Specialty my hesi

: A video question: About the student nurse giving meds through the gastrostomy tube, what would the nurse instruct the student nurse to do? Sellect all that apply:

A) the nurse must check the gastric residual before giving meds B) The student nurse should give all the meds separately

31. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?

assess for the presence of an impaction

: The patient comes with complain of chronic Arthritis pain on both hands and wrist. What would the nurse do before making the patient careplan

assess the patients ADLs

11. The community health nurse is making a home visit when the client, who is sitting at the kitchen table, begins to have a seizure. What action should the nurse take first?

assist the client to the floor

21. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

between the toes

: A patient with cyanosis what would the nurse do first?

check for respiratory rate

"A client has a nursing diagnosis of Excess Fluid Volume. After assessing the client, the nurse records which assessment data in the medical record that supports continued use of this nursing diagnosis?"

Bibasilar Crackles

24. A 24-hour urine specimen is being collected for analysis of creatinine clearance. After explaining the procedure, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take?

check the sample's pH and specific gravity

5. The nurse observes a newly admitted older adult female take short stems and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations?

complete a full fall risk assessment of the client

34. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take firs?

discuss with the client her meaning of heroic measures

36. A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). What intervention is most important for the nurse to implement before leaving the client alone?

elevate the head of the bead to a 45-degree angle

14. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in the client's teaching?

"do not allow the dropper bottle to touch the eye"

23. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact?

-a daughter-in-law designated as the client's Durable Power of Attorney (DPOA)

29. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? (Select all that apply)

-diminished visual activity syncope (dizziness) when bending hand tremors

A nurse is caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline solution (3%). The nurse determines that the treatment measures are effective when the laboratory results reveal a serum sodium level of:

140mEq/L

"An athlete comes to the ambulatory care center for treatment of a sports injury. Vital signs are: pulse 53 beats per minute, respiratory rate 20 breaths per minute, and blood pressure (BP) 110/64 mm Hg. The nurse interprets these vital signs as:"

Normal due to the cardiovascular response to physical conditioning

The nurse observes a newly employed unlicensed assistive personnel checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the clients auricle up and back and prepares to insert the thermometer. What action should the nurse implement?

A Demonstrate the correct technique for pulling the ear down and back

A registered nurse (RN) is planning the assignments for the day and has a licensed practical nurse (LPN) and a nursing assistant (NA) working on the team. The nurse assigns which client to the LPN?

A One day postoperative mastectomy client

A nurse reviewing the record of a client with Ménière's disease prepares dietary instructions for the client. Which of the following dietary prescriptions would the nurse expect to be prescribed for the client?

A low sodium diet

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. The nurse prepares to transfer the client from the stretcher to the bed by using:

A transfer board and the assistance of 4 people

The nurse is planning care for a group of clients during the night shift on a medical unit. Client should be assessed regularly during the night for sleep apnea?

An older male with multiple problems including obesity, diabetis and hypertension

A patient comes to the hospital saying that he has a painful rash on his abdomen, and he used all the over the counter oitments but the symptoms has not been relieved. What would the nurse do next?

Apply a PPE to assess the abdomen rash.

The nurse inserts a catheter for nostracheal suctioning as seen in the picture, what action should the nurse take next?

Apply intermittent suctioning

A nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which of the following is indicative of this complication of a spinal cord injury?

Areflexia below the level of injury

The patient comes to the nurse saying that he has difficulty urinating and it is painful. What would the nurse do first?

Ask the client about the color of his urine.

The nurse notices a male client grimacing as he moves from the bed to the chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first?

Ask the client what is making him grimace

a patient is mental confusion and the nurse wants to make his an important life decision for the patient. Who would the nurse ask?

Ask the daughter in law, who is appointed as the patient's attorney.

A person who has a potassium level of 2.5 what would you do as a nurse?

Assess the pulse, and heart rhythm.

A client with hypokalemia what dietary food is recommended to him: Select all that apply

Banana

A patient comes with a cerebral injury, and is on ventilation. Later the day, her daughter arrives to the hospital with the power of attorney saying that her mother did not want any life rescue things. What is the most appropriate action by the nurse?

Call the healthcare provider

A client with heart failure is receiving furosemide (Lasix) and digoxin (Lanoxin) daily. When the nurse enters the room to administer the morning doses, the client complains of anorexia, nausea, and yellow vision. The nurse should do which of the following first?

Check digoxin levels

a patient says that he gains 2 pounds every day for the last 3 days. After weighing the patient what would the nurse do next?

Check for extremity edema

A client with heart failure is receiving furosemide (Lasix) and digoxin (Lanoxin) daily. When the nurse enters the room to administer the morning doses, the client complains of anorexia, nausea, and yellow vision. The nurse should do which of the following first?

