HV1 1-55

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first

-Auscultate bilateral breath sounds.

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first?

-Begin manual ventilation immediately.

The practical nurse (PN) is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the leg straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement?

-Demonstrate to the PN how to position the client more effectively for the procedure.

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty in concentrating at work. Which coping strategy should the nurse include in the plan of care?

-Focus on small achievable tasks, not taxing problems.

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 UAP's behavior?

-Note date and time of the behavior. 1 - Discuss the issue privately with the UAP. 2 - Plan for scheduled break times. 3 - Evaluate the UAP for signs of improvement. 4

A client with cellulitis of the right great toe has been taking an antibiotic for 7 days. Which assessment

-Observe for signs of inflammation on and surrounding the toe.

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids." What nursing intervention is most useful in assisting the resident to meet this goal?

-Offer a glass of fluid every hour while awake.

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

-Persistent coughing while drinking.

A low-risk primigravida at 28-weeks gestation arrives for her regular antenatal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

-Pulse increase of 10 beats/minute.

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?

-Send a stool sample to the lab for a guaiac test.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the HCP?

-Serum lithium level of 1.6 mEq/L or mmol/L (SI).

A mother brings her four-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter supposed to fix her child hernia. Which explanation should the nurse provide?

-This hernia is a normal variation that resolves without treatment

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order priority, with the highest priority first, and least priority last or at the bottom.)

1. Stop the infusion 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate an adverse event report.

An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

1000, 1600, 2200, 0400.

The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching?

A diet of healthy fruits, such as bananas and kiwis, are best for the child.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first

A family member of a client with dementia who has been missing for five hours.

A client is admitted with a severe asthma attack. For the last 3 hours the client has experienced increasing shor mmol/). Which intervention should the nurse implement

Administer PRN dose of albuterol.

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement?

Apply an ice pack to the perinium for the first 24 hours.

***PICTURE QUESTION***A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the should the charge nurse take.

Assist the nurse in changing the intravenous tubbing attached to the blood.

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, sooner" Which intervention is best for the nurse to implement?

Assure the parents that a terminal diagnosis was inevitable.

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client?

Avoid urinary catheterization.

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?

Body mass index BMI of 17.

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course.

A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses should the nurse implement?

Check neurovascular status of the distal digits.

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client?

Chicken broth. Apple juice

After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next?

Continue with the blood pressure assessment.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose

Current diagnosis of hepatitis B.

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?

Defibrillate with one shock.

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?

Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure.

The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Examine the genitalia as the last part of the total exam.

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. Which response should the nurse provide?

Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease client's plan of care? (Select all that apply.)

Fluid volume excess. Decreased cardiac output. Altered peripheral tissue perfusion Fatigue.

A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Frequency that the child uses a rescue inhaler during the week.

The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed?

Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmg.

A female client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurses on duty now." Which response is best for the nurse to provide to this clients dichotomous tendency?

I am happy that you are getting better and will be able to go home.

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

Inform the client that gradual tapering must be used to discontinue the medication.

A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the best initial nursing action

Initiate seizure precautions.

An older client arrives to the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute, respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which intervention is most important for the nurse to implement?

Keep head of bed raised 45 degrees.

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?

Limit oral water intake.

A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include???

Monitor cardiac rhythm via telemetry. Report changes in preexisting murmurs. Schedule rest periods between activities. Maintain record of fluid intake and output.

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolved immediately.

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Obtain a capillary glucose level

The nurse is providing teaching to a client who has been recently diagnosed with gestational diabetes mellitus. Which complication poses the greatest risk to the fetus if euglycemia is not maintained

Preterm birth.

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child anxiety, what action is best for the nurse to implement?

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment?

RN completes the two admission assessments. 1 PN completes the blood glucose measurements, and 1 PN completes the post-operative visit

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?

Redress the abdominal incision.

The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take?

Request a consultation to confirm dysphagia.

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?

Review the client's current list of medications

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Risk for infection.

A client with diabetes insipidus (DI) has an average urinary output of 500 mL of dilute urine every hour for the last four hours. Which laboratory test is most important for the nurse to monitor?

Serum sodium.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? -

Supervise a newly hired graduate nurse during an admission assessment.

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?

The xenograft is taken from nonhuman sources.

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

Tracheal deviation toward the left lung.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

anxiety