HESI Practice Quiz Questions

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction?

"A cardiac output of 2 L/min is normal." Rationale:The cardiac cycle consists of contraction and relaxation of the heart muscle. In adults, the cardiac output ranges from 4 to 7 L/min. Therefore, option 1 identifies a low cardiac output.

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

The nurse in the well-baby clinic has provided instructions regarding dental care to the mother of a 10-month-old child. Which statement by the mother indicates a need for further instruction?

"I can coat a pacifier with honey during the day as long as I do not give my child a bottle at nap or bedtime." Rationale: The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey also may cause botulism, and broken-off pieces of the candy pacifier may be aspirated. In addition, sweet milk or other fluids such as juice in a bottle taken at naptime or bedtime will bathe the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant teeth, is needed, usually beginning at 6 months of age if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious foods promotes dental health.

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?

"I can store the open insulin bottle in the kitchen cabinet for 1 month." Rationale:An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, options 1, 2, and 4 are incorrect.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

"I don't need to use my walker to get to the bathroom." Rationale:The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bedtime." Rationale:Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. Smoking and alcohol should be avoided. Reading is also a helpful measure and is relaxing.

The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching?

"I need to decrease fiber in my diet." Rationale:An older client has an increased tendency to experience constipation because of decreased stomach-emptying time and a lowered basal metabolic rate. Adequate dietary fiber is an important factor in aiding bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of fecal mass through the gastrointestinal tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever or swelling to my health care provider." Rationale:After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider.

The nurse administers ondansetron to a client. Which statement by the client indicates that this medication has been effective?

"I no longer feel nauseous." Rationale:Ondansetron is an antiemetic used in the treatment of nausea and vomiting. All of the other options are incorrect. Headache and dizziness are side effects of ondansetron. It is not used to treat pain.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L) Rationale:The normal WBC count ranges from 5000-10,000 mm3 (5-10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating their pain." Rationale: Pain is a highly individual experience, and the new graduate nurse should not assume that the client is exaggerating his pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow up with the client after giving medication to ensure that the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute in this population.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking?

"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale:The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect.

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

"The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale:Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia." Rationale:Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?

"You're having difficulty sleeping?" Rationale:The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are not therapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

- Broth - Coffee - Gelatin Rationale:A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client?

Allowing the client to choose social activities Rationale:Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, is a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply.

- Decline in visual acuity - Increased susceptibility to urinary tract infections - Increased incidence of awakening after sleep onset Rationale:Anatomical changes to the eye affect the individual's visual ability, leading to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory usually is maintained. Change in sleep patterns is a consistent, age-related change. Older persons experience an increased incidence of awakening after sleep onset.

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.

- Draw 1 line through the error, initialing and dating it. - Document the correct information and end with the nurse's signature and title. Rationale: If the nurse makes an error in narrative documentation in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply.

- Pallor and coolness - Numbness and pain - Edema and blanched skin

A health care provider's prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. The nurse prepares how many milliliters to administer the correct dose? Fill in the blank.

0.8 mL

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding?

1+ edema Rationale:Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

A health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.

1.5 tablets Rationale: You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal 3 places to the left. Therefore, 150 mcg equals 0.15 mg. Next, use the formula to calculate the correct dose. Formula: Desired--------- × Tablet = Tablets per doseAvailable0.15 mg------- × 1 tablet = 1.5 tablets0.1 mg

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L) Rationale:The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for unlicensed assistive personnel (UAP)?

A client who requires urine specimen collections Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by UAPs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) Rationale: The nurse should plan to care for the client who has an elevated white blood cell count and a fever first because this client's needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem?

Ambulates 10 feet (3 meters) farther each day Rationale:Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A physical obstruction to the transmission of sound waves Rationale:A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

A willingness to participate in the planning of the care and treatment plan Rationale:In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since he or she is actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands his or her illness, only the client's desire for help.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse?

A woman who has advanced Parkinson's disease Rationale:Elder abuse includes physical, sexual, or psychological abuse; misuse of property; and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least 1 physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm. Rationale:The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?

Actual or life-threatening concerns Rationale:Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided.

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively?

Allow the client to interact with others in his or her (adolescent) same age group. Rationale:Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group.

Atenolol has been prescribed for a hospitalized client. The nurse should check which item before administering this medication?

Apical heart rate Rationale:Atenolol is a beta-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks beta-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The nurse should check the client's apical heart rate and blood pressure immediately before administering the medication. If the heart rate is 60 beats/min or lower or if the systolic blood pressure is less than 90 mm Hg, the medication is withheld and the health care provider is contacted. The remaining options are unrelated to the administration of this medication.

When communicating with a client who speaks a different language, which best practice should the nurse implement?

Arrange for an interpreter to translate. Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.

A client has refused to eat more than a few spoonfuls of breakfast. The health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation?

Assault Rationale:Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action?

Assess and treat the wound sites. Rationale:The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?

Assessment of vital signs Rationale:The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a health care provider's prescription; in addition, the vital signs should be checked before performing this procedure.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?

