exit hesi 1

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?

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

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm, but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Begin chest compressions at 100/minute

An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

Had a cold and ear infection for the past two days

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?

Have the client vocalize the instructions provided

An unlicensed assistive personnel (UAP) is assigned to ambulate a client with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take?

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

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Instructions about how much fluid the child should drink daily

The nurse notes that a client with depression has been more withdrawn and non- communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

encourage the client to participate in group activities

nurse is initiating taking a line out and there is a code called the nurse should

go assess the code

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicates the client understands how to maintain balance safely? (Select all that apply)

Locks knees while preparing food on the counter Bends from the waist to pick trash off the floor

The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care?

Maintain strict intake and output

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage?

Natural whole almonds Plain, air-popped popcorn

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Observe both lower extremities for redness and swelling

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Somnambulism

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (Select all that apply)

Uses common words with few syllables Uses pictures to help illustrate complex ideas Contains a list with definitions of unfamiliar terms

patient having a TENS unit placed and it beings to tingle

ask if the tingle is hurting

The nurse has complete the diet teaching of a 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?

A tuna fish sandwich with chips and ice cream

The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding?Sound: wheezing

Albuterol

A client with leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care?

Assess urine and stool for occult blood

A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

Ask the client to describe the pain

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Children usually resume their toileting behaviors when they leave the hospital

A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

Explain that this normal secretion can be assessed at the next visit

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?

Increase the warfarin dose

An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Measure neurological vital signs every 4 hours Encourage family to participate in the client's care Play classical music in room while client is awake

A client with Type 1 diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected Staphylococcus aureus infection. Which interventions should the nurse implement? (Select all that apply)

Monitor the client's white blood cell count Send wound drainage for culture and sensitivity Institute contact precautions for staff and visitors

When providing client care the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Relevance to the situation

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Report any client complaint of pain or discomfort Weigh the client and report any weight gain Note and report the client's food and liquid intake during meals and snacks

The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding?

Restrained and restless with a low volume alarm sounding

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply)

Swollen lymph nodes in the groin White blood cell count (WBC) Core body temperature

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

Use a residual limb shrinker Inspect skin for redness Wash the stump with soap and water

A client with diabetes mellitus tells the nurse that she uses cranberry juice to help with urinary tract infection. what instruction should the nurse provide

drinking cranberry juice does not prevent infection.