nurse to the appropriate interventions. The answer choice focuses on the client's "response" which the nurse can provide support, reflection and dialogue.

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

Infuse 10% dextrose and water at 54 mL/hr.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints?

Initiate a weight-reduction diet to achieve a healthy body weight. Rationale: Achieving a healthy weight is critical to protect the joints of clients with OA.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries". Based on this statement, which focused assessment should the nurse conduct?

Inquire about the source and type of pain. Rationale: Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "miseries".

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?

Instruct the client to take slow deep breaths and stop bearing down. Rationale: During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?

It is OK if you don't want to talk about your surgery. I will be available when you are ready. Rationale: It displays sensitivity and understanding without judging the client.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide?

It may hurt but we'll give you medicine to help you feel better.

Which action is most important for the nurse to implement when donning sterile gloves?

Keep gloved hands above the elbows. Rationale: Gloved hands held below waist level are considered unsterile.

What is the best action for the nurse to take when initiating contact with a toddler for the first time?

Kneel in front of the toddler and speak softly to the child.

Symptoms of Chorea

Loss of short-term memory, facial tics and grimaces, and constant writhing movements.

The low-birth-weight infant requires a neutral thermal environment. What action should the nurse implement?

Maintain a high-humidity atmosphere. Rationale: A neutral thermal environment provides warmth so the infant can maintain a normal core temperature with minimum oxygen consumption and calorie expenditure. Low-birth-weight infants are especially vulnerable to temperature instability. A high-humidity temperature maintenance by reducing evaporative heat loss.

Which method of medication administration provides the client with the greatest first-pass effect?

Oral. Rationale: The first-pass effect is a pharmacokinetic phenomenon that is related to the drug's metabolism in the liver. After oral medications are absorbed from the gastrointestinal tract, the drug is carried directly to the liver via the hepatic portal circulation where hepatic inactivation occurs and reduces the bioavailability of the drug.

The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?

Pale bluish coloration of the toes. Rationale: Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot. Assessment of adequate circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis, should be reported immediately.

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair?

Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

The nurse must prevent a 2-year old with severe eczema on the face, neck and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?

Place elbow restraints on the child's arms. Rationale: Elbow restraints prevent arm flexion and scratching of involved areas, but do not inhibit use of the hands for play activities.

A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement?

Place the child's hand under the examiner's hand while palpating.

How should the nurse handle the linens that are soiled with incontinent feces?

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. Rationale: The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen.

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

Position prone with a small pillow below the diaphragm. Rationale: The prone position using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence.

Which topic should the nurse include in planning a tertiary prevention project for the local retirement community?

Rehabilitation after surgery. Rationale: Tertiary prevention includes interventions aimed at disability limitation and rehabilitation from disease, injury or disability.

A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?

Remove restraints one at a time and provide range of motion exercises.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

Reposition in a Sim's position with the client's weight on the anterior ilium. Rationale: The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client is the Sims' position, which distributes the client's weight to the anterior ilium.

A female client with a nasogastric tube attacked to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take FIRST?

Reposition the client on her side. Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first.

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

Reposition the client's arm. Rationale: If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should FIRST attempt to reposition the client's arm to alleviate any obstruction.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take FIRST?

Reposition the head to validate that the head is in the proper position to open the airway.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?

Request and document the name of the certified translator.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?

Respiratory rate. Rationale: Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate before ambulation to determine tolerance for activity.

The nurse receives a unit of blood from the blood bank for a postoperative client who is currently in the X-ray department. What action should the nurse implement?

Return the blood to the blood bank for refrigeration within 30 minutes. Rationale: A blood transfusion should be hung for administration within 30 minutes of its arrival from the blood bank. If it is not used within this time frame, it must be returned to the blood bank for refrigeration.

A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?

Self-actualization.

The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit?

Shuffling gait, masklike facial expression, and tremors of the head. Rationale: Common clinical features of Parkinsonism.

How should the nurse measure the length of a 14-month-old child?

Supine recumbent position. Rationale: Children younger than 24 to 36 months of age should be measured for length in the supine position from crown to heel, known as recumbent length. Standing height measurements begin after 36 months or older, depending on the ability and cooperation of the child.

What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia?

Tachypnea. Rationale: Malignant hyperthermia, a potentially fatal genetic myopathy, can cause a change in vital signs that demands immediate attention in the perioperative period. Early symptoms of the disorder include tachycardia and tachyarrhythmias, tachypnea, hypercarbia, and metabolic and respiratory acidosis.

