HPE2

An older client is transferred to the rehabilitation unit with the diagnosis of Cerebrovascular Accident (CVA) with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg and states, "There is a leg in my bed!" What is the best response by the nurse?

"I know you think there is an extra leg in your bed, but I do not see it."

When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "There is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide to this client?

"Let's talk about what you may have in common with the other group members."

A client is diagnosed with terminal cancer and tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response should the nurse offer?

"Yes, your condition is serious."

A client asks the nurse to explain the location of the prostate gland. What is the best response? A. Close the rectal wall the prostate gland sits behind the

103. A client asks the nurse to explain the location of the prostate gland. What is the best response? A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around the beginning of the urethra A. At the bottom of the scrotal sac, the prostate gland rests beneath the testes, held in place by the spermatic fascia B. Attach to the front and sides of the pubic arch, the prostate is a mess of cavernous tissue held together by fibrous tissue E. Located at the lateral edge of the posterior segment of the testes, the prostate creates a bulge continuous with the vas deferens

Which pediatric client is most likely to experience a disturbed body image?

14-year-old with acne vulgaris

The nurse observes that there are secretions in the air vent lumen of client's double lumen Nasogastric tube (NGT). Which action should the nurse implement?

?

A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement?

????A. Offer the client a full glass of water B. Give medications 2 hours apart C. Provide a snack with the medications D. Administer only the docusate sodium

Which client should the nurse assess first?

A client who is ambulating with partial weight-bearing after a total hip replacement

After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse?

A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal

A 6-month old male with Bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing Respiratory Distress?

A high-pitched cry

A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take?

A. Tell the man when the elevator will see him B. Alert the staff to monitor exits to prevent escape C. Warn the client that he is likely to have a seizure D. Offer a hot meal a clean bed and a sleeping pill ????

The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1 unlicensed assistive personnel (UAP) and 1 certified medication aide. Which

Administer medications and formula to a client with a gastronomy tube

2 days after an abdominal hysterectomy, an elderly client with Diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limits, but her sugar is 325 mg/dL. What intervention should the nurse implement first?

Administer regular insulin per sliding scale

The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD?

Anemia

The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that apply).

Anemia, Orthostatic hypotension

The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action?

Ask a regular staff member to confirm the residents identity

The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse). Which instruction should the PN reinforce with the client?

Avoid all sources of alcohol while taking this drug including cough syrups

The nurse is caring for a client with Thrombocytopenia. What intervention should the nurse implement to prevent complications?

Avoid invasive interventions such as intramuscular injection

The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begins to show signs of improvement

The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have...

Black tarry stool

The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain?

Blood pressure and pulse rate

A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action?

Blowing forcefully into the mouthpiece

The nurse identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the nurse?

Bowel movements decrease to 1 every third day

Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected?

Bronchioles

The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement?

C. Re-teach the client about the action of the eye drops to decrease pressure in the eye

A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode?

Cessation of acute chest pain

The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take?

Check fundal consistency and continue to monitor the lochial flow amount

A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first?

Check the client's dorsalis pedis and posterior tibialis pulse point

The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site?

Chest wall below the clavicle

The nurse empties a large amount of serous drainage from a postoperative client 's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.)

Compress drain... close drain... discard drain... document

The charge nurse brings a #18fr urinary catheter (Foley) with a 30mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first?

Consult with the charge nurse about the catheter

The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication?

Decreased gastrointestinal motility

An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which sign or symptom?

Delusions of persecution

Which intervention is within the scope of practice for a nurse?

Demonstrating deep breathing and coughing to postoperative client

A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first?

Determine the amount of water and exact time it was taken

The nurse is preparing a client for a mammogram. What instructions should the nurse provide the client?

Do not use underarm deodorant on the day of the procedure

81. A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan?

Drink 3 quarts of water daily

The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit?

Dry skin and an increased heart rate

The nurse should perform oral suctioning for a client with what problem?

Dysphagia

. A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the client?

Dysphagia precautions

30. In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client?

Empty and measure the drainage in the suction drainage device

The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis ?

Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation

A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next?

Encourage the client's wife to express concerns about making the decision

An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity?

Evaluate pulse oxygen saturation

On a short-staffed unit of a long-term care facility, it is most important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first?

Frequent episodes of fecal incontinence

An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take?

Give 4 ounces of apple juice

The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first?

Gravida 3 Para 3 who delivered vaginally 2 hours ago

A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

Hepatitis

A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3 months. The nurse should assess the client for what additional information?

History of alcohol and tobacco use

The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the RN?

Hives with pruritus

29. Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately?

I've been feeling so light headed

The nurse observe that the IV catheter is no longer in a client's arm. It is on the bed, and the sheets are moist with IV fluid. The client is disoriented and states he does not remember pulling the catheter out. How should the nurse document this situations?

