HESI-RN Comprehensive Exam A

A staff nurse is reviewing the charting of a new graduate. Which notation concerns the nurse and will need to review with the new graduate? A. Morphine 5.0 mg IM at 0800 B. 1200 mL water po between 0800 and 1600. C. Sat in the chair for 2 hours, between 0900 and 1100. D. Consumed two eggs, one slice of toast and 120 mL of juice for breakfast.

A Rationale: Morphine 5.0 contains a trailing zero and is on the Do Not Use list from the Joint Commission. 5.0 can be confused with 50. The remaining options use correct abbreviations of po, mL and military time.

The charge nurse is making assignments for the day. On the unit are 2 RNs, 1 LPN/LVN and 2 UAPs. Which client will the charge nurse assign to the LPN/LVN? A. Newly admitted client with respiratory distress B. Post-op day 2 after an open appendectomy C. Transfer from the ICU 2 hours ago after a valve replacement D. Transfer from the ER with severe pelvic pain and hyperemesis

B Rationale: The post-op client is the most stable client. The remaining clients need the assessment skills of the RNs on the unit.

The nurse is working on an inpatient mental health unit and is providing care to a client newly admitted with a major depressive disorder. Which assessments place the nurse on alert that the client is considering suicide? (Select all that apply.)A. Reports feelings of sadness B. Mood changes from depressed to happy C. Begins giving away possessions D. Becomes compliant with medication regimen E. Independently joins a support group

B, C Rationale: Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide. Feelings of sadness are signs of depression but not impending suicide. Options D and E are not typically indicative of impending suicide.

A client was admitted to the hospital for IV antibiotic therapy for severe cellulitis of the left eye. Two days after the client was admitted she reports vaginal itching. What are the nurse's best actions? (Select all that apply.) A. Have the client drink 2500 mL of milk daily. B. Notify the health care provider. C. Inform the client this may be a secondary vaginal infection from the antibiotics. D. Ask the client if she likes yogurt. E. Ask the client if she has ever taken Flagyl or metronidazole for a vaginal infection. F. Ask the client if she like cranberry juice.

B, C, D, E Rationale: A vaginal yeast infection is not uncommon for women receiving antibiotics for a bacterial infection. The health care provider may consider treating the vaginal infection. Informing the client that a vaginal infection may occur with antibiotic treatment will help her understand the cause for the infection. Ingesting yogurt helps restore healthy bacteria in the vagina. Assessing for previous treatments helps with establishing a baseline for the client. Drinking that much milk a day will not assist treating a vaginal infection. Cranberry juice is used for urinary tract infections.

At which point should the nurse encourage a laboring client to begin pushing? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable

C Rationale: Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson reflex).

A 5-year-old is in Bryant's traction for intervention for a fractured femur. Which finding would require a nursing action? A. The parents are at the bedside reading a book with the child. B. The child's hips are in 90-degree flexion. C. The child's hips are gently resting on the bed. D. The child is consuming 120 mL of grape juice.

C Rationale: The In Bryant's traction, the buttocks should be elevated off the bed not resting on the mattress. Drinking grape juice with a volume of 120 mL is acceptable and the family should be incorporated into the child's plan of care.

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?"

D Rationale:Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member. Options A and C are not related to glaucoma. Glaucoma rarely causes pain, which is why screening is so important.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A. A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B. A client who is receiving continuous ambulatory peritoneal dialysis C. A client with continuous bladder irrigation for hematuria D. A client with renal calculi whose urine needs to be strained

D Rationale:The client with renal calculi (kidney stones) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. Options A, B, and C require careful assessment from an experienced nurse because of the potential for significant complications.

When the nurse manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse manager implement? A. Speak privately with the nurse. B. Hold a staff meeting to discuss this issue. C. Review the nurse's current salary. D. Nominate the nurse for employee of the month.

A Rationale: The nurse manager should speak privately with the nurse to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. Option B might become confrontational. Option C is irrelevant. Option D is not warranted.

An elderly client with a swallowing disorder is complaining of being thirsty and is requesting ice water. The nurse is preparing the client for discharge to home on hospice care. What is the nurse's best action for this client? A. Tell the client, "Unfortunately, I cannot give you any water, or you will choke." B. Provide the client with a washcloth dipped in ice water and apply to the lips and tongue. C. Give the client 30 mL of ice water, but do it with the curtain and the door closed. D. Tell the spouse that it is okay to give the client ice water since hospice is now involved.

B Rationale:The washcloth dipped in ice will help moisten the lips and tongue without causing the client to aspirate water. Water may cause the client to choke, but telling the client that without action does not address the client's needs. The remaining options could induce choking in the client, whether on hospice or not. There is no indication of the client's longevity, and hospice is called with a terminal illness with generally less than 6 months to live.

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly.

B STUDY MODE: Comprehensive Exam A Question 51 of 125 ID: 1_54 HomeCalculatorHelpBackNext A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? Rationale:When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples when let-down occurs. Options A, C, and D provide inaccurate information.

A 95-year-old client with full mental capacity is admitted to the hospital with hemoglobin of 6 g/dL and melena. The health care provider orders a capsule endoscopy. The client refuses the treatment to evacuate the bowel. What is the nurse's best action? A. Inform the client of the risks of refusal. B. Tell the client this treatment is mandatory. C. Ask the client's family to convince the client to take the treatment. D. Call the health care provider to come and talk to the client.

A Rationale: A client with capacity who at the age of consent has the right to refuse treatment. The nurse's first responsibility is to make sure the client is aware of the ramifications of the decision and to support the client's choice. The remaining options do support the client's right to refuse treatment.

To decrease the incidence of urinary tract infections, the hospital mandated that no nursing students may insert a urinary catheter. What is the next step for the nursing management staff? A. Assess for any changes in the rate of infection in 6 months. B. Tell the area nursing school program director to take catheter placement out of the curriculum. C. Work with the obstetricians to remove the standing order for an indwelling catheter with epidural placement. D. Tell the nursing staff that students may not be present when a urinary catheter is placed.

A Rationale: Assessment is necessary to determine if the nursing students are the root cause of the rate of infection. The nursing curriculum is not hospital dependent. Placing multiple variables in the assessment will not help determine the root cause. Students can learn from observation.

The nurse is providing care to a post-operative client with an indwelling Foley catheter. The client reports to the nurse the sensation of bladder fullness. What is the nurse's priority action? A. Check the tubing for kinks. B. Assure the client that feeling is expected. C. Check the color of the urine for infection. D. Assess the urinary meatus for redness.

A Rationale: Bladder fullness could indicate the drainage tube is not functioning as it is intended. Check to make sure the tube is draining. Burning, pain, and itching would be signs of infection. The client may experience a feeling of fullness with catheter placement, but assure the tubing is functioning first.

The nurse is providing care to a client newly diagnosed with asthma. Which client finding indicates that the bronchodilator treatments are effective? A. An O2 saturation reading of 98% B. Urinary output of 250 mL in 4 hours C. Apical pulse rate is 84 beats/min. D. Blood pressure reading of 102/62 mm Hg

A Rationale: Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator.

The nurse is providing care to an 86-year-old admitted with generalized weakness. Dietary modifications and levothyroxine are prescribed. Which physiologic finding in an older adult could precipitate an adverse reaction to the medication? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

A Rationale: During the aging process, reduced renal function is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not option C, predisposes an older adult to an increase in adverse drug reactions. Option B may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders is not increased, nor does it affect drug pharmacotherapeutics

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A. Failure to collect all urine specimens during the period of the study will invalidate the test. B. Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C. Dialysis is started when the GFR is lower than 5 mL/min. D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

A Rationale: Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results will be inaccurate. As renal function decreases, the creatinine level will decrease in the urine. Dialysis is usually started when the GFR is 12 mL/min. There is no need to record the frequency and amount of each voiding during the time span of urine collection.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited.

A Rationale: HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Nystatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated.

After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.

A Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.

The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours

A Rationale: Nifedipine is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose.

Which assessment finding for a client with peritoneal dialysis requires an immediate action by the nurse? A. The color of the dialysate outflow is opaque yellow. B. The dialysate outflow is greater than the inflow. C. The inflow dialysate feels warm to the touch. D. The inflow dialysate contains potassium chloride.

A Rationale: Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia.

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy

A Rationale: Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse.

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa? A. "Has your child been swimming recently?" B. "Has you child had a recent sore throat?" C. "Does your child drink from a sippy cup?" D. "Is anyone else in the home ill?"

A Rationale: Otitis externa is an external ear infection and often due to swimming and the retention of fluid in the ear. Options B and C are not relative to otitis. Otitis externa is not contagious, so option D is not relevant.

Staff on a cardiac unit consists of an RN, two practical/vocational nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day post angioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A. Team 1: RN team leader, PN; team 2: PN/VN team leader, UAP B. Team 1: RN team leader, UAP; team 2: PN/VN team leader, PN C. Team 1: PN/VN team leader, PN; team 2: RN team leader, UAP D. Team 1: PN/VN team leader, UAP; team 2: RN team leader, PN

A Rationale: Team 1 includes high-risk clients who require a higher level of assessment and decision-making, which should be provided by an RN and PN. Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. Options B, C, and D do not use the expertise of the nursing staff for the high-risk clients.

40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. What is the priority nursing action for this client? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history. D. Assess the fetal heart rate.

A Rationale: The blood pressure should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and who have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. Options B, C, and D can be done if the blood pressure is normal.

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. Which client will the charge nurse select for transfer? A. A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci

A Rationale: The client with colonized MRSA is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy, which makes recovery very difficult. Positive blood cultures indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer at high risk for poor healing and bone infection.

A client tells the nurse that he is suffering from insomnia. What priority question will the nurse include in the client's intake interview? A. "Before your insomnia, what is your usual bedtime, and when do you generally wake up?" B. "I see you listed you are a smoker. Generally, how many cigarettes do you smoke a day?" C. "Do you often take in any fluids after 6:00 pm? If so, about how many glasses?" D. "About how many servings of coffee, tea, or other caffeinated beverages do you drink each day?"

A Rationale: The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained.

Prior to administering an oral suspension, what is the most important nursing action? A. Assess the client's ability to swallow liquids. B. Obtain applesauce in which to mix the medication. C. Determine the client's food likes and dislikes. D. Auscultate the client's breath sounds.

A Rationale:An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used. If a food product is used to thicken the liquid, option C would be beneficial. Option D may also be warranted, but only if the client is at risk for aspiration, determined by option A.

Allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my arthritis pain in my knees." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." D. "I observe my skin daily to see if I have an allergic rash to the medication."

A Rationale:The client should be taught to avoid aspirin because the ingestion of aspirin or diuretics can precipitate an attack of gout. Options B, C, and D are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation. Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate. Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs.

The nurse walks into the hospital room and observes a child is having a generalized tonic-clonic seizure. Which action should the nurse take first? A. Move objects out of the child's immediate area. B. Quickly slip soft restraints on the child's wrists. C. Insert a padded tongue blade between the teeth. D. Place in the recovery position before going for help.

A Rationale:The first priority during a seizure is to provide a safe environment, so the nurse should clear the area to reduce the risk of trauma. The child should not be restrained because this may cause more trauma. Objects should not be placed in the child's mouth because it may pose a choking hazard. Although option D should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. What is the priority nursing action? A. Examine for clamp closures. B. Irrigate with a larger syringe. C. Assess for signs of infection. D. Flush the line with heparin.

A Rationale:Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps first. Irrigation with a larger syringe will not alleviate the cause for the resistance and can rupture the line. A central line infection should not cause resistance while flushing the line. The CVC should be flushed with normal saline or a diluted solution of heparin (10 to 100 U/mL) after option A is completed, if necessary.

A client with arterial peripheral vascular disease (PVD) complains of pain in the feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A. Help the client dangle legs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times a day.

A Rationale: The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling, which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. Option B is indicated for venous insufficiency and indicated for bed rest. Ambulation is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

A client with chronic back pain reports to the clinic nurse that the primary income provider is no longer working and the family is without medical insurance. What low-cost therapies for pain will the nurse include in the client's plan of care? (Select all that apply.) A. Meditation B. Music therapy C. Imagery D. Physical therapy E. Decreasing hydromorphone frequency

A, B, C Rationale: Meditation, music therapy, and imagery are alternative, no/low cost, therapies that can be taught and implemented to reduce pain. Physical therapy can be cost prohibitive as is the prescription medication.

The client is prescribed propranolol 60 mg twice a day. What teaching will the nurse include in the client's plan of care related to this medication? (Select all that apply.) A. Change positions slowly. B. Take your heart rate before ingesting the medication. C. You may experience feelings of weakness with this medication. D. Avoid eating grapefruit. E. Use sunscreen when outside.

A, B, C Rationale: This medication can slow the heart rate. Changing positions slowly is necessary to avoid the risk for falling. This medication should not be given if the heart rate is less than 60 beats/minute. Weakness and tiredness are common side effects of this medication. There are no dietary restrictions with this medication. Use of sunscreen while outdoors is not limited to those on this medication; it is a common recommendation.

The nurse is preparing a client for surgical stabilization of fractured lumbar vertebrae. Which nursing actions best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A. Hourly urine output monitoring B. Palpation of a distended bladder C. Changing an incontinence pad every 2 to 3 hours D. Intraoperative bladder decompression E. Urine sample for culture

A, B, D Rationale:Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E), are not indicated based on the client's description.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which actions will the nurse provide after the procedure? (Select all that apply.) A. Monitor maternal vital signs for hemorrhage. B. Instruct the woman to report any contractions. C. Ensure that the woman has a full bladder prior to beginning. D. Monitor fetal heart rate for 1 hour after the procedure. E. Place the client in a side-lying position.

A, B, D Rationale:These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

The hospice nurse is reviewing end-of-life care with a couple who have been married for 61 years and report to be of the Orthodox Jewish faith. Which statements by the terminal client would the anticipate? (Select all that apply.) A. "I want to pass at home." B. "I have made arrangements to be cremated." C. "The Rabbi will visit every other day." D. "Our children will come home for a week after I pass." E. "We will need to cook ahead for all of the visitors from temple."

A, C, D Rationale: Death and mourning practices of the Jewish faith include having a peaceful passing, spiritual support, and an observation of a week-long period of mourning. Cremation is generally considered against Jewish law. For the week-long period of mourning, mourners provide food for the family.

The nurse performs an assessment on a client with heart failure. Which findings are consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins

A, C, D Rationale: Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure.

At 0800 the nurse placed a 1 inch/2.54 cm of 2% nitroglycerin paste to a client's right thigh. The nurse placed the time, date and initials on the patch when it was applied. An hour later the client was complaining of a sudden onset of dizziness; the blood pressure was 90/50 mm Hg. Upon further assessment, a nitroglycerine patch was noted on the client's back with the same date, and the time was 0830. What are the nurse's next actions? (Select all that apply.) A. Take the clients vital signs every 15 minutes. B. Find out who applied the second dose of ointment. C. Have the client stay in bed. D. Complete an occurrence/incident report. E. Notify the health care provider. F. Chart, occurrence report complete.

A, C, D, E Rationale: The nurse's priority is the safety of the client who is going to require frequent vital signs. The client's blood pressure is low and is at risk for falling. Notify the health care provider of the event for any alternative prescriptions that may be necessary. Complete the occurrence report to document the objective findings. Do not place in the client's chart "occurrence report completed." Only chart the findings and the client's physiologic responses to the treatments. The manager will complete the investigation.

An 84-year-old client is scheduled for transfer from the hospital to skilled care to rehabilitate after a hip repair. What disciplines will the nurse coordinate in the sending and receiving of this client? (Select all that apply.) A. Medical care B. Palliative care C. Nursing care D. Physical therapy E. Social work F. Respiratory therapy

A, C, D, E Rationale:Multiple disciplines need to be involved to rehabilitate this client. There is no mention of any level of cognitive decline, so it cannot be assumed in the elderly. Medical, nursing care and social work, as well as physical therapy are all needed. Medicine to prescribe the care needed. Nursing to implement and coordinate care. Physical therapy for strengthening. Social work to work with the rehabilitation facility and medicare. There is no indication that palliative care, or care for life-limiting diseases. There is no mention of respiratory compromise, so respiratory care is not indicated.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which actions should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A. Shave the area where the TENS will be placed. B. Obtain small needles for insertion. C. Place the TENS unit directly over or near the site of pain. D. Explain to the client that drowsiness may occur immediately after using TENS. E. Describe the use of TENS for postoperative procedures.

A, C, E Rationale: The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

Two nurses are participating in hand off report. Which statements are best for the off-going nurse to include in report? (Select all that apply.) A. "The client in 123A has been afebrile all night." B. "The client's blood pressure in 124A has been at baseline." C. "The client in 125A is on clear liquids and has taken in 1350 mL." D. "The client in 123B has slept all day." E. "The client in 124B had an output of 850 mL of clear, pale yellow urine." F. "The client in 125B is able to demonstrate insulin self-injection."

A, C, E, F Rationale: When participating in hand-off report make objective statements. The blood pressure at baseline does not indicate what the baseline is and assumes the on-coming nurse is aware of the baseline. Slept all day needs to include the number of hours slept. The remaining statements are objective.

Which actions should the nurse include in the plan of care for a client with bipolar disorder in the manic phase? (Select all that apply.) A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status.

A, D, E Rationale:A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli are therapeutic for the manic phase (C).

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A. Flex the hips and knees and align the knees with the client's knees for safety. B. Allow the client to sit on the side of the bed for a few minutes before transferring. C. Place the client's weight-bearing or strong leg forward and the weak foot back. D. Grasp the transfer belt at the client's sides to provide movement of the client.

B Rationale: A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt provides a secure hold to prevent sudden falls.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished.

B Rationale: A priority goal for the client with infectious diarrhea caused by C. difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission. Options A and C are goals dependent on the return of the client's normal bowel pattern.

The standard acceptable level of staffing for the unit is 4 RNs and 2 UAPs. For the fifth time in 2 weeks the staff mix is 3 RNs and 1 UAP. What is the on-coming nurse's best response? A. "I am sick and tired of being understaffed! Do other area hospitals have this problem?" B. "I wonder if the nurse manager is aware this is the 5th time this has happened in 2 weeks." C. "If this happens again, I am going to walk out and never return! I am afraid for my license." D. "They must think we are super heroes, again. Come on team, let's get it done."

B Rationale: Assessment of the situation comes first. The manager may not be aware of the frequency of the issue. The super heroes' statement is reassuring, but it does not address the issue. The remaining statements are reactionary. Conducting an assessment for understaffing will lead to steps towards resolution.

A client newly admitted to hospice care with end-stage bladder cancer is being discharged from the hospital to home with a list of medications. Which medication will the nurse need to confirm with the prescribing health care provider? A. Morphine sulfate oral solution 10 mg per 5 mL q 4 hours prn. B. Atorvastatin 20 mg po daily C. Acetaminophen 650 mg suppositories prn every 6 hours. D. Lorazepam oral solution 1 mg per 1 mL, 1 mL every 2 hours as needed.

B Rationale: Atorvastatin treats high cholesterol. In the terminal phases of life, this medication is no longer necessary. Morphine is for the pain associated with end-stage cancer. Acetaminophen is for the fever than can accompany the dying process. Lorazepam can treat the restlessness or anxiety often seen in dying clients.

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse manager to the client's room immediately.

B Rationale: Discussing the incident privately promotes open communication between the charge nurse and staff member. The client is free to share unwanted food with family or friends, but the employee should not ask for the client's food. Option C is not necessary, and the charge nurse can respond to this situation without implementing option D.

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A. Diabetes insipidus B. Hypotension C. Hyperkalemia D. Uremia

B Rationale: During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension. Option A is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not option C. Option D is characteristic of chronic renal failure with multiple body system involvement.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse manager to take? A. Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C. Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D. Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

B Rationale: Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling.

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?"

B Rationale: It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings. Option A is a leading response, and the client may not be feeling sad. Options C and D are closed-ended questions that do not facilitate communication.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A. Sexual intercourse with the spouse occurs four times a week. B. The spouse has never seen the client naked. C. The client has had surgery for permanent birth control. D. A history of a 20-lb weight loss occurred in the past year.

B Rationale: It is usual for spouses to see each other without clothing, so a follow-up question about option B should provide additional information about the client's self-concept and body image. Options A and C are choices within the continuum of normal and acceptable sexual needs based on each couple's preferences. Body image is a perception of one's physical self, and weight gain or loss normally affects one's self-image.

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications?

B Rationale: Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria, an expected finding. Metabolic acidosis is the potential complication, not alkalosis. During the diuretic phase of acute renal failure, there can be a normal output volume (≈2000 mL/day), which can result from IV fluid hydration.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A. Assess skeletal pins for infection. B. Assist the client with toileting. C. Establish thrombus prevention care. D. Evaluate pain management plan.

B Rationale: The PN can implement nursing care, such as option B. The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. Options A, C, and D are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A. Keep the residual limb elevated during positioning. B. Instruct the client to grasp the overhead trapeze bar. C. Maintain alignment with an abduction pillow. D. Use pillow support to prevent turning to a prone position.

B Rationale: The client will gain upper body strength and independence by using the overhead trapeze bar for positioning. Elevation of the residual limb is controversial because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. Option C is used for alignment following some hip surgeries. A prone position should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. What is the best nursing action based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes.

B Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse take first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication.

B Rationale:After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment.

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction? A. "I should balance my daily exercise with my dietary intake and insulin dosages." B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C. "I should inject my insulin into a different site to reduce the development of scar tissue." D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

B Rationale:Aspiration is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the absorption of the insulin. Options A and D are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight serum glucose level control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.

The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A. Tachypnea B. Guaiac-positive stool C. Multiple small abdominal bruises D. Dependent pitting edema

B Rationale:Dalteparin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding such as guaiac-positive stool while receiving an anticoagulant, the medication should be held and coagulation studies completed. Option A is not an indication to hold the medication unless accompanied by signs of bleeding. Option C is an expected result. Option D is related to fluid volume, rather than anticoagulant therapy.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. 1. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." 2. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." 3. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." 4. "Would you like to make a change in his pharmacologic regimen?" A. 3, 1, 4, 2 B. 2, 3, 1, 4 C. 1, 4, 2, 3 D. 2, 1, 3, 4

B Rationale:SBAR:S—Situation and includes introduction of the nurse and client/setting (option B).B—Background and includes the presenting complaint and relevant history (option C).A—Assessment and includes current vital signs and other information (option A).R—Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (option D).