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

Take measures to promote as much comfort as possible. Rationale: Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort during all activities.

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time?

Tell me what you would like to see happen with your children in the future.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 degreed Fahrenheit, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?

Tell the student to proceed directly to his regularly scheduled class. Rationale: This student has just completed football practice, and increased muscle activity increased body heat production. A temperature of 100 degreed Fahrenheit is normal for this student at this time. The student should attend class since no further nursing action is required.

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

The clamp on the urinary drainage bag is open.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?

The client voluntarily signed the form. Rationale: The nurse signs the consent form to witness that the client voluntarily signs the consent and that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure.

The healthcare provider prescribes oral anti-fungal therapy for a client with onychomycosis. What information should the nurse tell the client?

The infection is difficult to eradicate and and requires prolonged therapy for 3 to 6 months. Rationale: Treatment of onychomycosis, a fungal infection of the fingernails and toenails, is difficult to treat and requires prolonged therapy of 3 to 6 months for oral anti-fungal therapy.

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement, is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

Thinning of the skin with loss of elasticity. Rationale: Thin, non-elastic skin is an important factor in decubitus formation. Proportion of body fat to lean mass increases with age and might help decrease ulcer tendency.

What should the nurse assess last when examining a 5-year-old child?

Throat. Rationale: More invasive, so save it for last.

Which topic should the nurse include in planning a secondary prevention project for the local retirement community?

Vision and hearing screening. Rationale: Health screenings are the mainstay of secondary prevention, which focuses on health promotion, which includes screening, early detection and diagnosis of disease.

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

Vitamin B12. Rationale: Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12.

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?

Wash hands after caring for the client. Rationale: The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good hand washing is all that is needed to prevent nosocomial spread.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

Wear gloves when coming in contact with the blood or body fluids of any client. Rationale: The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from any client.

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?

What vitamin and mineral supplements do you take?

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?

Which activities during a routine day are impacted by your pain?

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?

Yellowish discoloration of the sclerae.

Wheezing

a continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls that are first evident on expiration and may be audible

Adventitious lung sound

abnormal lung sounds

Pleural friction rub

creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together heard during inspiration, expiration and with no change during coughing

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?

is disoriented to place and time.

Beta-blockers

used to inhibit aqueous humor production

The nurse is assessing the effectiveness of high dose aspirin therapy for an 88-year-old client with arthritis. The client reports that she can't hear the nurse's questions because her ears are ringing. What action should the nurse implement?

Notify the healthcare provider of this finding immediately. Rationale: Tinnitus is an early sign of salicylate toxicity. The healthcare provider should be notified immediately and the medication discontinued.

Symptoms of Multiple Sclerosis

Numbness of the extremities, loss of balance, and visual disturbances.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take FIRST?

Observe the appearance of the skin under the ice pack. Rationale: The first action taken by the nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the other actions: -Instruct the client regarding the need for the covering. -Reapply the covering after filling with fresh ice. -Ask the client how long the ice was applied to the skin.

Which site should the nurse assess to obtain the pulse rate for a 1-year-old child?

Apical Rationale: Apical pulse rates should be obtained in children less than 2 years of age to assess cardiac function.

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?

-Nail polish -Hearing aid. -Contact lenses. -Partial dentures.

Which topic should the nurse include in planning a primary prevention project for the local retirement community?

-Safety measures in the home. -Adult immunization program. Rationale: These two are primary prevention topics which include health-promoting activities designed to reduce the likelihood of a specific illness occurring.

The nurse plans to obtain health assessment information from a secondary source. Which options are a secondary source for the completion of the health assessment?

-Healthcare provider. -A family member. -Previous medical records.

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.5 Rationale: 1,000 mg : 1 gram :: X mg : 0.1 gram X = 100 mg D/H = 150 / 100 = 1.5 tablets

A client with a gastrostomy tube (GT) receives a prescription for Osmolite 1/2 strength enteral formula at 80 mL/hour/ To prepare a 4 hour solution, the nurse should dilute the full-strength formula with how many mL of water? (Enter numeric value only.)

160 Rationale: Determine the total volume needed at 80 mL/hour x 4 hours = 320 mL. Use the formula, Desired strength / strength on Hand x Volume = 50 / 100 x 320 = 160 mL of Osmolite enteral formula, which must be diluted to half strength. Or use ratio and proportion, Desired strength (1/2 = 1 part : 2 parts) :: Volume of full strength : Total Desire volume 1 : 2 :: X : 320 mL 2X = 320, and X = 160 mL of Osmolite enteral formula, full strength 320 mL total volume - 160 mL of full strength formula = 160 mL of water to create 1/2 strength or 50% concentration.