IV catheter found lying on bed sheets

The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be used to obtain the specimen?

Iliac crest

Which technique should the nurse use to give a Z-track intramuscular injection?

Inject the medication into the dorsal gluteal site

The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will develop within 2 weeks," which intervention should the nurse implement?

Irrigate wound with sterile normal saline

An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement?

Keep the catheter intact and assist the client with a shower

What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)?

Keep the catheter intact while assisting the client with a shower

The healthcare provider tells the family of a 6-year-old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news?

Listen to the family's reactions and reflect on their fears and concerns

A female client is being prepared for a speculum exam. In which position should the nurse place the client?

Lithotomy

22. A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what intervention should the nurse implement?

Maintain a quiet calm darkened environment

Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary Incontinence?

Maintain standard precautions

After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-pound weight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next?

Measure the client's blood pressure

The nurse is caring for a 10-year-old child with Hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurse take when interacting with the child and mother?

No special precautions are needed

An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide?

Oatmeal

A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression device (SCD) to both lower extremities. (BLE). What

Observe the SCDs continue to inflate and deflate when the client is turned

A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings?

Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings

A client complains of kidney pain. The nurse understands that the kidneys are located where?

On the retroperitoneal posterior abdominal wall at the costovertebral angle

Which term describes 2 or more tissues that compose a structure and perform a specific function?

Organ

A client returns to the unit following a cardiac catheterization with a Femoral Artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return?

Pedal pulses

The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. Which action should the nurse first take?

Perform oral suctioning

What is the function of neutrophils?

Phagocytotic action

97. The nurse can also refer to the external ear as what other known name...

Pinna

What technique should the nurse use to administer a medicated ophthalmic ointment?

Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus

A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take?

Place the client in a side-laying position

A 75-year-old male client with Alzheimer's Disease (AD) is admitted to an extended care facility. What intervention should the nurse include into his client's Nursing care plan?

Plan to have the same Nursing staff provide care for the client whenever possible

The nurse is preparing to insert an indwelling catheter for an 89-year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take?

Position laterally for posterior access in visualizing the meatus for insertion

A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of Tuberculosis (TB)?

Proper disposal of tissues when coughing

The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer?

Prostate-specific antigen (PSA)

While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

Provide a Yankauer tip for oral suction

Wrist restrains were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep, which finding should be reported to the charge nurse?

Radial pulse volume decreases from +3 to +1

During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take?

Record the findings and report the symptoms to the charge nurse

The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize?

Report any drainage observed around the GT insertion site

The nurse assesses a client receiving a hypertonic full strength tube feeding that is infusing continuous at 50 mL/hr. Which finding is most important for the nurse to report to the charge nurse?

Report of increased hunger

A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take?

Report the incident to the person in charge of the unit or Nursing supervisor

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first?

Reposition the head to ensure an open airway

During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse?

Reposition the oximeter clip

98. During immediate postoperative period, which condition has the highest priority when planning Nursing care?

Respiratory obstruction

The nurse is caring for a primagravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse?

Rubor lochia saturating 3 perineal pads per hour

The nurse is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next?

Separate the labia

105. The nurse is caring for an elderly client who has suddenly become confused after 2 days of vomiting and diarrhea. What laboratory result should the nurse report first to the RN?

Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L

Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain?

Subjective score on a 1 to 10 pain scale

A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should the nurse take?

Supervise the UAP after reviewing the protocol

What length of blood pressure cuff should the nurse use when obtaining a client's blood pressure?

The cuff and its bladder should nearly encircle the extremity's circumference

A client is complaining of muscle fatigue in the lower extremities. What is the physiological cause of muscle fatigue?

The depletion of glycogen and energy stores

An elderly female client tells the nurse that she does not do regular Breast Self Examination (BSE) because she is too old. The nurse's response to the client is based on what information?

The incidence of breast cancer increases with age

A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer?

The sac surrounding the heart has become inflamed from the cells damaged by the heart attack

A 26-year-old primagravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client?

They can have intercourse when the episiotomy is healed and the lochial flow has stopped

When providing oral care to an unconscious client who is a mouth breather and does not swallow, which action is most important for the nurse to implement?

Use an oral suction catheter in the buccal cavity

The nurse is caring for a mother who is bottle-feeding and develops breast engorgement. Which intervention is most effective in reducing breast engorgement?

Wearing a tight-fitting bra

The nurse is working at a family planning clinic. Under which circumstance should the client who is taking oral contraceptives for birth control be told to use additional protection?

When taking antibiotics for an infection

The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best Nursing action?

Write an incident report and submit it to the unit manager

In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is...

a 32-year-old whose mother had breast cancer

Which membrane lines the abdominal cavity?

peritoneum

An 82-year-old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to...

prevent foot drop