Hesi

Normal serum potassium level

3.5-5.0 mEq/L

normal fasting blood glucose

70-110 mg/dL

Who cannot tolerate excessive fluid volume

Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

High-Fowler's position

If you drop the iv tubing

change the tubing

NSAIDs can amplify the effects of anticoagulants, such as warfarin,

these medications should not be taken together

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

"At this age, the child is developing his or her own personality."

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain?

1. Check the drain for patency. 2.Check that the drain is decompressed. 3.Observe for bright red, bloody drainage. 4.Maintain aseptic technique when emptying. 5.Empty the drain when it is half full and every 8 to 12 hours.

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions?

2."I will not sleep lying on my left side." 3."I will sit at the table to eat breakfast." 4."I will sit in my recliner with my feet elevated." 5."I will not lift anything heavier than 10 pounds

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note?

50 mL of drainage in the drainage-collection chamber 4.The drainage system is maintained below the client's chest. 5.An occlusive dressing is in place over the chest-tube insertion site. 6.Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

The normal blood urea nitrogen

6 mg/dL to 20 mg/dL (2.1-7.1 mmol/L). Values of 29 mg/dL mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration.

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

Access patency of the airway

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?

Allow the infant to signal a need

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns?

Ask the client to discuss information known about the planned surgery.

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

Beginning of toilet training.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately?

Chills, itching, or rash

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube?

Enables the client to speak Must have the cuff deflated when capped.

The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

Every hour

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding?

Explain the procedure, Irrigate NG tube with saline, Elevate the head of the bed to 45 degrees.

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

Green, leafy vegtables

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

aim at the base of the fire

The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred?

Infiltration

NSAIDs drugs

aspirin, phenylbutazone, carprofen (cox-2 inhibitor)

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?

Limit bleeding from the biopsy site

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first?

call the poison control center

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?

Sterile 2x2 Gauze

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?

continue to monitor

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include?

Perform TSE after a bath, same time every day, rolling each testicle between fingles.

The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter.

Phlebitis of the vein

In Respiratory Acidosis

the pH is down, and the Pco2 is up.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

Place two fingers under the restraint to determine snugness.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

Pneumonia

COPD leads to

Respiratory acidosis

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?

Supine with head elevation no greater than 30 degrees

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

Supine, with the residual limb supported with pillows

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

The blood bank

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

The blood will be held, and the primary health care provider (PHCP) will be notified.

Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled

then normal amount of prescribed tube feeding is administered *Document reinstill

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

transfusion reaction

The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item?

Vital signs

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?

a normal psychosocial response

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?

gentle, blowing or swooshing noise

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development?

good boy nice girl orientation

The nurse should tell the client to select which food item that is high in riboflavin?

milk

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

pair of sissors

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

placement is verified on x-ray

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection?

presence of prulent drainage tender firmness palpate around the incision

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?

punishment obedience stage

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

semi fowler's position with the foot of the bed flat

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent?

set limits on the child's behavior

In a Romberg test

the client is asked to stand with the feet together, the arms at the sides, and to close the eyes and hold the position.

When 200 mL of residual formula is obtained

the feeding is held and the RN is notified because this is an indication that the feeding is not being absorbed. The nurse should obtain data concerning the presence of nausea, bowel sounds, and abdominal distention indicating possible bowel obstruction.

Normal White Blood Cell Count (WBC)

5,000-10,000/mm3

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

wheezes and accessory muscles

The normal reference range for the glycosylated hemoglobin A1c (HgbA1c) 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. 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 nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?

Adolescents love to sleep late in the morning.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event?

Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once.

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery?

Have the client void before surgery determine the client has signed consent for the surgical procedure

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation.

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process?

Cover the site with an occlusive dressing after the tube is removed. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take?

Report observation to PCP

When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm,

the nurse must discontinue suctioning until the client is stabilized.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon