Hesi Questions Missed

The nurse is assisting the healthcare provider with a chest tube removal. Which intervention should be done before the chest tube is removed?

A chest x-ray should be done before chest tube removal to ensure that the lung has remained expanded.

The nurse is caring for a client admitted with a diagnosis of Addison's disease. Which nursing intervention is most appropriate?

A client with Addison's disease is dehydrated, hypotensive, and very weak. Frequent rest periods are needed to prevent exhausting the client. Potassium levels are elevated in Addison's disease. Sodium is decreased and potassium increased in Addison's. Fluid should be encouraged.

A client diagnosed with Guillain-Barré syndrome is hospitalized. Which finding is most important for the practical nurse to report to the primary health care provider?

A decline in cognitive status in a client is indicative of symptoms of hypoxia as result of the respiratory muscles being affected and indicates that the client require mechanical ventilation. Signs and symptoms of Guillain-Barre syndrome may include: Prickling, pins and needles sensations in fingers, toes, ankles or wrists. Weakness in the legs that spreads to upper body. Unsteady walking or inability to walk or climb stairs. Difficulty breathing. Difficulty with eye or facial movements, including speaking, chewing or swallowing. Severe pain that may feel achy or cramplike and may be worse at night. Difficulty with bladder control or bowel function.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube?

A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak.

What is a fenestrated tracheostomy tube?

A fenestrated tube has an opening (fenestration) in the back of the outer cannula. The front of the tube can be blocked which allows the air to flow upwards to the upper part of the trachea and larynx. It e allows the patient to breathe normally and to speak or cough through the mouth. A fenestrated trach tube is often used as the final step before trach tube removal. It permits the patient to speak and cough on their own, providing an experimental trial for life after the trach tube.

A nurse is caring for a child with cystic fibrosis. The parents ask the nurse if any foods make it worse. Which diet should the nurse include when reinforcing dietary education?

A high-calorie, high-protein diet is recommended for a child with cystic fibrosis due to impaired intestinal absorption. Fat restriction isn't required because digestion and absorption of fat in the intestine are impaired. The child usually increases enzyme intake when high-fat foods are eaten. Low-sodium foods can lead to hyponatremia; therefore, high-salt foods are recommended, especially during hot weather or when the child has a fever.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as malignant melanoma. The nurse should expect which characteristic of this type of lesion to be documented in the client's record?

A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color.

A client has been admitted to the clinic with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?

A painless genital ulcer is a symptom of primary syphilis. Macules on the palms and soles after fever are indicative of secondary syphilis, as is patchy hair loss. Less commonly, syphilis may spread through direct unprotected close contact with an active lesion (kissing) or through an infected mother to her baby during pregnancy or childbirth (congenital syphilis).

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:

A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow.

A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about:

A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus.

A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager?

A weight loss of five pounds in 1 month. Clients with COPD need additional calorie intake because they are using up a lot of energy to breath.

A nurse is caring for a client who had a gastroscopy. What is a major concern associated with this surgery?

Abdominal distention: may be associated with pain, and indicate perforation, a complication that can lead to peritonitis.

Active Immunity

Active immunity results when exposure to a disease organism triggers the immune system to produce antibodies to that disease. Exposure to the disease organism can occur through infection with the actual disease (resulting in natural immunity), or introduction the form of the disease organism through vaccination (vaccine-induced immunity). Either way, if an immune person comes into contact with that disease in the future, their immune system will recognize it and immediately produce the antibodies needed to fight it. Active immunity is long-lasting, and sometimes life-long.

A client is admitted with a diagnosis of acute renal failure. The nurse monitors the client closely for which sign or symptom?

Acute renal failure is characterized by oliguria and rapid accumulation of nitrogen waste in the blood. Kidneys excrete medications, so the nurse should monitor the client closely for drug toxicity.

The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. What life style choices will help decrease the risk of developing osteoporosis?

Alcohol in moderation and smoking cessation, weight-bearing exercises at least 30 minutes a day, and a diet rich in calcium and vitamin D decrease the risk for osteoporosis.

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?

An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma.

A nurse is preparing to administer digoxin to a client with heart failure. When obtaining the client's vital signs, the nurse notes an apical pulse rate of 58 beats/min and the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings?

Anorexia and nausea are two of the symptoms associated with digoxin toxicity. The nurse should withhold the digoxin until the registered nurse has been consulted if the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin toxicity. The nurse then checks the most recent digoxin level, which will provide additional data to report to the registered nurse.

DIET for Ulcers:

Avoid spicy, acidic foods(tomato/citric juices/fruits), foods with caffeine, chocolate, soft drinks , fried foods, alcohol. Consume a low-fiber diet that is bland and eat to digest, eat white rice, bananas etc.

A client with renal insufficiency is admitted with a diagnosis of pneumonia, episodes of hypotension, and is receiving intravenous antibiotics. Which laboratory value should the nurse monitor?

BUN and creatinine levels are used to monitor renal function. Because the client is receiving IV antibiotics, which can be nephrotoxic, these tests would be used to closely monitor renal function. The client is also hypotensive, which is a prerenal cause of acute renal failure.

A client recovering from a spinal cord injury has a great deal of spasticity. What medication administered by the nurse may be used to control spasticity?

Baclofen is a skeletal muscle relaxant used to decrease spasms.

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience:

Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function. By removing fluids, hemodialysis decreases blood pressure.

A client with a positive skin test for tuberculosis isn't showing signs of active disease. Still, the client is worried and asks the nurse what can be done to help prevent the development of active TB. Which therapy would be best for this client?

Because of the increasing incidence of resistant strains of TB, the disease must be treated for up to 24 months in some cases, but treatment typically lasts from 9 to 12 months. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are added to the regimen to obtain the best results.

A nurse is providing postoperative care for a client one hour after the client had an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication?

Because the adrenal glands play an part in stress responses and BP regulation, close monitoring of BP is necessary. Postadrenalectomy patients require close monitoring of electrolytes, especially potassium. Due to the small laparoscopic incisions, patients are prescribed pain medications prn. Patients are encouraged to ambulate shortly following surgery.

A client with COPD is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

COPD patients depend on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions.

Which statement made by a client with a chlamydial infection indicates understanding of the potential complications?

Chlamydia is a common cause of pelvic inflammatory disease and infertility. It does not affect the kidneys or cause birth defects. It can cause conjunctivitis and respiratory infection in neonates exposed to infected cervicovaginal secretions during birth.

The nurse is reinforcing education with a parent of a preschool-age child with nephrosis who will be discharged on prednisone. Which statement by the parent indicates that the teaching has been effective?

Clients taking a systemic corticosteroid for longer than 2 weeks should wait at least 3 months before receiving a live-virus vaccine. Corticosteroids suppress the immune response, should not be discontinued abruptly due to the risk of acute adrenocortical crisis. Weight gain may occur do to an increase in appetite.

A client who has been on long-term steroid therapy now has drug-induced Cushing's syndrome. The client is residing in an extended-care facility because of multiple chronic health problems. The nurse identifies which condition as closely related to chronic use of steroids?

Clients taking steroids on a long-term basis lose subcutaneous fat under their skin and are vulnerable to skin breakdown and easy bruising. Clients taking steroids long-term are likely to have hyperglycemia. Typically, these clients experience weight gain in the abdomen and thinning of the extremities while on steroids. They should be monitored for weight gain and edema.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Complications of respiratory acidosis include shock and cardiac arrest.

A nurse is assigned to care for a client with a chest tube and observes that there's constant bubbling in the water seal chamber of the closed drainage system. Which explanation best describes this observation?

Constant bubbling in the water seal chamber indicates that there's a leak or loose connection between the client and the water seal chamber.

A nurse monitors the chest tube drainage system of a client who has undergone surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, the nurse would first check which item?

Continuous bubbling in the water seal chamber indicates that air is leaking into the drainage system or pleural cavity. Locate the source of the air leak by checking all of the chest tube connection sites. If a break in the tubing or a loose connection is found, tighten the connection or seals the break with tape.

A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?

Deficient fluid volume occurs as a result of diarrhea associated with gastroenteritis.

A client diagnosed with viral influenza is prescribed vitamin C 1000 mg PO daily and acetaminophen 650 mg PO every 4 hours PRN. The client complains to the practical nurse of abdominal cramping and increasing episodes of diarrhea. Which prescription change should the nurse anticipate?

Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C.

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect?

Dry skin is a sign of dehydration in response to polyuria associated with the osmotic effect of an elevated serum glucose level. Abdominal pain is associated with diabetic ketoacidosis. In the absence of insulin, glucose cannot enter the cell or be converted to glycogen, so it remains in the blood. Breakdown of fats as an energy source causes an accumulation of ketones, which results in acidosis.

A client with benign prostatic hyperplasia (BPH) does not respond to medical treatment and is admitted to the facility for surgical intervention, transurethral resection of the prostate (TURP). In the postoperative period, the nurse reviews the laboratory values for which potential electrolyte imbalance?

Due to the large amount of bladder irrigation, the fluid may be retained by the tissues, causing fluid overload, hypertension, and hyponatremia. The LAB values are also observed for high WBC.

Dumping Syndrome:

Dumping syndrome is a condition that can develop after stomach surgery or bypass to lose weight. Also called rapid gastric emptying, dumping syndrome occurs when food move from the stomach into the small bowel too quick. Signs and symptoms include: abdominal cramping and diarrhea, 10 to 30 minutes after eating.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?

During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Controlling pain isn't important because ARF rarely causes pain.

A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which observation indicates that the UAP assigned to the client needs further instruction and guidance?

Elastic cuffs can contribute to the development of lymphedema and should be avoided. Simple exercises such as squeezing a ball help promote circulation and should be started as soon as possible after surgery. Elevation of the affected arm promotes venous and lymphatic return from the extremity. Blood pressure measurements in the affected arm should be avoided.

Administration of which childhood vaccination assists in decreasing a child's incidence of developing epiglottitis?

Epiglottitis is caused by the bacterial agent H. influenzae. The American Academy of Pediatrics recommends that, beginning at age 2 months, children receive the Hib conjugate vaccine. A decline in the incidence of epiglottitis has been seen as a result of this vaccination.

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify?

Excessive hairiness, especially a male pattern of hair distribution on a woman (hirsutism), occurs with Cushing syndrome because of an androgen excess. Cushing syndrome results from excess adrenocortical activity. Hypercortisolism causes fat redistribution, resulting in "buffalo hump"; it also contributes to slow wound healing, hirsutism, weight gain, hypertension, acne, thin arms and legs, and behavioral changes.

The nurse is caring for a client with chronic renal failure (CRF). The client reports severe fatigue and appears pale. What complication does the nurse suspect has developed?

Fatigue and pallor are indications of anemia, and anemia occurs in CRF due to decreased production of erythropoietin by the failing kidneys. Test results that show a BUN level of 100 mg/dL and serum creatinine level of 6.5 mg/dL are abnormally elevated, reflecting CRF, which is the client's primary diagnosis. Anasarca can occur in clients with CRF, but it presents as generalized swelling.

The home health practical nurse is visiting with a client who has a history of second degree heart block and pacemaker placement six months ago. Which symptom compliant by the client would be indicative of pacemaker failure?

Feelings of dizziness a result of a decreased heart rate, leading to decreased cardiac output.

A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse see first?

First assess the client who was admitted during the night because of congestive heart failure. This client's problem is directly related to airway, breathing, and circulation, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who has been fitted with a closed chest tube drainage system. This client's problem also involves airway; however, there is no indication that this client is experiencing any acute problems.

Liquids measurements

Fluids recorded in cups, liters, or ounces need to be converted to milliliters. 1 cup = 240 mL 1 ounce = 30 mL

A licensed practical nurse reinforces dietary instructions to the mother of a child with iron-deficiency anemia. The nurse should tell the mother that which food is highest in iron?

Foods high in iron include liver, beans, baked beans, iron-fortified cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables.

A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which disorder?

GER is regurgitation of gastric contents back into the esophagus. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.

Complications of Peptic Ulcer Disease:

GI bleeding, formation of holes in the stomach at the site of ulceration which is perforation and this can cause peritonitis, bowel blockage in the pylorus due to chronic ulceration from a duodenal ulcer, and increases the risk of GI cancer.

Complications of peptic ulcer disease or surgery:

GI bleeding: pale skin, mucous membranes, increased HR and decreased BP, bloating or mass in abdomen, dark/tarry stool, vomiting blood that is red or coffee ground....collecting occult blood in stool. Perforation/Peritonitis: severe abdominal pain with bloating, vomiting, fever, increase HR and respirations. Obstruction in pylorus: due to scarring.

A client is admitted to the hospital with a diagnosis of peptic ulcer. The nurse should assess the client for which complication commonly associated with the diagnosis?

Hemorrhage because of erosion of blood vessel walls is the most common complication of peptic ulcer disease.

The practical nurse is assessing a client's 2 days status/posthip replacement surgery. In assessing the client's vital signs, which finding requires the most immediate action by the PN?

Hyperthermia, an elevated body temperature, requires the most immediate action to determine the cause of the fever and contact the health care provider.

Amniocentesis Preop:

If the amniocentesis is done before week 20 of pregnancy, the bladder should be full during the procedure to support the uterus. After 20 weeks of pregnancy, the bladder should be empty during amniocentesis to minimize the chance of puncture. Patient must lie still while the needle is inserted and the amniotic fluid is withdrawn. A stinging sensation is felt when the needle enters skin, and cramping when the needle enters the uterus.

The nurse is preparing the room for a client diagnosed with varicella. Which sign would the nurse place on the room door?

In addition to contact precautions, the nurse would place the client diagnosed with varicella in airborne precautions.

A nurse is caring for a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, what is the priority nursing action?

In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort.

Signs and Symptoms of Peptic Ulcer Disease:

Indigestion and Epigastric pain....described as burning, dull, or gnawing pain.

In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication?

Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, and an increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children.

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action?

Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive for glucose. The presence of CSF indicates a disruption in the integrity of the cranium.

Meningitis

Meningitis is an inflammation of the membranes (meninges) surrounding the brain and spinal cord. The swelling from meningitis can trigger an headache, fever and a stiff neck. Meningitis is mostly cause by a viral infection, but bacterial, parasitic and fungal infections are other causes. Bacterial meningitis is serious, and can be fatal within days without prompt antibiotic treatment.

A client diagnosed with diabetes complains to the practical nurse of decreased tactile sensation in their feet and feelings like their feet are on fire sometimes. Which abnormal laboratory finding should the practical nurse (PN) identify that indicates that a client with diabetes needs further evaluation for diabetic nephropathy?

Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Microalbumin tests are recommended for people with an increased risk of kidney disease, such as those with type 1 diabetes, type 2 diabetes or high blood pressure. The doctor recommend a urine microalbumin test to detect early signs of kidney damage.

Which serum laboratory value should the PN monitor carefully for a client who has a nasogastric tube to suction for the past week?

Monitoring serum sodium levels for hyponatremia is during prolonged NG suctioning.

A client has a serum potassium level of 3 mEq/L. Which findings should the practical nurse report to the charge nurse?

Normal potassium level ranges: 3.5 to 5 mEq/L. Signs and symptoms of low potassium: muscle cramps and dysrhythmias.

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml at 8 a.m. 60 ml at 9 a.m. Based on these amounts, what should the nurse do?

Normal urine output for an adult is approximately 1,500 ml/24 hours, which averages to about 60 ml/hour. Therefore, this client's output is normal. The nurse should report urine output less than 30 ml/hour.

A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptom would prompt the nurse to notify the registered nurse immediately?

One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal.

Passive Immunity

Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn baby acquires passive immunity from its mother through the placenta. A person can also get passive immunity through antibody-containing blood products such as immune globulin, which may be given when immediate protection from a specific disease is needed. This is the major advantage to passive immunity; protection is immediate, whereas active immunity takes time (usually several weeks) to develop. However, passive immunity lasts only for a few weeks or months. Only active immunity is long-lasting.

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?

Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Initiating oxygen therapy may be done, but positioning should be done first because it will have an immediate effect.

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial data collection findings, the nurse realizes the client's risk for injury is related to:

Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This causes bone demineralization and result in pathologic fractures and a risk for injury.

Which of the following laboratory values supports a diagnosis of pyelonephritis?

Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count will be high.

A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that she:

Reorganizing a kitchen cabinet or painting a picture in a quiet environment are suitable outlets for this client's excess energy. By transferring inappropriate aggressive drives into a constructive activity, these activities help the client control manic behavior.

Which of the following is an appropriate nursing diagnosis for a client with renal calculi?

Retention of urine and infection can occur with renal calculi from urine stasis caused by obstruction.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

Rule of nines: head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%

Adrenal Crisis requires immediate treatment to maintain essential metabolic functions. Follow the "5 S's" for management:

Salt replacement Sugar (dextrose) replacement Steroid replacement Support of physiologic functions. Search for and treat any identified cause. Replace extracellular fluid volume with 5% dextrose and 0.9% sodium chloride solution as prescribed. Monitor for electrolyte abnormalities; hyperkalemia is often present and may be treated with I.V. insulin and glucose to shift potassium into the cells. Administer I.V. hydrocortisone or dexamethasone, followed by continued use of hydrocortisone for long-term treatment, as prescribed.

Which educational materials should the practical nurse select for reinforcement of teaching for secondary prevention?

Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.

A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which intervention should the nurse plan to implement immediately?

Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist HEAT to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain. The client may have calf measurements prescribed once per shift or once per day, but not hourly. Range-of-motion exercises of the leg would be dangerous to the client because activity after clot formation can cause pulmonary embolus.

A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the practical nurse (PN)?

Steroids cause immunosuppression, and purulent sputum is an indication of infection.

A hospitalized client is receiving continuous nasogastric tube feedings at 90 mL/hour via a small-bore tube and an enteral infusion pump. Upon entering the client's room, which action should the practical nurse (PN) take first?

The 30° degree elevation of the head of the bed for a client receiving continuous tube feedings to prevent aspiration.

A client status post-48 hours femoral rod placement surgery, suddenly complains of chest pain and becomes short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses their vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate, and 36 breaths/min respiratory rate. What nursing action should the PN to do next?

The PN should immediately provide oxygen while performing further assessment. Pulmonary embolism and pneumothorax are risks associated with major surgery.

A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which nursing action would be appropriate for the nurse to perform first?

The affected child should immediately be placed in respiratory isolation

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?

The client needs to be in isolation for 2 weeks, not 6, while receiving antitubercular drug therapy. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He will be positive when tested, and if he's sick or under some stress he could have a relapse of the disease.

A client who returned from a cystoscopic examination complains of pain while attempting to void. Which intervention should a nurse suggest to ease the client's pain while attempting to void?

The client should sit in a warm sitz bath when trying to void. Warm water relieves pain and increases circulation to the perineal area and relaxes the muscles, which helps ease the pain and start the voiding process.

