HESI with Rationale 12
The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching a 16 gauge needle. What action should the charge nurse take?`
Answer A. Direct the nurse to remove the needle before the procedure. Rationale
A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?`
Answer A. Cleanse the foot with soap and water and apply an antibiotic ointment. Rationale
A morbidly obese woman is scheduled for gastric bypass surgery. She completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement?`
Answer A. Discuss small, low-fat, low sugar meal preparation techniques. Rationale
The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit?`
Answer A. Document that the client has remained NPO. Rationale
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/ liter of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
83 ml/hour
When assessing a client, the nurse should establish which findings as objective? (Select all that apply.)`
Answer A. Edema. D. Diaphoresis. E. Hypertension. F. Urticaria. Rationale
A male client is admitted for the removal of an internal fixation that was inserted for a fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (Vancocin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)`
Answer A. Collect multiple site screening culture for MRSA. C. Place the client on contact transmission precautions. E. Continue to monitor for client sign of infection. Rationale
During an assessment by the home health nurse of an older man who lives alone, the client reports that he is troubled by constipation. To formulate a plan of care, what additional information should the nurse obtain? (Select all that apply.)`
Answer A. Daily food and fluid intake. B. Current prescribed and over-the-counter medications. D. Level of physical activity and exercise. E. Methods currently used to treat constipation. Rationale
The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?`
Answer A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. Rationale
A client who is having an allergic reaction receives a prescription for epinephrine 0.4 mg subcutaneously. The available vial is labeled, Epinephrine Injection, USP, 1:1000 (1 mg/ml) For Subcutaneous use only. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Answer 0.4 Rationale
An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAPs behavior? (Place the actions in order from first on top to last on bottom.)`
Answer 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. Rationale
The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)`
Answer 1. Obtain blood glucose level. 2. Verify the insulin prescription. 3. Draw insulin into insulin syringe. 4. Cleanse the selected site. Rationale
The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)`
Answer 1. Start chest compressions with assisted manual ventilations. 2. Administer epinephrine 0.01 mg/kg intraosseous (IO). 3. Apply pads and prepare for transthoracic pacing. 4. Review the possible underlying causes for bradycardia. Rationale
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first and least priority last or at the bottom.)`
Answer 1. Stop the infusion. 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate adverse event report. Rationale
The nurse is interviewing a 18-year-old female client who was released 3 weeks ago following two months of treatment for anorexia nervosa. Which statement is characteristic of a young woman who has been successfully treated for anorexia nervosa?`
Answer A. "My parents attempt to smother me, but I will not allow them to make my decisions." Rationale
During a family group meeting, the client's daughter tells the group, "I hope I didn't cause mom to be depressed." Which response should the nurse provide?`
Answer A. "You seem worried. What about your mom is bothering you?" Rationale
Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? `
Answer A. A 39-week primigravida with biophysical profile score of 5 out of 8. Rationale
A 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% of personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?`
Answer A. Administer a prescribed bronchodilator. Rationale
In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?`
Answer A. An immobile client receiving low molecular weight heparin q12h. Rationale
The healthcare provider prescribed oxycodone/aspirin 1 tab PO every 4 hours as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?`
Answer A. Aspirin content. Rationale
The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse to first? `
Answer A. Assess the level of consciousness and vital signs for both clients. Rationale
A postpartum client who is bottlefeeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?`
Answer A. Avoid stimulation of the breasts and wear a tight bra. Rationale
A client who returns from surgery after the removal of a malignant thyroid tumor has a serum calcium level of 4.5 mg/dL or 1.125 mmol-L (SI). Which findings require immediate action by the nurse? (Select all that apply.)`
Answer A. Carpopedal spasms with inflation of the blood pressure cuff. B. Spasm of the cheek and mouth when the facial nerve is tapped. Rationale
The nurse is administering a 750 ml cleansing enema to an adult client. After approximately 150 ml of enema has infused, the client states, "Stop! I can't hold anymore." What action should the nurse take?`
Answer A. Clamp the tubing and instruct the client to breathe deeply before continuing. Rationale