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference

B Rationale:The Centers for Disease Control and Prevention indicates that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of options A, C, and D provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity.

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PN/VNs, and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PN/VNs to assist health care providers on rounds and perform glucometer checks.

B Rationale: A UAP can take vital signs and daily weights on stable clients. UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN. All team members can answer call lights, and PNs can administer some of the medications, so assigning the RN these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds, and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A. Pain scale B. Vital signs C. Breath sounds D. Level of consciousness

C Rationale: Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds. Options A, B, and D are important assessment data but are not specifically related to insertion of a central venous catheter.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing action is most important in reducing the client's stress associated with repeated hospitalizations? A. Allow the client to discuss the seriousness of the illness. B. Ensure that the client is provided with information about medications. C. Encourage as much independence in decision-making as possible. D. Include the client in planning the course of treatment.

C Rationale: Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand and participate in the hospitalized plan of care.

The nurse is preparing to administer a dose of digoxin. Which finding would indicate withholding the medication? A. Serum digoxin level is 1.5 ng/mL. B. Blood pressure is 104/68 mm Hg. C. Serum potassium level is 2.5 mEq/L. D. Apical pulse is 68/min.

C Rationale: Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL). Option A is within this range. Option B would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is <60/min.

Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. Which term will the nurse highlight on the infant's assessment tool? A. Cryptorchidism B. Priapism C. Hypospadias D. Epispadias

C Rationale: In hypospadias, there is a congenital defect of urethral meatus in males and the urethra opens on ventral side of penis behind the glans. Answers A, B, and D are consistent with other conditions.

A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. What is the most important nursing action for this client? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium. C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client

C Rationale: Long-term use of levofloxacin can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen. Impaction is unlikely, so option A is of less priority and may not be necessary. Option B is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort are important interventions but of less priority than determining the cause of the client's diarrhea.

Which nursing is most important when caring for a client with multiple myeloma? A. Inspection of the skin B. Breath sound auscultation C. Pain scale measurement D. Mobility limitations

C Rationale: Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority. Options A, B, and D are part of the complete assessment but do not have the priority of option C for this client.

The nurse is providing care to a client newly admitted with meningitis. Which symptom indicates to the nurse the client has developed nuchal rigidity? A. Hyperexcitability of reflexes B. Hyperextension of the head and back C. Inability to flex the chin to the chest D. Lateral facial paralysis

C Rationale: Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest. Although options A, B, and D may occur in meningitis, option A describes exaggerated spinal nerve reflex responses, option B describes opisthotonus, and option D may be related to cranial nerve pathology of the trigeminal nerve

Which assessment finding indicates to the nurse that the nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake.

C Rationale: Nystatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication.

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A. A client with an admitting diagnosis of menorrhagia who is now 24 hours' post-vaginal hysterectomy B. A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C. A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D. A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

C Rationale: Option C requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic, and careful assessment is essential. Options A, B, and D could all be cared for by a PN under the supervision of the RN.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse take first? A. Teach the client testicular self-examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones.

C Rationale: Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms. Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer. Although hematuria is associated with renal disease or calculi, the client's pain is associated with ejaculate, not urine.

The client rates pain at an 8 of 10 scale from muscle spasms and associated acute lumbosacral strain. What is the best nursing action for this client? A. Perform range-of-motion exercises on the lower extremities every 4 hours. B. Place a small firm pillow under the upper back to flex the lumbar spine gently. C. Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D. Position in reverse Trendelenburg with the feet firmly against the foot of the bed.

C Rationale: Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Range-of-motion exercises can result in paravertebral muscle spasms and increased pain. Bending the knees, rather than option B, reduces stress on the lower back. Option D places stress on the lower back and increases the client's pain.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A. Participating in telephone consultations with clients B. Identifying oneself by name and title to clients in telehealth communications C. Sending medical records to health care providers via the Internet D. Answering a client-initiated health question via electronic mail

C Rationale: Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred. Client confidentiality is protected by federal wiretapping laws making telephone consultation a private and protected form of communication. By stating one's name and credentials in telehealth communication, one is taking responsibility for the encounter. E-mail initiated by the client poses less risk than sending records via the Internet.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A. Obtain the remainder of the preoperative admission information. B. Check the vomiting client for signs of tube feeding aspiration. C. Position the client who has vomited on his side and obtain vital signs. D. Teach the preoperative client coughing and deep breathing exercises.