Check the morning serum digoxin level

A nurse just saw a fire in the bathroom of an empty room, and called the 911. What would the nurse do next

Close the bathroom door of the fire and the empty room door

"A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which of the following actions should the nurse take first?"

Compare these values to those recorded previously

nurse notes that the client has been complaining of this severe pain every morning during the past 3 days, regardless of the fact that pain medication was received during the night. The same nurse has cared for this client for the past 3 nights and the nurse suspects that the night nurse is not administering the pain medication to the client as prescribed. According to the Nurse Practice Act, which of the following should the nurse who discovered the occurrence do?"

Report the information to the nursing supervisor

Which assessment is most significant in determining the level of assistance a client needs with personal care.

Disorientation to time, place and person

A nurse administers digoxin (Lanoxin) 0.25 mg instead of the prescribed order of 0.125 mg. The nurse discovers the error while charting the medication. The nurse completes an incident report and notifies the physician of the incident. The nurse takes which additional action?

Documents the incident in the client records

A client has a serum sodium level of 129 mEq/L resulting from hypervolemia. The nurse consults with the physician to determine whether which measure should be instituted?

Fluid restrictions

The client recovering from cardiogenic shock has experienced episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Have the client dangle the legs at the edge of the bed before transferring to the chair

"The client who sustained an inhalation injury arrives in the emergency department. On assessment of the client, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing:"

Hypoxia

The client who has been receiving intravenous (IV) aminophylline (Theophylline) has been prescribed an immediate-release oral form of the medication. The IV medication is to be discontinued. The nurse should administer the first dose of the oral medication:

In 4-6 hours after discontinuing the iv form

: Patient who is at risk for dyspnea, what food would the nurse give?

Oatmeal with honey, applesauce, and nectar juice

The patient is with Nasograstric tube and is placed on a continuous intermittent suctioning. When the nurse enters the room to check on the patient, what would make the nurse to immediately take an action:

Patient is vomiting in the emesis basin.

Which patient is at risk of dyspnea

Patient whose is obese and has hypertension and diabetes

38. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client's oxygen saturation level is 92%. What intervention should the nurse implement?

Place padding around the cannula tubing

A patient is saying that she has good breathing when her head is elevated. What would the nurse tel the UAP?

Place the bed head down and elevated to waist level for moving the patient.

The nurse is gathering data from a client newly diagnosed with diabetes mellitus concerning events leading to the client's seeking medical attention. The nurse identifies which of the following as the major symptoms of diabetes mellitus?

Polydipsia, Polyuria, Polyphagia

13. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?

Potassium 3.1 mEq/L (3.1 mmol/L)

8 hours after the removal of an indwelling catheter a male client reports lower abdominal pain, and palpations of the bladder indicate it is distended and dull to percussion. Even after assisting the client to a standing position he is unable to void. What actions should the nurse take?

Prepare to reinsert the catheter

The nurse is discharging an adult client who was hospitalized for 5 days after an pneumonia. While the nurse is reviewing the prescribed medication the client appears anxious. Which actions are most important for the nurse to implement?

Provide written instructions that are easy to follow

Which assessment is most significant in determining the level of assistance a client needs with personal care

Provide written instructions that are easy to follow

The nurse educator is conducting a class for Unlicensed assistive personnel. Which action indicates that the UAP understands the gloving procedure?

Puts on new gloves when entering a clients room

41. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first?

Reassess the client to determine the need for continuing restraints.

The nurse notes that a client has Cyanosis of the toes and fingertips, Which vital signs should the nurse obtain first?

Respiratory Rate

"A hospitalized 19-year-old famous pianist wanders in and out of other client rooms taking their possessions while singing to herself, and then giggling for no apparent reason. The nurse, recognizing the severe regression of the client and the difficulty with limit setting, implements which action?"

Saying " I can see you very anxious today, lets go and play the piano"

A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. The nurse would do which of the following to assess the client's blood pressure most accurately?

Seat the client with the arm bared, supported and at heart level

A nurse is assisting with transferring a client from the operating room table to a stretcher. To provide safety to the client, the nurse:"

Secures client with safety belts after transferring to the stretcher

A girl visits the doctor saying that she has vaginal bleeding, after the nurse assess the perianal area, she notices that her vagina is torn. What would the nurse do next?

Teach her safe sex practices.

It is most important for a nurse to recalculate the Braden Scale score for a client who has developed which problems?

Urinary Incontinence

An unlicensed assistive personnel is assigned to help a female patient with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP?

Wear gloves while giving the bath

A patient whose infant is diagnosed with Fallot diseases, asks the nurse, why did it happen to my baby? What did I do wrong? What is the appropriate action by the nurse.

You must have been going through a very difficult time right now.

A nurse is planning a discharge teaching plan for a client with a spinal cord injury. To provide for a safe environment regarding home care, which of the following would be the priority in the discharge teaching plan?"