When conducting diet teaching for a client who is diagnosed with Crohn's Disease, which foods should the nurse encourage the client to eat? (Select all that apply.)`
Answer A. Clams. B. Raisins. Rationale
An older adult female asks the clinic nurse about getting a Herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond? `
Answer A. Explain the use of the vaccination to reduce risk for Herpes zoster. Rationale
A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care?`
Answer A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures. Rationale
The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?`
Answer A. Jaundice. Rationale
The client with which type of wound is most likely to need immediate intervention by the nurse?`
Answer A. Laceration. Rationale
An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest indication that the client is experiencing increased intracranial pressure (ICP)?`
Answer A. Lethargy. Rationale
The home health nurse is visiting an older client who was just charge from the hospital 3 days ago following hip pinning surgery. The client lives with her daughter, who prepares the family meals. In discussing nutrition for postoperative healing it, which meal choices should the nurse suggest for this clients diet? (Select all that apply.)`
Answer A. Low-fat milk. B. Oat bran. D. Grilled salmon. E. Baked chicken. Rationale
A male client who was just discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen lower left leg. The nurse is preparing to initiate heparin therapy. What additional intervention should the nurse include in this clients plan of care?`
Answer A. Maintain the client on bed rest. Rationale
A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply.)`
Answer A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. Rationale
In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)`
Answer A. Place personal religious artifacts on the body. D. Attach identifying name tags to the body. E. Follow cultural beliefs in preparing the body. Rationale
A 56-year-old man shares with the nurse that he is having difficulty making a decision about terminating life support for his wife. What is the best initial action by the nurse?`
Answer A. Provide an opportunity for him to clarify his values related to the decision. Rationale
To evaluate the effectiveness of a male clients new prescription for ezetimibe, what action should the clinic nurse implement?`
Answer A. Remind the client to keep his appointments to have his cholesterol level checked. Rationale
At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)`
Answer A. Remove sequential compression devices. Rationale
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?`
Answer A. Respiratory apnea of 30 seconds. Rationale
A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?`
Answer A. Send stool sample to the lab for a guaiac test. Rationale
Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?`
Answer A. Sudden dysphagia. Rationale
The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decreased milk supply for the mother who is breastfeeding?`
Answer A. Supplemental feedings with formula. Rationale
A client is admitted to the mental health unit with relationship distress with spouse and depressed mood. Findings of which diagnostic tests provide the most information for developing this client's plan of care?`
Answer A. Urine drug screen. Rationale
A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences`
Answer A. palpitations and shortness of breath. Rationale
When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, what question is most important for the nurse to ask the UAP?`
Answer B. "What experience do you have performing this task?" Rationale
In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the correct Apgar score for this infant? `
Answer B. 8. Rationale
A client is scheduled to receive an IV dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has a saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?`
Answer B. Administer the Zofran after flushing the saline lock with saline. Rationale
A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?`
Answer B. Allopurinol (Zyloprim). Rationale
While receiving a male postoperative client's staples the nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledging the client's anxiety, what action should the nurse implement?`
Answer B. Attempt to distract the client with general conversation. Rational
A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement?`
Answer B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. Rationale
The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension?`
Answer B. Baked pork chop, applesauce, corn on the cob, 1% milk, and key-lime pie. Rationale
The nurse is assessing a client with diabetes mellitus who is at risk of developing acute renal failure. Which assessment finding is earliest indication of acute renal failure?`
Answer B. Blood urea nitrogen 35 mg/dL (12.4 mmol/L SI units). Rationale
The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?`
Answer B. CPT should be performed more frequently, but at least an hour before meals. Rationale
A client is admitted with the diagnosis of Wernicke's Syndrome. What assessment finding should the nurse use in planning the clients care? `
Answer B. Confusion. Rationale
An older client is admitted with pneumonia, and the healthcare provider prescribes penicillin G potassium IV. Which assessment finding increases the risk of adverse reactions in this client?`
Answer B. Daily use of spironolactone for hypertension. Rationale.
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increase in glaucoma surgeries?`
Answer B. Decreased prevalence of glaucoma in the population. Rationale
The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?`
Answer B. Decreases the amount of HCl secretion by the parietal cells in the stomach. Rationale
After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?`
Answer B. Determine client's pulse, blood pressure, and respirations. Rationale
The nurse is palpating the lymph nodes of an 18-month-old. Which findings should the nurse call to the attention of the healthcare provider?`
Answer B. Enlarged, warm, tender preauricular node. Rationale
A client who received partial thickness (second degree) burns over the anterior surfaces of both arms, legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a stretcher into the therapeutic bath. Which intervention should the nurse implement first?`
Answer B. Explain the procedure to the client. Rationale
The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)`
Answer B. Fluid shifts from intravascular to interstitial area due to decreased serum protein. C. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen. D. Increased circulating aldosterone levels that increase sodium and water retention. Rationale
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?`
Answer B. Foods sweetened with aspartame. Rationale
A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT?`
Answer B. Her mother and sister have a history of breast cancer. Rationale
A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?`
Answer B. How many departments can use this equipment? Rationale
Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. The client's fluid and fiber intake is deficient and he eats microwaved foods at home and frequents fast-food restaurants. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply)`
Answer B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. Rational
An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are pH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required?`
Answer B. Increase ventilator rate. Rationale
Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?`
Answer C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale
A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?`
Answer B. Inform her that some antianxiety medications are safe to take while breastfeeding. Rationale
A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?`
Answer B. Initiate seizure precautions. Rationale
The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicates that the client understood the teaching?`
Answer B. Keeps the irrigating container less than 18 inches above the stoma. Rationale
When providing diet teaching for a client with cholecystitis, which types of food choices should the nurse recommend to the client?`
Answer B. Low fat. Rationale
An adult woman who was seen earlier today in the clinic is admitted to the hospital because she is very nervous, has a racing heart beat, and reports a weight loss of 15 pounds in the last month. The healthcare provider suspects that she has hyperthyroidism and prescribes further testing. What intervention should the nurse include in this client's plan of care?`
Answer B. Monitor the client for shortness of breath. Rationale
A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?`
Answer B. Muffled heart sounds. Rationale
An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)`
Answer B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. Rationale
The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?`
Answer B. Observe him as he demonstrates the self-technique to another diabetic adolescent. Rationale
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?`
Answer B. Obtain a clean catch mid-stream specimen. Rationale
In early septic shock states, what is the primary cause of hypotension?`
Answer B. Peripheral vasodilation. Rationale
A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?`
Answer B. Reduced level of pain. Rationale
A female client's estranged husband arrives at the hospital and demands that his wife have no other visitors. The client becomes angry and insists that the estranged husband be barred from visiting her. Which intervention should the nurse implement?`
Answer B. Request a multidisciplinary care conference to discuss husband's demands. Rationale
While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?`
Answer B. Respiratory rate 6 breaths/minute. Rationale
While caring for a client who is mechanically ventilated, the nurse response to a high-pressure alarm. Which assessment finding warrants immediate intervention by the nurse?`
Answer B. Restless client who is biting the endotracheal tube. Rationale
To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?`
Answer B. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale
A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup". The client's abdomen is distended. Which prescribed PRN medication should the nurse administer?`
Answer B. Simethicone (Mylicon). Rationale
The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply.)`
Answer B. Take postoperative vital signs for a client who has an epidual following knee arthroplasty. D. Collect a sputum specimen for a client with a fever of unknown origin E. Ambulate a client who had a femoral-popliteal bypass graft yesterday. Rationale
A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?`
Answer B. Teach tracheal suctioning techniques. Rationale
An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices?`
Answer B. They decrease the risk for joint trauma. Rationale
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?`
Answer B. To reduce abdominal pressure on the diaphragm. Rationale
When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? (Select all that apply.)`
Answer B. Yogurt. E. Processed cheese. Rationale
The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?`
Answer C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. Rationale
A primigravida client at 36-weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates 2 cm cervical dilation, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, and contractions occurring 3 to 5 minutes with a decrease in fetal heart rate after the last contraction peaks. Which action should the nurse implement first?`
Answer C. Administer Oxygen via face mask. Rationale
While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?`
Answer C. Administer prescribed antibiotics. Rationale
The healthcare provider changes a client's medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduced bioavailability. What action should the nurse implement?`
Answer C. Administer the medication via the oral route as prescribed. Rationale
A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority?`
Answer C. Assign private room. Rationale
A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?`
Answer C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness. Rationale
A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet?`
Answer C. Demonstrates willingness to adhere to the diet consistently. Rationale
In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?`
Answer C. Enable clients to become active participating in controlling the disease process. Rationale
A male client's laboratory results include a platelet count of 105,000/mm3. Based on this finding, the nurse should include which action in the client's plan of care?`
Answer C. Encourage him to use an electric razor. Rationale
A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?`
Answer C. Evaluate the newly hired UAP's level of competency by observing him deliver care. Rationale
A client has been taking an oral corticosteroid for two weeks. Nursing assessment reveals that the client has developed a rounded face. What action should the nurse take in response to this finding?`
Answer C. Explain this side effect to the client. Rationale
When development a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sing of diabetes ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs ?`
Answer C. Give a dose of regular insulin per sliding scale. Rationale
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?`
Answer C. Heat loss. Rationale
The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?`
Answer C. Hemoglobin A1C (HbA1C) reading less than 7%. Rationale
A client with cirrhosis is receiving a low protein diet. The nurse should explain to the family that the diet restriction is implemented to reduce the risk of which complication of cirrhosis?`
Answer C. Hepatic encephalopathy. Rationale
The nurse learns during shift report that a client is experiencing frequent ectopic beats on the cardiac telemetry monitor. Which assessment findings should the nurse expect this client to exhibit?`
Answer C. Irregular heart rhythm. Rationale
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take next?`
Answer C. Listen with the bell at the same location. Rationale
A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?`
Answer C. Medicare. Rationale
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies.)`
Answer C. Murmur. Rationale
A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F. He is drooling and becoming increasingly more restless. What action should the nurse take first?`
Answer C. Notify the healthcare provider and obtain a tracheostomy tray. Rationale
A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? `
Answer C. Obtain vital signs and breath sounds. Rationale
A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting which problem to the healthcare provider?`
Answer C. Persistent fever. Rationale
When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?`
Answer C. Review the client's use of over the counter (OTC) medications. Rationale
Following discharge teaching, a male client with a duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?`
Answer C. Review with the client the need to avoid foods that are rich in milk and cream. Rationale
The nurse identifies the presence of a clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?`
Answer C. Test the fluid on the dressing for glucose using a chemstrip. Rationale
A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications?`
Answer C. The additive effect of multiple medications has caused the blood pressure to drop too low. Rationale
The nurse is assessing an older adult with Type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?`
Answer C. The hemoglobin A1C was 6.5g/100 ml last week. Rationale
What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?`
Answer C. The technique is intended to maintain straight spinal alignment. Rationale
A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider prescribes a low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?`
Answer C. Turkey salad sandwich. Rationale
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?`
Answer D. "Have you noticed any changes in your fingernails?" Rationale
Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?`
Answer D. "I have a headache that gets worse when I sit up." Rationale
The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? `
Answer D. A 2-year-old who plays on aging outdoor playground equipment. Rationale
The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?`
Answer D. A family member of a client with dementia who has been missing for five hours. Rationale
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?`
Answer D. Administer the analgesic as requested. Rationale
Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?`
Answer D. Advise the client that assignments are not based on clients requests. Rationale
While the nurse is providing morning care for a client with chronic obstructive pulmonary disease (COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement first? `
Answer D. Assist the client to an upright position. Rationale
A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?`