C Rationale: The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs. Options A and B involve assessment, which should be performed by a nurse. Option D involves initial client teaching, which should be performed by the nurse.

A client says angrily to the nurse, "Get out of my room! I do not like you or the care you are giving me." The nurse reports the client's refusal of care to the nurse manager. What is the nurse manager's best response? A. "What did YOU do to anger the client?" B. "I'm sure the client did not mean to say that." C. "How has the client been behaving before this?" D. "I'll get another nurse to care for this client."

C Rationale: The nurse manager must assess the baseline for this client before intervening. Asking about the client's behavior before refusing the nurse's care helps establish that baseline and does not place the nurse on the defensive. Do not offer false reassurance. Prior to reassigning the client, the manager must determine the root cause for the dismissal. It may have nothing to do with the nurse.

A nurse is assigned to a client with a newly placed colostomy. The nurse has never provided care to a client with a colostomy. What is the nurse's next action? A. Refuse the assignment. B. Accept the assignment and look up colostomy care on the Internet. C. State to the charge nurse, "I have never taken care of anyone with a colostomy." D. Ask another nurse to trade assignments.

C Rationale: The nurse must realize limitations, but can provide post-operative care. Letting the charge nurse know of the limitations allows the charge to reassign the client, or to maintain the client assignment and find the necessary assistance for the nurse. Refusing to take an assignment is uncooperative. Trading assignments does not involve the charge nurse who has the knowledge of the needs of the entire unit.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. 1. Gently insert the catheter without suction using sterile technique. 2. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). 3. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. 4. Apply suction intermittently while withdrawing the catheter. A. 2, 3, 1, 4 B. 1, 3, 4, 2 C. 3, 2, 1, 4 D. 2, 1, 4, 3

C Rationale:Equipment should be set up and adjusted prior to beginning the procedure. Hyperoxygenation using an MRB should be completed prior to inserting the catheter. After preoxygenation, the catheter can be inserted and suction can be applied intermittently.

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A. Parents of children with spina bifida B. High school girls in a health class C. Those interested in having children D. Postpartum women attending a baby care class

C Rationale:Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is option C. Parents with children who already have a neural tube defect such as spina bifida are not as invested in the content as option C. High school age students may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than option C. Option D may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.

A nurse manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse manager respond to this situation? A. Advocate for the rights of the staff to watch television once their assignments are complete. B. Confront the administrator about making a decision that will negatively affect the residents. C. Offer to develop an alternate solution so that the residents can continue to watch television. D. Remind the administrator that watching television helps the night shift staff remain awake.

C Rationale:The role of the nurse manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise. The staff do not have the right to watch television while being paid to work. Option B challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. Option D is not a sound rationale for the use of the television.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size.

C Rationale:With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation. Option A is not the primary reason for the changes in body structure. Option B is not indicated because loss of muscle tone and constipation are age-related changes. Option D dismisses the client's concerns and does not help her understand the changes that she is experiencing.

The nurse is preparing for discharge teaching for the client who had open abdominal surgery. The client is a 46-year-old, Hispanic male client; weight 220 pounds/100 kg; food preferences include beans, rice and fresh fruit; smokes ½ pack cigarettes daily; and large extended family. Which factors place the client at risk for wound evisceration? (Select all that apply.) A. Large extended family B. Dietary preferences C. Smoker D. Weight E. Abdominal surgery F. 46 years old

C, D, E Rationale: Risks for evisceration include abdominal surgery, poor wound healing secondary to smoking, and obesity. The family offers social support; the diet is balanced with protein, carbohydrates, vitamins and minerals; age is not a factor.

Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing actions are most likely to maintain client safety? (Select all that apply.) A. Direct the client to sign a liability release form. B. Restrict the client's ability to leave the unit. C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed. E. Provide the client with names of local support groups. F. Notify the health care provider of the client's intention.

C, D, F Rationale:To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat milk

D Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D. Option A is high in fat and sugar. Options B and C are high in fat and sodium.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler position without a pillow behind the head B. Semi-Fowler position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table

D Rationale: Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler position does not allow maximum expansion of the posterior lobes of the lungs. A semi-Fowler position restricts the expansion of the anterior-posterior diameter of the thoracic cage. Positioning a client on the right side with the head of the bed elevated does not facilitate lung expansion.

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today.

D Rationale: The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse take first? A. Ask the UAP to check for the advanced directive while the nurse completes the assessment. B. Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C. Check the medical record for the advanced directive and then complete the client assessment. D. Call for the charge nurse to check the advanced directive while continuing to assess the client.

D Rationale: Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated.