Including the clients significant others in the teaching session

A nurse checks for the pulse rate for a systolic BP of a client. Once the cuff is inflated the 90 pulse is not palatable. What would the nurse do next?

Inflate the cuff to 120 degree.

A stage 4 lunch cancer patient gets a discharge paper. The client tells the nurse that he is worried about his pain. What would the nurse do?

Instruct the client on PCA pump of analgesics

A client who is 2 day postoperative surgery for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain at 5 on a scale of 1-10. After placing a call to the health care provider what should the nurse implement

Instruct the client to use guided imagery and slow rhythmic breathing

An older patient comes to the nurse saying that she can not sleep at night. What techniques does the nurse teach to the patient: Select all that apply

a) Avoid caffeine and smoking before bed b) Do not drink fluids/ snacks before bedtime

1) Muslim male patient with minimal English speaking, has a renal failure goes to daialysis every 0700. This time when he was taken the patient was anxious and upset. What Is the most appropriate intervention by the nurse?

a) Call the interpreter to talk to the client and finds out why he is angry today

43. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. What action should the nurse implement?

apply a hydrocolloidal gel (Duoderm) dressing

7. A middle-aged male client tells the nurse that two weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes him an hour to fall asleep at night. Which action should the nurse implement?

ask the client to describe the exercise schedule that he has been following

28. To assess the quality of an adult client's pain, what approach should the nurse use?

ask the client to describe the pain

32. A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

paper mask and gown

35. A male client has right-sided hemoglobin following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take?

place the wheelchair on the client's left side

22. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?

position the client supine for a few minutes

: a patient comes to the clinic saying that he has dysuria, and pain on his abdomen. What would the nurse do?

reinsert the catheter to get the urine flow

2. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he does for the swelling in his leg. Which should the nurse implement?

instruct the client to flex both of his feet several times a day

40. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care?

measure the client's vital signs before the client walks; report the onset of any dizziness or light headedness; offer to assist the client to void prior to walking in the hall

18. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement s of several clients. Which descriptions warrant additional follow-up by the nurse?

multiple hard pellets, tarry appearance, and brown liquid

37. While interviewing a client, the nurse records the assessment in the electronic health record. which statement is most accurate regarding electronic documentation during an interview

the nurse has limited ability to observe nonverbal communication while entering the assessment electronically

3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for a routine urinalysis. In later review of the client's medical record, which data indicates to the nurse that the specimen collection should be repeated?

the urine specimen shows multiple organisms in low colony counts

25. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan?

toxicity

27. Which landmarks are useful to the nurse when administering an intramuscular injection in the ventrogluteal site?

trochanter and anterior superior iliac spine

44. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

complete a functional assessment of the client's self-care abilities

6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first?

respiratory rate

A nurse is giving a bed bath to an assigned client. A nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which of the following?

Cover the client, raise the siderails, tell the client that you will return shortly and administer the pain medication to the other client

"A home care nurse is caring for an older female adult client at home. The nurse is told that the client was found wandering the highway in her nightgown last night. Her daughter, who lives with her, says to the nurse, "This wandering started last week, but this is the first time she got out of the house. She always seems to do it around 10:00 pm. What can I do?" Based on an evaluation of the situation, the nurse makes which response to the client's daughter?"

Since this is the first time your mother has gotten away from you, what has worked to prevent this before this time

26. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?

assess for side effects/adverse effects of the medication

8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

complete the intermittent suction of nasopharynx

4. During the admission assessment of a terminally ill male client, the client states that he is an agnostic. What is the best nursing action in response to this statement?

document the statement in the client's spiritual assessment

17. *Hygiene self-care deficit

evaluate the client's participation in self-care to optimal level of capacity is the best goal to evaluate progress in recovery

The patient has a tracheostomy and complains to the nurse that his lips are dry. What would the nurse do?

give a sponge toothless to clean around the mucosa membrane and moist the mouth

45. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures he taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. What action should the nurse take?

initiate an ethics committee review of the case

10. A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take first?

instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client

9. An older male client returns to the clinic for chronic pain management after taking morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement?

instruct the client to take the MS Contin every 12 hours as prescribed

Sleeping side

lying with hips and knees flexed prevents unnecessary pressure on support muscles, ligaments, and lumbosacral joints and reduces low back pain

33. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the dressing wound. What action should the nurse implement?

replace dressing with cotton pads and silk tape

42. While planning care for a client experiencing pain, which outcome statement should the nurse include in the plan of care?

report a 5-point decrease on a 1 to 10 pain scale one hour after analgesia

12. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions?

restart the IV, perform tracheostomy care, change the coccyx dressing

30. The nurse measures the client's blood pressure (PB) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)

retake the client's blood pressure in the opposite arm, determine the client's activity and feeling prior to the BP measurement

19. A client with a gastronomy tube is recovering a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. What is the action by the nurse?

stop the tube feeding and assess the client