At least 30 minutes before exposure to the sun Rationale:Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

Avoid sudden head movements. Rationale:The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?

Call the nursing supervisor. Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the HCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

Check the client's status and lead placement. Rationale:Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

Clarify with the team leader to make a safe ICU client assignment. Rationale:Floating is an acceptable practice used by hospitals to solve understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. That is why clarifying the client assignment with the team leader to ensure that it is a safe one is the best option. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Submitting a written protest and calling the hospital lawyer is a premature action.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?

Decreased oozing of blood from puncture sites and gums Rationale:Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes because these cells were instrumental in fighting infection in the body.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?

Determine whether there are medication duplications. Rationale: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate?

Document the findings. Rationale:The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/minute. The normal apical heart rate is 90 to 130 beats/minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

Which is the best nursing intervention regarding complementary and alternative medicine?

Educating the client about therapies that he or she is using or is interested in using Rationale: Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Touch and hold the client's or family member's hand if appropriate. Be honest and let the client and family know they will not be abandoned by the nurse.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears?

Encourage the child's parents to stay with the child. Rationale:Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

Encouraging active range-of-motion exercises Rationale:Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?

Every 30 minutes Rationale:The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremity should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

An adolescent is admitted to the hospital after an accidental self-inflicted gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury?

Explore the client's knowledge of gun safety. Rationale: A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield Rationale:Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)?

Glucose intolerance Rationale:Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Hairdressers Rationale:Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; or those who have had multiple surgeries, have spina bifida, wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement?

Identify recent behaviors or accomplishments that demonstrate the client's skills. Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness Rationale:Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia Rationale:The normal hemoglobin level for an adult female client is 12-16 g/dL (120-160 mmol/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

A client has an as needed prescription for ondansetron. For which condition(s) should the nurse administer this medication?

Nausea and vomiting Rationale:Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect reasons for administering this medication.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy. Rationale:Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy vegetables Rationale:Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services. Rationale:The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?

Partial-thickness skin loss of the dermis Rationale:In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record. Rationale:A normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia Rationale:The normal reference range for the glycosylated hemoglobin A1c is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated hemoglobin A1c of 9% is 212 mg/dL (11.8 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action?

Pull down and back on the earlobe and direct the solution toward the wall of the canal. Rationale:The infant should be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

A health care provider's prescription reads phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.

Rationale: You must convert 0.2 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point 3 places to the right. Therefore, 0.2 g equals 200 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose. Formula: Desired × Capsule(s)-------------------- = Capsule(s)/doseAvailable200 mg × 1 Capsule------------------ = 2 Capsules100 mg

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?

Reflecting a cultural value Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases. Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger Rationale:Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea Rationale:Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

Lisinopril has been prescribed for a client. What should the nurse instruct the client about this medication?

Rise slowly from a reclining to a sitting position. Rationale:Lisinopril is an angiotensin-converting enzyme inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a reclining to a sitting position and to dangle the legs from the bed for a few moments before standing to reduce the hypotensive effect. It is not necessary to take the medication with food. If nausea occurs, the client should drink a noncola carbonated beverage and eat salted crackers or dry toast. A full therapeutic effect may be achieved in 1 to 2 weeks.

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?

Safely securing the safety device straps to the side rails Rationale:The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

Nursing staff members are sitting in the lounge taking their morning break. Unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort?

Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take?

Speak at normal tone and pitch, slowly and clearly. Rationale:Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?

Sterile 2 × 2 gauze Rationale:A dry sterile dressing such as a sterile 2 × 2 gauze is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A povidone iodine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred.

The nurse is explaining the appropriate methods for measuring an accurate temperature to unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion Rationale:An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze. Rationale:Testing the 6 cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the 2 eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

Thank the client for the input, but inform the client that others now need a chance to contribute. Rationale:If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed toward helping the client in a therapeutic manner.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale:For optimal lung expansion with the incentive spirometer, the client should assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

The client was found lying on the floor. Rationale: The incident report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating Rationale:The client's self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question.

The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss?

They respond to low-pitched tones. Rationale:Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate characteristics related to aging.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

Transport the victim to the operating room for surgery. Rationale: In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 mL/hour Rationale:Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period?

Urinary retention Rationale: Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.

A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?

Using open-ended questions and silence Rationale:Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

Venturi mask Rationale:The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate?

Very high, indicating severe renal failure Rationale: The normal serum creatinine level for an adult male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). A creatinine level of 4.0 mg/dL (353 mcmol/L) is a critical value and indicates serious impairment in renal function. This value is not low, normal, or slightly elevated.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes Rationale:Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

Withdraws the NPH insulin first Rationale:When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.

The nurse is auscultating a 56-year-old adult client's apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action should the nurse take?

Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. Rationale:The normal heart rate is 60 to 100 beats/minute in an adult. If the nurse notes a heart rate that is less than 60 beats/minute, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output, so this would also be assessed.

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client is not acceptable to consume?

processed oat cereal Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content.