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. The nurse must plan on performing which task? A. Remove the client's nail polish and dentures. B. Assist the client to the restroom to void. C. Obtain the client's height and weight. D. Offer the client emotional support

D Rationale: By using therapeutic techniques to offer support, the nurse can determine any client concerns that need to be addressed. Options A, B, and C are all actions that can be performed by the UAP under the supervision of the nurse.

A young nurse on the night shift has called medical records to have her own mother's paper chart delivered to unit. What is the charge nurse's next response? A. "If you open that chart, I will have to report you to the manager." B. "I hope you are not going to review that chart." C. "Is your mother having surgery here tomorrow?" D. "What are your plans with your mother's chart?"

D Rationale: Family members have the same right to confidentiality as all other client's receiving care. Asking for the nurse's plans helps identify the need for the chart. If the nurse plans on reviewing the chart, this is a teachable moment for the charge nurse to review client confidentiality. Having surgery is secondary to the concern for confidentiality.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department.

D Rationale: Past medical records must be "secured" and "reasonably protected" from inadvertent viewing. A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without his or her diagnosis or treatment) is not considered confidential or PHI. Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous, but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions.

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A. Reduced peripheral edema B. Urinary output of at least 70 mL/hr C. Decrease in urine osmolarity D. Serum sodium level of 137 mEq/L

D Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema, but the higher priority outcome is the effect on serum electrolyte levels. Although options B and C are findings associated with resolving SIADH, they do not have the priority of option D.

A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical-surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines.

D Rationale: The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical.

The nurse is providing care to a client with head trauma with the most recent intracranial pressure reading of 22 mm Hg. The health care provider has prescribed morphine for pain control. What is the best rationale for the nurse to question this prescription? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP.

D Rationale: The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP.

A client has been on a mechanical ventilator for several days. What assessment data should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations

D Rationale: The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. What is the best nursing action for this client? A. Request a prescription for a bed board to provide increased back support. B. Reposition the client so that both feet are supported by the bed board. C. Move the trapeze bar to allow the client to pull with the upper extremities. D. Place trochanter rolls on the lateral aspects of the client's thighs.

D Rationale: Trochanter rolls should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although options A, B, and C are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board provides increased back support, especially with a soft mattress. The footboard maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received.

D Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her now grown daughter only grew 2 inches after she was 12 years of age. Which question is most important for the nurse to ask this mother? A. "Is your son's short stature a social embarrassment to him or the family?" B. "What types of foods do both your children include in your meals?" C. "Did any significant trauma occur with the birth of your son?" D. "Did your daughter also start her menstrual period at 12 years of age?"

D Rationale:Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is worried that something is wrong with her son physically. Option B has less to do with stature than growth and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without known causes).

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years."

D Rationale:Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area.

The nurse is completing the 7:00 am to the 7:00 pm shift and has four actions left to complete in the remaining 30 minutes in the shift. Which action takes priority over the remaining actions? A. Assess the dressing change completed 3 hours ago for any oozing blood. B. Massage lanolin into the feet of a diabetic client. C. Administer the prescribed sleep aid requested by the client. D. Effectiveness of a repeat dose of IV morphine delivered 30 minutes ago.

D Rationale:The effectiveness of the morphine is the priority action because the nurse has provided care for the client for the past 11 hours, and can determine if the medication has had a similar or different outcome than previous doses. That assessment requires previous knowledge of the client and is best performed by the current care provider. The dressing change assessment is the next priority; however, not at the same level as the pain med assessment. This can be reviewed at the bedside hand-off report with the outgoing and the oncoming nurses. The lanolin can be delegated to an aide or delayed to the next shift. While the client requested a sleep medication, it can be delayed to after 7:00 pm and to the oncoming nurse.

The admission nurse is preparing a client for surgery. Which statements indicate to the nurse the client is well informed and has participated in the informed consent process? (Select all that apply.) A. "I didn't want the surgeon to tell me about the surgery for fear it would make me vomit." B. "I signed the consent form in the office a week ago. But, I have a few questions now." C. "Because I was in so much pain, I took two hydrocodone pills an hour before I signed the consent." D. "The surgeon is going to make incisions in my tummy and belly button for this laparoscopic surgery." E. "The surgeon addressed all of my concerns and then I signed the consent form 2 days ago."

D, E Rationale: Describing the procedure and having no questions indicate to the nurse that the client is knowledgeable and informed. Fears about surgery are common, but the client must have a rudimentary understanding of the procedure, risks, and alternatives. The surgeon must address all questions as the client has the right to refuse consent at any time in the pre-operative process. The client must not sign an informed consent after ingesting sedating medication. That is not considered an informed consent.