A client is receiving D5W 1000 mL at 75 mL/hour. The nurse hangs the bag of IV fluids at 0300. At what time, based on the 24-hour clock, should the infusion be completed?

1620 Rationale: 1000 mL / 75 mL/hr = 13.33333333 hours .33333333 x 60 min = 20 minutes 13 hours & 20 min 0300 + 1320 = 1620

A male client receives a prescription for ondansetron hydrochloride (Zofran) 4 mg IV to prevent postoperative nausea after an inguinal hernia repair. The medication is available in 2 mg/mL. How many mL should the nurse administer? (Enter numeric value only)

2 Rationale: Use ratio and proportion, 4mg: X mL = 2 mg : 1 mL 2X = 4 X = 2

A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125 mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only)

2 Rationale: Using Desired / Available formula: 500 mg / 250 mg x 1 tablet = 2

Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer? (Enter numeric value only. If rounding is required, round to the whole number.)

3 Rationale: 1 gram = 1000 mg 0.3 gram = 300 mg 1 cap = 100 mg 300 mg / 100 mg x 1 capsule = 3 capsules

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of sever coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

After clearing the tube with 30 mL of air, check the pH of fluid withdrawn from the tube. Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample fluid withdrawn from the tube (after clearing the tube with 30 mL of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action.

An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client?

Apply the patch at least 4 hours prior to departure. Rationale: Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours before departure on the cruise ship. The duration of the transdermal patch is 72 hours. Scopolamine blocks muscarinic receptors in the inner ear and to the vomiting center, so the best application site of the patch is behind the ear. Anticholinergic medications are CNS depressants, so the client should be instructed to avoid alcohol while using the patch.

What action by the nurse demonstrates culturally sensitive care?

Asks permission before touching a client. Rationale: Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

Assess for bladder distention.

The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma 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?

Avoid allergy medications that contain pseudoephedrine or phenylephrine. Rationale: OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased ocular pressure, so a client with glaucoma should avoid using these OTC medications.

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?

Be sure to have a complete physical examination before beginning your planned exercise program. Rationale: Teaching the client is most important, so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, heart attack, or stroke.

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP?

Bend at the knees when lifting heavy objects.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

Blood transfusions are forbidden. Rationale: Blood transfusions are forbidden in the Jehovah's Witness religion.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states. "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide FIRST?

Explain that the records are hospital property and may not be removed. Rationale: The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed, even with the client's permission. Next the clinical instructor must be notified so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor should also be alerted to ensure appropriate supervision of students as well as protection of client information.

Symptoms of Myasthenia Gravis

Extreme muscular weakness, easy fatiguability, and ptosis.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?

Hot remedies restore balance after surgery, which is considered a "cold" condition. Rationale: Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body.

What client statement indicates to the nurse that the client requires assistance with bathing?

I don't understand why I'm so weak and tired.

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond?

I will ask one of the female nurses to bathe you.

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

Identify the break in surgical asepsis and provide another set of sterile supplies. Rationale: Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings?

Immediately after the assessments are completed. Rationale: Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained.

A peak and trough level must be drawn for a client receiving antibiotic therapy. What is the optimum time for the nurse to obtain the trough level?

Immediately before the next antibiotic dose is given.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 mL of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications". What initial action is most important for the nurse to take?

Measure the pulse volume and capillary refill distal to the infiltration. Rationale: Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity.

Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color?

Medium yellow. Rationale: Yellow is the easiest for a person with failing vision to see.

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?

Method of insertion.

A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement?

Provide information about infection prevention. Rationale: Several factors impact a client with anger, which is a cognitively driven problem. The correct nursing intervention helps the client test cognition and may lead to lowering anger, which impacts the client's readiness for acceptance of the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary is therapeutic to forming a relationship.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted?

Pulse rate decreases from 78 to 52 beats/min.

A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement?

Quiet the child and retake the blood pressure.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?

Rashes in the axillary, groin, and skin fold regions. Rationale: Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes, skin breakdown, and the development of pressure ulcers.

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

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

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the

Upper torso. Rationale: The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips and elbows flex. This stooped posture results in the upper torso becoming the center of gravtiy for older persons.

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?

Use a happy-face/sad-face pain scale. Rationale: A 4-year-old can readily identify with simple pictures to show the nurse how he/she is feeling.