Primary syphilis:

The first sign of syphilis is a small sore, called a chancre (SHANG-kur). The sore appears at the spot where the bacteria entered the body. While most people infected with syphilis develop only one chancre, some people develop several of them. Many people who have syphilis don't notice the chancre because it's usually painless, and it may be hidden within the vagina or rectum. The chancre will heal on its own within three to six weeks.

Before performing a fecal occult blood test or guaiac test on a stool specimen, the PN should ask the client about the regular use of which vitamin?

The guaiac test measures microscopic amounts of blood in feces. A false-positive result can occur from the regular use of vitamin C.

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should the nurse include in a bladder retraining program?

The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding.

A client is determined to require tracheal suctioning. Which action is correct for the nurse performing this procedure?

The length of time a client should be able to tolerate the suction procedure is 10 to 15 seconds. Preoxygenation will help prevent hypoxia. Suctioning during insertion can cause trauma to the mucosa and removes oxygen from the respiratory tract. Suctioning, with supplemental oxygen between suctions, is performed in a minimum of 1-minute intervals in order to allow the client to rest.

A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 35 mg/dL. Which is the nurse's first action?

The normal blood glucose level in a newborn is 40 mg/dL or higher. Glucose levels of less than 40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory.

A client with gastroenteritis is admitted to an acute care facility with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse will continue with which action?

The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. Norovirus infection can cause the sudden onset of severe vomiting and diarrhea. The virus is highly contagious and commonly spread through food or water that is contaminated during preparation or contaminated surfaces. You can also be infected through close contact with an infected person. Diarrhea, abdominal pain and vomiting typically begin 12 to 48 hours after exposure. The infection occurs most frequently in closed and crowded environments such as hospitals, nursing homes, child care centers, schools and cruise ships.

A nurse is assigned to care for a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first take which action?

The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions for the client who has attempted suicide. The client would be asked to sign a no-harm contract.

During a client's routine physical examination, a chest x-ray film reveals a lesion in the right upper lobe. What information in the client's history supports the health care provider's diagnosis of pulmonary tuberculosis?

Tuberculosis is an infectious disease in which recurrent fevers are present, usually in the late afternoon. Profuse diaphoresis at night (night sweats) is a classical sign. Blood-tinged sputum (hemoptysis) results from pathophysiological trauma to mucous membranes. The cough is productive, because the inflammatory process causes purulent mucus.

Which of the following clinical findings would the nurse look for in a client with chronic renal failure?

Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are manifestations of chronic renal failure.

The nurse is collecting data on a child with acute glomerulonephritis. Which finding would be of immediate concern to the nurse?

Visual disturbances can be an indication of rising blood pressure and should be investigated. Presence of albumin in the urine, red blood cells (causing the cola-colored urine), and peripheral edema are common symptoms in acute glomerulonephritis.

The nurse provides a dietary list to a client who is taking oral anticoagulants with foods that should be avoided because they are high in vitamin K. What foods should be included on the list?

Vitamin K decreases clotting time. Egg yolks are high in vitamin K. Liver, an organ meat, is high in vitamin K and all organ meats. Cheese, all dairy products are high in vitamin K. Squash is low in vitamin K and is not limited in the diet of clients who are taking anticoagulants. Chicken contains about half the vitamin K that green, leafy vegetables contain and is permitted in the diet.

Which I.M. injection site might the nurse use for a 2-year-old child?

When administering an I.M. injection to a 2-year-old child, the nurse might select the ventrogluteal muscle if the muscle is well developed. However, the preferred site is the vastus lateralis. The pectoral, femoral, and deltoid muscles aren't appropriate injection sites for a child.

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process?

When the chest tube is removed, the client is asked to perform Valsalva's maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

Conditions that causes High Urine Osmolality:

dehydration congestive heart failure high glucose acute kidney injury

Conditions that causes Low Urine Osmolality:

excessive fluid intake, or over-hydration kidney failure renal tubular necrosis