Answer D. Auscultate bowel sounds in all four quadrants. Rationale
The nurse identifies an electrolyte imbalance, an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease. Which is the most important action for the nurse to take?`
Answer D. Auscultate for irregular heart rate. Rationale
A male client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in this discharge teaching?`
Answer D. Avoid all isometric exercises, but walk regularly. Rationale
Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?`
Answer D. Bagel with jelly and skim milk. Rationale
A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next?`
Answer D. Begin parenteral antibiotic therapy. Rationale
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?`
Answer D. Bowel patterns. Rationale
An older male client with Type 2 diabetes mellitus reports that has experiences leg pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?`
Answer D. Completely stop cigarette/ cigar smoking. Rationale
A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?`
Answer D. Condition of hair, nails, and skin. Rationale
The nurse assesses a client who has just returned from a diagnostic study, as seen in the picture. The client has a prescription for a nasogastric tube to low intermittent suction and now reports feelings of nausea. What action should the nurse implement first?`
Answer D. Connect the tube to suction. Rationale
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?`
Answer D. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider. Rationale
Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?`
Answer D. Direct the nurse to continue the surgical hand scrub for a 5 minute duration. Rationale
In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?`
Answer D. Document the assessment data. Rationale
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?`
Answer D. Explore client's readiness to discuss the situation. Rationale
A female client with otosclerosis is scheduled for a stapedectomy. What information is most important to provide the client about the postoperative care?`
Answer D. Hearing may seem muffled initially. Rationale
The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?`
Answer D. Identify the source and amount of bleeding. Rationale
A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of parenthesia in the fingers and toes. Which serum laboratory findings should the nurse expect to find?`
Answer D. Low serum calcium. Rationale
While assisting a client who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?`
Answer D. Measure the client's oral temperature. Rationale
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?`
Answer D. Place the implant in a lead container using long-handled forceps. Rationale
While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value?`
Answer D. Potassium. Rationale
What action should the nurse take first when discontinuing and indwelling urinary catheter?`
Answer D. Remove the normal saline from the balloon. Rationale
A 6-month-old is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last four hours. Which laboratory finding is most important for the nurse to monitor?`
Answer D. Serum sodium levels. Rationale
When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?`
Answer D. Sitting upright. Rationale
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?`
Answer D. Skills of staff and client acuity. Rationale
An older male client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?`
Answer D. Start an intravenous (IV) infusion of normal saline. Rationale
A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?`
Answer D. Toasted wheat bread and jelly. Rationale
A client with history of bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?`
Answer D. Ventricular arrhythmias. Rationale
A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulses, and hypotension. Which assessment finding warrants immediate intervention by the nurse?`
Answer D. Ventricular arrhythmias. Rationale
During a postpartum assessment of a client who is five hours post vaginal delivery, the nurse determines the fundus is three finger breadths above the umbilicus and positioned to the client's left side. What action should the nurse implement first?`
Answer A. Encourage the client to void. Rationale
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?`
Answer B. Urinate at specified time, discard the urine, and collect all subsequent urine during the next 24 hours. Rationale
The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is the best for the nurse to implement?`
Answer C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale
The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? `
B. A tunafish sandwich with chips and ice cream.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?`
Answer C. Stroke secondary to hemorrhage. Rationale
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?`
Answer D. Explain that the client may be placed in five positions. Rationale
When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next?`
Answer D. Place cardiac monitor leads on the client's chest. Rationale
Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)`
Answer Correct order: (PADD) 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces. 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds. 4. Document normal breath sounds and location of adventitious breath sounds. Rationale
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication?`
C. Hypertension.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?`
C. The client states that his right calf is aching, and wants pain medication.
The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?`
C. The client's previous GCS score.
A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The Unlicensed Assistive Personnel (UAP)s working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?`
Rationale D. Tell all their assigned clients to stay in their rooms. Rationale
